A 58-year-old man with a 3-year history of stable angina presents to the outpatient clinic. He is currently on aspirin 75 mg daily and atenolol 50 mg twice daily. He reports 2–3 episodes of chest pain per week, each lasting 5–10 minutes and relieved by rest. On examination, blood pressure is 128/82 mmHg and heart rate is 58 bpm. ECG shows no acute changes. What is the most appropriate next step in management?

Explanation

## Clinical Assessment This patient has **inadequately controlled stable angina** despite monotherapy with a beta-blocker. He experiences 2–3 episodes per week, which indicates the need for optimization of antianginal therapy. ## Management Strategy for Stable Angina **Key Point:** The stepwise approach to stable angina management follows a tiered protocol: 1. First-line: Beta-blocker or rate-limiting calcium channel blocker 2. Second-line: Add a second agent from a different class (calcium channel blocker, long-acting nitrate, or ivabradine) 3. Third-line: Triple therapy or revascularization consideration ## Why Amlodipine Is the Correct Choice **High-Yield:** Amlodipine (a dihydropyridine calcium channel blocker) is the ideal second-line agent because: - It provides **additive antianginal benefit** when combined with beta-blockers - It causes **vasodilation** of coronary and peripheral vessels, reducing myocardial oxygen demand - It has **no negative inotropic effect** (unlike non-dihydropyridines), making it safe with beta-blockers - The patient's heart rate (58 bpm) is already controlled; further beta-blocker escalation risks bradycardia and hypotension **Clinical Pearl:** The combination of a beta-blocker + dihydropyridine calcium channel blocker is synergistic and well-tolerated, addressing both heart rate and vasodilation. ## Differential Consideration | Intervention | Rationale for/against | |---|---| | **Add amlodipine** | ✓ Correct: Second-line agent, different mechanism, safe combination | | **Increase atenolol** | ✗ Already on adequate dose; HR = 58 bpm suggests adequate beta-blockade | | **Nitroglycerin only** | ✗ Addresses acute symptoms but does not prevent recurrent episodes | | **Coronary angiography** | ✗ Premature; patient is stable, no high-risk features; medical optimization first | [cite:Harrison 21e Ch 297]