The prevalence of chronic coronary syndromes and angina has been increasing due to the increase in the numbers of elderly people, life expectancy and the reduction of mortality in acute coronary syndromes. The pillars of treatment include 1/ healthy life style and control of cardiovascular risk factors in all cases, 2/ coronary revascularization in selected cases and 3/ the appropriate use and selection of antianginal drugs. 

Antianginal drugs are intended to control myocardial ischemia and include nitrates, betablockers, calcium channel blockers, nicorandil, ivabradine, trimetazidine and ranolazine. All may be used in clinical practice although the evidence available in contemporary cardiovascular therapy is limited for most of them and some may be harmful in certain clinical settings. That is the case for chronic use of nitrate and for ivabradine.

The selection of antianginal drugs should be based on: 1/ the mechanisms of myocardial ischemia and type of angina in each patient (with or without epicardial coronary stenosis or evidence of microvascular dysfunction), 2/ the hemodynamic profile of the patient and 3/ the patient comorbidities. The figure illustrates the potential best selection of anti-ischemic drugs considering these 3 conditions. The use of 2 simultaneous antianginal drugs is recommended.Ranolazine could be considered in the first choice of drugs in patients with microvascular angina, diabetes and blood pressure or heart rate that limit or contraindicate the use of betablockers or calcium channel blockers.

Jose Lopez-Sendon obtained his doctoral title at the Universidad Autonoma de Madrid. He has been the chair of the cardiology department of La Paz University Hospital in Madrid, professor of Cardiology and director of the IdiPaz Research Institute.He participated in numerous clinical research program; has published over 1000 articles in medical journals, and has been a member of different task forces for guidelines in acute coronary syndromes, heart failure and angina.He is a Foundation Fellow of the European Society of Cardiology and Fellow of the American College of Cardiology. He continues actively working in teaching and research programs with different international research organizations as Emeritus Professor at the Universidad Autonoma in Madrid.