Stable angina: drugs, angioplasty or surgery?

Stable angina is a common condition with a good overall prognosis and annual mortality is 2-4%, whatever treatment is employed. Medical therapy with nitrates, beta-blockers, calcium antagonists and lipid-lowering agents is appropriate as first-line therapy in those patients not specifically identified as being at risk by exercise testing and/or angiography. Dosage should be optimized. Coronary artery bypass grafting appears to improve prognosis in those at risk when compared with medical therapy but the trials are old and do not take into account major advances in medical therapy nor the use of arterial conduits in coronary artery bypass grafting (CABG). Percutaneous transluminal coronary angioplasty (PTCA) relieves symptoms when medical therapy is ineffective but its role as an initial therapy has not been established, nor does it compare favourably with CABG with regard to the degree of revascularization and subsequent re-intervention or need for additional anti-anginal drugs. There are little substantial data on prognostic effects. PTCA is, however, less traumatic, less expensive and associated with a quicker recovery than CABG, providing a viable alternative for symptomatic (not prognostic) benefit in appropriately selected and informed patients. Medical therapy, PTCA and CABG should not be seen as competitive but complementary strategies. Optimal utilization of all three treatment modalities, either alone or in combination, can provide substantial symptomatic relief for the angina patient.