A 69-year-old man with a history of coronary artery disease comes to the office with chest pain on moderate exertion. Over the last year, he has experienced pressure-like chest pain when walking at a fast pace or climbing stairs. He thinks this affects his quality of life as he has to stop to rest and take sublingual nitroglycerin each time. The patient has no shortness of breath, lightheadedness, syncope, or lower extremity swelling. He underwent coronary artery bypass surgery 8 years ago and has had 2 percutaneous coronary interventions over the last 2 years. Current medications include metoprolol succinate, amlodipine, lisinopril, extended-release isosorbide mononitrate, aspirin, clopidogrel, high-intensity rosuvastatin, and sublingual nitroglycerin as needed. He stopped smoking 10 years ago and does not drink alcohol.
Blood pressure is 105/65 mm Hg and pulse is 55/min. The lungs are clear on auscultation. ECG shows normal sinus rhythm with T-wave inversion in leads III and aVF and a QTc interval of 410 msec. His last serum creatinine was 0.8 mg/dL and LDL cholesterol level was 68 mg/dL. Echocardiogram shows apical hypokinesis with left ventricular ejection fraction of 55%. Myocardial perfusion imaging reveals moderate ischemia of the inferior wall. Coronary angiography shows no intervenable lesions.
Which of the following is the best next step in management of this patient's symptoms?

Question

A 69-year-old man with a history of coronary artery disease comes to the office with chest pain on moderate exertion.  Over the last year, he has experienced pressure-like chest pain when walking at a fast pace or climbing stairs.  He thinks this affects his quality of life as he has to stop to rest and take sublingual nitroglycerin each time.  The patient has no shortness of breath, lightheadedness, syncope, or lower extremity swelling.  He underwent coronary artery bypass surgery 8 years ago and has had 2 percutaneous coronary interventions over the last 2 years.  Current medications include metoprolol succinate, amlodipine, lisinopril, extended-release isosorbide mononitrate, aspirin, clopidogrel, high-intensity rosuvastatin, and sublingual nitroglycerin as needed.  He stopped smoking 10 years ago and does not drink alcohol.
Blood pressure is 105/65 mm Hg and pulse is 55/min.  The lungs are clear on auscultation.  ECG shows normal sinus rhythm with T-wave inversion in leads III and aVF and a QTc interval of 410 msec.  His last serum creatinine was 0.8 mg/dL and LDL cholesterol level was 68 mg/dL.  Echocardiogram shows apical hypokinesis with left ventricular ejection fraction of 55%.  Myocardial perfusion imaging reveals moderate ischemia of the inferior wall.  Coronary angiography shows no intervenable lesions.
Which of the following is the best next step in management of this patient's symptoms?

Quizplus · Accepted Answer

11ec193a_976d_68dd_853d_ef1f8bf5f70c_MD0002_00 This patient continues to have activity-limiting chronic stable angina despite optimal medical therapy and coronary revascularization. When initial treatment is unsuccessful in relieving anginal symptoms, the addition of ranolazine may be used as a substitute for or in combination with beta blockers and other antianginal therapies. Ranolazine is a late sodium channel blocker that causes decreased influx of calcium into cardiomyocytes, resulting in lower ventricular wall tension and reduced myocardial oxygen consumption. This drug has the advantage of decreasing the frequency and severity of anginal symptoms and improving overall exercise capacity without significantly affecting heart rate or blood pressure. However, ranolazine has not been shown to improve other cardiovascular outcomes, including mortality and incidence of myocardial infarction. (Choice A) This patient is already taking a calcium channel blocker (amlodipine), and the addition of another agent from a similar class (eg, diltiazem, verapamil, felodipine) is not indicated. (Choice C) Although ACE inhibitors and angiotensin-receptor blockers reduce myocardial oxygen consumption by decreasing afterload, their overall effect on improving anginal pain is small. Furthermore, the addition of an angiotensin receptor blocker (eg, valsartan) to an ACE inhibitor (eg, lisinopril) is not typically recommended due to limited additional benefit and risk of side effects (eg, hyperkalemia, hypotension). (Choice D) Beta blockers are the preferred first-line therapy for patients with stable angina because beta blockers, unlike calcium channel blockers, improve long-term survival in patients with prior myocardial infarction or left ventricular systolic dysfunction. Discontinuing metoprolol and starting diltiazem is not indicated in the absence of beta blocker intolerance. (Choice E) Long-acting nitrates (eg, isosorbide mononitrate) are effective in improving chronic stable angina symptoms; however, long-term use is limited by the development of nitrate tolerance. Extended-release isosorbide mononitrate is typically dosed once daily; increasing to twice daily is unlikely to provide significant benefit. Educational objective: Ranolazine decreases myocardial oxygen consumption and provides effective treatment for chronic stable angina without significantly affecting heart rate or blood pressure. It may be used as a substitute for or in combination with beta blockers and other antianginal therapies when initial treatment is unsuccessful in relieving chronic stable angina. __________ References: Ranolazine: a review of its use as add-on therapy in patients with chronic stable angina pectoris. (http://www.ncbi.nlm.nih.gov/pubmed/23329466) 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. (http://www.ncbi.nlm.nih.gov/pubmed/23166211) 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary disease of the European Society of Cardiology. (http://www.ncbi.nlm.nih.gov/pubmed/23996286)

A 69-Year-Old Man with a History of Coronary Artery Disease