Consensus document – The diamond approach to personalised treatment of angina

The management of chronic stable angina encompasses lifestyle modification, control of risk factors for coronary artery disease, and both invasive and noninvasive treatment. Pharmacological therapy has two main goals: firstly to alleviate symptoms, increase angina-free walking time, and improve quality of life; and secondly to prevent cardiovascular events, mainly myocardial infarction and death.
Regarding the pharmacological management, the clinical guidelines typically classify drugs for symptomatic angina are as being first choice (β-blockers, calcium-channel blockers, short-acting nitrates) or second choice (ivabradine, nicorandil, ranolazine, trimetazidine).
No direct comparisons between first‐choice and second‐choice treatments have demonstrated the superiority of one group of drugs over the other. Moreover, meta‐analyses show that all antianginal drugs have similar efficacy in reducing symptoms, but provide no evidence for improvement in survival. In addition,
This expert consensus by R. Ferrari et al. propose a different, more individualised approach to angina treatment, according to the patient comorbidities, and to the mechanisms of chronic stable angina. This ‘diamond’ approach will help clinicians to make the best possible therapeutic choices, independently of whether the drugs are first or second choice.
Take-home message: an individualized approach to angina treatment is needed. It should take into consideration the patient, their comorbidities, and the underlying mechanism of disease. The “diamond approach” is useful in clinical practice, in combination with the more recent guidelines.