Anti-ischaemic medication must be adapted to each patient’s characteristics and preferences in patients with chronic coronary syndromes

This commentary refers to ‘Beta blockers, calcium channel blockers, and long-acting nitrates for patients with stable angina and low blood pressure levels: should this recommendation be reconsidered?’, by M.S. Kallistratos et al., on page 479. Kallistratos et al.1 appropriately highlight that managing patients with chronic coronary syndromes (CCS) and low blood pressure (BP) are very difficult in practice. In figure 8 of the 2019 CCS guideline,2 the Task Force suggested a stepwise approach for long-term anti-ischaemic drug therapy in patients with CCS and five baseline characteristics and emphasized that ‘the strategy must be adapted to each patient’s characteristics and preferences, and does not necessarily follow the steps indicated in the figure’. Given the limited evidence on various combinations of drugs in different clinical conditions, the proposed options are only indicative of potential combinations and do not represent formal recommendations (Figure 1). The updated figure about anti-ischaemic medication in the 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes.2 The guideline also included a recommendation table on anti-ischaemic drugs. The task force could not find evidence-based recommendations for the management of CCS patients with low BP as indicated by the ‘C’ level of evidence for the recommendation regarding prescription of ranolazine or trimetazidine in patients with low BP and low heart rate. For the management of patients with low BP, it is stated that: ‘A low-dose beta-blocker or low-dose non-Dihydropyridine-Calcium channel blocker (non-DHP-CCB) can be tested first under close monitoring of tolerance. Ivabradine (in patients with sinus rhythm), ranolazine, or trimetazidine can also be used’. A Question & Answer document was added to the ESC Guideline website to clarify this and other issues. Although this has not been tested, Kallistratos et al. are correct in suggesting that, even at low doses, β-blockers, non-dihydropyridine calcium channel blockers, and nitrates may further lower BP in CCS patients with low BP and not exert an antianginal effect. Hence, the cautious approach is suggested in figure 8 of the CCS guideline. It should be remembered that the decrease in BP with antihypertensive drugs is influenced by baseline BP and is less pronounced or absent in normotensive subjects.3 Beta blockers have been used successfully in patients with heart failure and low BP although management of low BP in those patients does limit the prescription of β blockers. Prescription of ranolazine, ivabradine, or trimetazidine as a first step in symptomatic CCS patients with low BP is indeed a possible choice but the task force took into consideration the warnings that the European Medicine Agency has made on ranolazine,4 ivabradine,5 and trimetazidine6 emphasizing their use after testing other antianginal drugs. Conflict of interest: J.K. has received speaker fees from GE Healthcare and Lundbeck and fees for study protocol review from GE Healthcare and AstraZeneca. W.W. has received Institutional grants from MicroPort and Terumo (to former institution) and speaker fee and honoraria from Biortonik, MicroPort Co-founder Argonauts, an innovation facilitator, Cardiology Advisor Rede Optimus Research C.F-B. has nothing to declare.