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Long-Term Angina Therapy

Long-term treatment for angina often involves aspirin therapy. Aspirin makes platelets less "sticky," decreasing the chances of blood clot formation. One 75 to 325 mg coated tablet daily is the typical dosage for chronic stable angina and unstable angina.

Studies have shown that some patients are resistant to the effects of aspirin therapy. Regular blood tests may be performed to monitor the patient's response; the results of these tests can be used to adjust the aspirin dosage or change the medication.

Clopedigrol (Plavix®), which is slightly more potent than aspirin, is considered a long-term alternative to aspirin therapy. Clopedigrol is usually taken in a dose of one 75 mg tablet daily.

Nitrates (nitroglycerin) are used to relieve angina and prevent the onset of angina when physical or emotional stress is anticipated. They dilate (open up) the coronary arteries and veins, which may increase blood flow to the heart, particularly the area receiving an insufficient blood supply.

Nitrates usually are administered as a small pill placed under the tongue, where it quickly dissolves and is absorbed into the bloodstream. Isosorbide dinitrate (Isordil®) is usually taken 3 times a day; isosorbide mononitrate (Ismo®, Imdur®) is taken either twice a day or once daily.

The most common side effects of nitrates are headache and flushing. In most cases, the headaches are not severe and occur less frequently or resolve over time. Some patients find the headaches intolerable and decrease the dosage or discontinue taking the drug.

Because tolerance to nitrates can develop quickly, combination therapy of a nitrate and a beta blocker or calcium channel blocker is commonly prescribed.

Beta blockers slow the rate at which the heart beats and weaken the contractions of the heart's chambers. This reduces strain on the heart and its need for oxygen.

Beta blockers commonly used include atenolol (Tenormin®), metoprolol (Lopressor®, Toprol XL®), nadolol (Corgard®), and propranolol (Inderal®). Most of these medications are taken once or twice daily.

Side effects (e.g., fatigue, dizziness) usually are mild and transient. The primary risk is reduced ability of heart muscle to contract and pump blood to the lungs for re-oxygenation (cardiac depression).

Calcium channel blockers dilate coronary arteries and veins, which increases blood flow to the heart. This allows the heart to pump blood more easily and decreases strain on the heart. Calcium channel blockers used to treat angina include nifedipine (Adalat®), diltiazem (Cardizem®), verapamil (Calan®, Covera®, Isoptin®, Veralan®).

Side effects include headaches, flushing, dizziness, and swelling (edema). Constipation has been associated with verapamil, especially in elderly patients.

Warfarin (Coumadin®) is an anticoagulant that is prescribed for patients who have a history of or are at risk for formation of blood clots (thrombosis).

Cholesterol-reduction therapy reduces the level of "bad" (LDL) cholesterol in the blood using medications called statins: atorvastatin (Lipitor®), cerivastatin (Baycol®), fluvastatin (Lescol®), lovastatin (Mevacor®), pravastatin (Pravachol®), and simvastatin (Zocor®).

Side effects are rare and include inflammation of the liver, and muscle pain and inflammation.

Underlying conditions associated with ischemic heart disease and angina, such as diabetes mellitus and hypertension, should be treated and closely monitored.

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