Ranolazine: A New Option in the Management of Chronic Stable Angina

Pharmacotherapy for the management of chronic stable angina has not changed much in the past 10-20 years. Although the use of revascularization has increased, beta-blockers, calcium channel blockers, and long-acting nitrates are still widely used in the management of patients with chronic stable angina. Despite the demonstrated effectiveness of these agents, a number of patients do not achieve the American College of Cardiology-American Heart Association goal of freedom from exertional angina attacks. For the first time in more than a decade, a new agent, ranolazine, is available to assist in controlling exertional angina. Ranolazine has a novel mechanism of action of inhibiting the late sodium current during ventricular depolarization. This mechanism contributes to a reduction in intracellular sodium and, therefore, a reduction in intracellular calcium, reducing ischemic injury. Unlike currently available pharmacotherapy for chronic stable angina, ranolazine does not produce clinically meaningful changes in heart rate or blood pressure. A number of clinical trials have demonstrated the ability of ranolazine to increase exercise tolerance, decrease weekly anginal episodes, and decrease sublingual nitroglycerin consumption for breakthrough angina. Based on the results of these trials, ranolazine recently was approved by the United States Food and Drug Administration for treatment of patients with chronic stable angina. Because of ranolazine's pharmacokinetic and pharmacodynamic profile, pharmacists will have to play a significant role in patient selection and monitoring.