Management Options in chronic stable Angina pectoris: Focus on Ranolazine

Chronic stable angina pectoris results from a fixed coronary arterial obstruction causing an imbalance between myocardial oxygen supply and demand. Current therapy aims to reduce cardiovascular events (vasculoprotective) thereby improving survival, and/or relieve ischemic symptoms (antianginal) thereby improving the quality of life. Vasculoprotective therapy consists of lifestyle
modification, antiplatelet agents, lipid lowering therapy and angiotensin-converting enzyme (ACE) inhibitors. Conventional antianginal  therapy  for  patients  with  chronic  stable  angina  consists  of  beta-blockers,  calcium  channel  blockers  and  nitrates,  with  surgical  or  percutaneous revascularization serving an adjunctive role. Despite the investigation of multiple novel therapies and medications over  the past 25 years, arguably the most significant contribution to antianginal therapy during that time involved the recent introduction of  ranolazine. Ranolazine acts via a distinctive pathway, inhibiting the late sodium current of the action potential in ischemic myocytes.
Multiple  studies  have  demonstrated  that  ranolazine  significantly  reduces  anginal  symptoms  and  improves  exercise  performance   in patients with chronic stable angina but does not reduce mortality. Ranolazine does not affect either heart rate or blood pressure,  a unique property among the current antianginal agents. Despite its QT prolongation, ranolazine has a proven safety profile and is not  proarrhythmic. In fact, in a recent large randomized trial, ranolazine reduced the incidence of supraventricular tachycardia, ventricular  tachycardia, new-onset atrial fibrillation and bradycardic events. Ranolazine may confer some additional benefits such as a reduction in HbA1c levels and improved left ventricular diastolic function. Ranolazine is now approved for use in chronic stable angina. Current guidelines recommend beta-blockers as the first line antianginal agent due to the proven mortality reduction. However, for patients with bradycardia or hypotension, ranolazine may be considered as initial antianginal therapy.
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