A 62-year-old man with chronic stable angina continues to have exertional chest pain despite maximum tolerated doses of metoprolol and amlodipine. His resting heart rate is 58 per minute and blood pressure is 104/66 mmHg. Which of the following drugs can be added for angina relief WITHOUT further reducing his heart rate or blood pressure?

• A Ivabradine
• B Nicorandil
• C Isosorbide mononitrate
• D Ranolazine ✓

Explanation

Ranolazine inhibits the late inward sodium current, indirectly reducing intracellular calcium overload in ischemic myocardium. It exerts an antianginal effect with no clinically significant effect on heart rate or blood pressure, making it ideal when bradycardia or hypotension limits other therapy. Ivabradine slows the sinus rate by blocking the If current in the SA node, while nitrates and nicorandil are vasodilators that would worsen this patient's borderline blood pressure.

Reference: Katzung's Basic and Clinical Pharmacology, 15th ed.

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Written and medically reviewed by the StethoPrep medical team.