6 cases spanning antianginal drug selection and escalation in chronic and refractory angina.
A single patient, symptomatic on two anti-anginal agents already at target dose. The disagreement isn't about which add-on works best on paper — it's about a six-year-old prescription, for something else entirely, that has quietly taken the guideline-preferred answer off the table.
Two guideline-level cautions apply to the same patient in opposite directions: the calcium channel blockers best studied for coronary spasm are classified as harmful at her ejection fraction by current heart failure guidance, and the beta-blocker she was about to start carries an older warning against use in spasm. Neither drug list accounts for the other diagnosis.
A single patient, whose only new symptom is a four-times-repeated twenty minutes of chest tightness at the start of his daily swim. The question isn't whether his nitrate schedule is working — it's whether the guideline-standard gap in that schedule happens to fall exactly when his own coronary risk is highest.
Residual angina on a beta-blocker dose that has already pushed his resting heart rate down to 54. The question isn't whether he needs more anti-anginal therapy — it's whether the next drug should share his current agent's one real limitation or avoid it entirely.
Guidelines treat beta-blockers and calcium channel blockers as interchangeable first steps for stable angina. His resting heart rate of 58, documented and asymptomatic, makes them clearly not interchangeable for him.
A single patient whose case for a third antianginal agent has two genuine benefits attached to it, and the disagreement is about which one should carry more weight in the decision.