p.63 抽出テキスト

............................................................... presence and extent of CAD and evaluate the potential indication for revascularization (see section 4.3).5

12.2.1 Medical therapy Beta-blockers are the mainstay of therapy in patients with HFrEF and CAD because of their prognostic benefit.116120,568 Ivabradine should be considered as an alternative to beta-blockers (when contraindicated) or as additional anti-anginal therapy in patients in SR whose heart rate is >_70 b.p.m.139,569 Other anti-anginal drugs (e.g. amlodipine, felodipine, nicorandil, ranolazine, and oral or transdermal nitrates) are effective for treating symptoms, although data about their effects on outcomes are neutral or lacking.5,570574 Trimetazidine seems to have additive effects, such as improvement of LV function and exercise capacity, in patients with HFrEF and CCS already on beta-blockers.575577 Trimetazidine and other anti-anginal drugs may be considered in patients with HF and angina despite beta-blocker and/or ivabradine. Short-acting nitrates should be used with caution in patients with HF as they cause hypotension. Diltiazem and verapamil increase HF-related events in patients with HFrEF and are contraindicated.578 An algorithm for the use of anti-anginal medications in patients with HFrEF is reported in Figure 15. Beta-blockers, long-acting nitrates, calcium channel blockers (CCBs), ivabradine, ranolazine, trimetazidine, nicorandil and their combinations should be considered in HFpEF for angina relief but without a foreseen benefit on HF and coronary end points.

Low-dose of rivaroxaban [2.5 mg twice daily (b.i.d.)] did not add prognostic benefit in patients with HFrEF and CCS in the COMMANDER-HF trial, a study to assess the effectiveness and safety of rivaroxaban in reducing the risk of death, MI or stroke in participants with HF and CAD following an episode of decompensated HF.579 This trial included patients with HFrEF and a recent episode of worsening HF occurring within 21 days from the time of enrolment. These patients are at high risk of HF-related events and these were the main cause of deaths and hospitalizations in the trial. Rivaroxaban had no effect on these events. In contrast, in a non-pre-specified subgroup analysis of the COMPASS trial, low dose of rivaroxaban, on top of aspirin, was associated with a reduction in ischaemic events in patients with HF, mainly HFmrEF or HFpEF.580 Based on these data, low-dose rivaroxaban may be considered in patients with CAD (or peripheral artery disease) and

Use of anti-anginal medications in patients with CCS and HFrEF

Beta-blockers

(Class I)

Persistence of CCS symptoms

In absence of improvement Trimetazidine

(Class IIb)

Nicorandil (Class IIb) OR

OR

OR

Felopidine (Class IIb) Ranolazine

(Class IIb)

Nitrates (Class IIb)

Amlodipine (Class IIb)

Ivabradine (Class IIa) HR <70 bpm, and/or

atrial fibrillation HR ≥70 bpm, and

sinus rhythm

Diltiazem (Class III)

Verapamil (Class III)

Figure 15 Algorithm for the medical treatment of chronic coronary syndrome in patients with heart failure with reduced ejection fraction. CCS = chronic coronary syndrome; HFrEF= heart failure with reduced ejection fraction; HR= heart rate. Colour code for classes of recommendation: Green for Class of recommendation I; Yellow for Class of recommendation IIa; Orange for Class of recommendation IIb; Red for Class of recommendation III (see Table 1 for further details on classes of recommendation). Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026