The aerosol spray has the advantage of a long storage life compared with glyceryl trinitrate tablets, which deteriorate rapidly in their container. With all nitrates, troublesome headache can prevent their use in certain susceptible individuals. They are specifically contraindicated in patients with obstructive airways disease and severe ventricular dysfunction, and relatively contraindicated in diabetes and in those with peripheral vascular disease, bradycardia or heart block. Calcium antagonists Calcium antagonists are certainly effective in angina, achieving their effect by smooth muscle relaxation in the coronary arteries and peripheral circulation, increasing myocardial supply and reducing myocardial work. There is a progression in therapy before medical treatment can really be said to have failed.
Most patients begin treatment with nitrates and a beta-blocker or a calcium antagonist.
Surgical treatment of angina Effective surgical treatment has had a marked effect on the management of IHD in the developed world. Significant results has been achieved with the use of the internal mammary artery as a graft. Unfortunately, complete cardiac revascularisation is not often possible even when both internal mammary arteries are used. Survival is improved by surgery in those with left main stem disease and those with three vessel coronary disease and impaired left ventricular function. It is very likelty to improve survival in patients with severe angina, three vessel coronary disease and normal ventricular function.