Chronic stable angina pectoris. Strategies for effective drug therapy.

In most patients with stable angina pectoris, severe eccentric atherosclerotic narrowing of coronary arteries is responsible for chest pain and myocardial ischemia. If myocardial infarction or death occurs, it is usually the consequence of a ruptured plaque. About 10% to 20% of patients with stable angina have normal coronary arteries, and their long-term prognosis is excellent. In patients with angina secondary to atherosclerotic lesions, the annual mortality rate is 1.6% to 3.2%; prognosis is determined by systolic left ventricular function and the extent of coronary artery disease. Patients can be stratified into low- and high-risk groups by medical history, left ventricular function at rest, and results of physical examination and stress testing. Coronary angiography should be reserved for high-risk patients. Risk-factor modification and appropriate use of antianginal drugs are successful in most patients, but those who fail to respond should be considered for angioplasty or coronary bypass surgery; patients with left main coronary artery disease or three-vessel disease and poor left ventricular function should be considered for coronary artery bypass surgery.