What is a second-line treatment for angina if first-line agents are ineffective?

Ranolazine is recognized as a second-line treatment for angina when first-line agents, such as beta-blockers and calcium channel blockers, do not provide adequate relief. It works differently from traditional antianginal agents by inhibiting the late sodium current in cardiac myocytes, which helps to reduce myocardial oxygen demand and improve exercise tolerance. This unique mechanism makes ranolazine effective for patients whose angina persists despite the use of other medications.

In contrast, atenolol, diltiazem, and nitroglycerin are primarily first-line treatments for angina. Atenolol, a beta-blocker, reduces heart rate and myocardial contractility, thus lowering oxygen demand. Diltiazem is a calcium channel blocker that dilates coronary arteries and reduces heart workload. Nitroglycerin, which can be used for immediate relief or as a preventive measure due to its vasodilatory properties, is also often one of the first choices for angina management.

Because ranolazine is typically used when other options are not effective, it holds a specific place in treating chronic stable angina where traditional therapies fall short.