Pharmacology  ·  Cardiovascular

Drug Selection and Combination Strategies

Synthesizing the chapter — two goals, combination logic, and subtype-specific first-line choices

• Antianginal therapy pursues two separate goals: symptom control, served by nitrates, beta-blockers, calcium channel blockers, ranolazine, and ivabradine; and cardioprotection, served by aspirin, statins, and beta-blockers post-infarction — most antianginal drugs address only the first goal, not both.
• The standard combination escalation begins with a beta-blocker, which addresses two hemodynamic levers and often provides cardioprotection; a long-acting dihydropyridine is the preferred second agent, since its mechanisms complement rather than duplicate the beta-blocker's effects.
• When symptoms persist on combination hemodynamic therapy, ranolazine or ivabradine can be added without compounding bradycardia or hypotension, since their mechanisms do not overlap with the drugs already in use.
• Vasospastic angina reverses the usual strategy: calcium channel blockers are first-line because they counteract the calcium-mediated coronary spasm directly; beta-blockers are contraindicated in all subtypes of vasospastic angina because they leave alpha-1 vasoconstriction unopposed.
• Microvascular angina has no single best agent — the impaired small-vessel dilation is less well understood than epicardial spasm, and response to beta-blockers and calcium channel blockers varies considerably between patients.