Abstract

Myocardial ischemia due to coronary or microvascular dysfunction affects the supply of oxygen and nutrients to the myocardium. The underlying pathophysiological processes are diverse and include atherosclerosis of the extracardiac coronary arteries, vasospasm of large or small vessels, and microvascular dysfunction - clinical relevance is increasingly appreciated. Myocardial ischemia can have a variety of clinical manifestations, all of which are expressed as chronic coronary syndromes. The most common anti-anginal drugs relieve symptoms by dilating coronary vessels and modulating factors that determine myocardial oxygen consumption: heart rate, myocardial wall stress, and ventricle contractility. Alternatively, cardiac substrate metabolism can be altered to alleviate ischemia by modulating myocardial oxygen utilization efficiency. Although there is general agreement on the prognostic importance of lifestyle and event prevention interventions with aspirin and statin therapy, the optimal treatment for patients with chronic coronary syndromes has not been established and clearly defined. The ESC’s 2019 guidelines recommend an individualized approach in which anti-anginal drugs are tailored to each patient’s comorbidities and hemodynamic profile. Although no anti-anginal drugs improve survival, their effectiveness for reducing symptoms is profoundly dependent on the underlying mechanism of angina. In this review, we provide clinicians with a rationale for when to use a compound or combination of drugs based on angina pathophysiology and the anti-anginal agents’ mode of action.