Management of pain

Abstract

Management of patients with persistent angina and no obstructive coronary artery disease continues to be a challenging area. Currently, pharmacotherapy used in patients with microvascular coronary dysfunction (MCD) is targeted at their underlying mechanism for pain. Therapies used in patients with coronary artery disease such as nitrates, β-blockers, calcium channel blockers, and statins have also been found to be beneficial in those with MCD. Other agents found to have promising effects on anginal symptoms includes ranolazine and angiotensin converting enzyme inhibitors. Hormone therapy in women with MCD improves quality of life, although improvement in myocardial ischemia remains to be determined. In patients with cardiac syndrome X, small trials have been performed showing either beneficial or indeterminate results with the use of other pharmacologic agents such as tricyclic medications, L-arginine, xanthine derivatives, n-3 polyunsaturated fatty acids, nicorandil, and trimetazidine. Non-pharmacologic therapies in the management of chronic angina also play an important role. Lifestyle modification, exercise, and cognitive behavioral therapy have shown to improve angina and exercise capacity in those with MCD. The use of neurostimulation, including transcutaneous electrical nerve stimulation and spinal cord stimulation, can also improve symptoms in those with chronic angina. Incorporating both pharmacologic and non-pharmacological therapies can lead to the effective management of chronic angina in patients with MCD.