The Role of Long Term Nitrate Therapy in Vasospastic Angina

A 65-year-old female has recently moved to your city and is in your clinic today to establish care with a cardiologist. She has a past medical history of vasospastic angina with non-occlusive coronary artery disease that was diagnosed two and half years ago and she was started on medical therapy. Her other past medical history is significant for hypertension and hyperlipidemia. She is a past smoker and has a 10-pack year smoking history. Her family history is significant for hypertension and diabetes.

At present the patient does not have any symptoms of chest pain, shortness of breath, dizziness, palpitations, pedal edema, orthopnea or PND. In the past, she was having symptoms of chest pain that was unrelated to exertion almost on a daily basis. Her last angina event was about two years ago. Her previous cardiologist had started her on metoprolol tartrate 25 mg twice a day, amlodipine 10 mg daily, isosorbide mononitrate 120 mg daily, Aspirin 81 mg daily and Atorvastatin 40 mg daily. She has been religiously taking her medications, exercises for about 30 minutes every day and eats a healthy diet.

On physical examination, her heart rate is 62 beats/min, regular rhythm and blood pressure is 108/62 mm Hg. Her cardiovascular examination is unremarkable. She had her fasting lipid profile done and it shows a total cholesterol of 120 mg/dl, HDL of 54 mg/dl and LDL of 48 mg/dl. EKG done today shows normal sinus rhythm and there are non-specific ST-T wave changes in the anterior leads and this is unchanged from her previous ekg tracing. The results of an echocardiogram done two years ago shows the ejection fraction to be in the range of 60-65%, with trace mitral regurgitation and normal diastolic function.

What changes in therapy would you like to recommend to this patient today?

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