Treating persistent angina

Q. I'm a 75-year-old Black man who's had coronary artery disease, including two heart attacks and two bypass surgeries in my 40s and 50s. Although I take a number of heart medications (including a statin and a PCSK9 inhibitor), I still have frequent chest pain when I'm walking, especially when I'm climbing stairs. My LDL cholesterol is 61 and my triglycerides are 43. Are there any other treatments that can shrink atherosclerotic plaque? My doctor says I'm not a candidate for a stent.

A. You may be reassured to know that angina (chest pain with exertion or emotional stress) is quite common among people with coronary artery disease.  Your symptoms sound quite severe, although that's not surprising, given your history of heart disease. The good news? There are definitely some other options you can pursue to alleviate your angina.

Even though your doctor says that a stent is not an option, you might want to get a second opinion about whether this procedure may be feasible for you. For complicated situations such as yours, a second opinion is often helpful.

In addition, there are a number of other drug treatments you can try, which fall under two broad strategies. One, as you noted, is to shrink the plaque in your arteries. Your current LDL level is excellent, but lowering that number even further may help. Another cholesterol-lowering drug — either ezetimibe (Zetia) or bempedoic acid (Nexletol) — could be added to your current medications. Another drug, icosapent ethyl (Vascepa) has also been shown to reduce plaque, but only in people who have elevated triglycerides (higher than 150 milligrams per deciliter). Since your triglycerides are normal, it's not clear that this would help.

There are other medications to help decrease the frequency and severity of your symptoms. For example, the calcium-channel blocker diltiazem (Cardizem) can slow down your heart rate (ideally to around 60 beats per minute), and a long-acting nitrate such as isosorbide (Isordil) helps dilate your coronary arteries. Another drug called ranolazine (Ranexa) that works on the metabolism of heart cells can be added if your heart rate and blood pressure are already well controlled.

Finally, you might want to ask your doctor about colchicine (Lodoco). This anti-inflammatory drug has long been used to treat a form of arthritis called gout. But a lower dose has been shown to prevent heart attacks in people with coronary artery disease.

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