Stable angina management and pharmacotherapy varies widely despite the longstanding availability of several drug classes. We herein review current angina management strategies through the lens of optimal medical therapy (OMT), while highlighting emerging therapies and the growing clinical significance of coronary microvascular dysfunction (CMD). This narrative review synthesizes findings from existing research and key clinical trials to outline both established and evolving treatment approaches for chronic stable angina. Beta-blockers and calcium channel blockers remain the foundation of symptom management, while nitrates, ranolazine, ivabradine, and trimetazidine may be considered for refractory symptoms. Few novel pharmacologic therapies have emerged in recent decades, underscoring a critical need for innovation-particularly in the treatment of CMD, which is increasingly recognized as a distinct pathophysiologic entity requiring targeted therapy. Advances in invasive coronary function testing have improved diagnostic accuracy for CMD, yet consensus on optimal treatment remains elusive. Emerging interventional strategies and stem cell-based interventions show promise for patients with refractory angina who lack further revascularization options. The limited progress in novel pharmacologic development reinforces the need for ongoing research to refine therapeutic strategies for CMD and expand treatment options for patients with treatment-resistant angina.
© 2025. The Author(s).