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With the absence of acidosis, there may be no initial hyperkalemia unless associated renal failure is present This results in less severe total potassium depletion than in diabetic ketoacidosis, and less potassium replacement is therefore needed However, because initial serum potassium is usually not elevated and because it declines rapidly as a result of insulin s effect on driving potassium intracellularly, it has been recommended that potassium replacement be initiated earlier than in ketotic patients, assuming that no renal insufficiency or oliguria is present Potassium chloride (10 mEq/L) can be added to the initial bottle of fluids administered if the patient s serum potassium is not elevated

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because the former, at least, may cause fewer side effects Nifedipine, nicardipine, and amlodipine are also approved agents for angina Isradipine, felodipine, and nisoldipine are not approved for angina but probably are as effective as the other dihydropyridines 6 Ranolazine Ranolazine is the first new antianginal drug to be approved by the FDA in many years It is a novel agent that decreases the late sodium current and thereby decreases intracellular calcium overload Ranolazine has no effect on heart rate and blood pressure, and it has been shown in clinical trials to prolong exercise duration and time to angina, both as monotherapy and when administered with conventional antianginal therapy The usual dose is 500 mg orally twice a day Because it can cause QT prolongation, it is contraindicated in patients with existing QT prolongation; in patients taking QT prolonging drugs, such as class I or III antiarrhythmics (eg, quinidine, dofetilide, sotalol); and in those taking potent and moderate CYP450 3A inhibitors It is also contraindicated in patients with significant liver and renal disease Ranolazine is not to be used for treatment of acute anginal episodes 7 Alternative and combination therapies Patients who do not respond to one class of antianginal medication often respond to another It may, therefore, be worthwhile to use an alternative agent before progressing to combinations If the patient remains symptomatic, a -blocker and a long-acting nitrate or a -blocker and a calcium channel blocker (other than verapamil, where the risk of AV block or heart failure is higher) are the most appropriate combinations A few patients will have a further response to a regimen including all three agents 8 Platelet-inhibiting agents Coronary thrombosis is responsible for most episodes of myocardial infarction and many unstable ischemic syndromes Several studies have demonstrated the benefit of antiplatelet drugs for patients with stable and unstable vascular disease Therefore, unless contraindicated, aspirin (81 325 mg daily) should be prescribed for all patients with angina Clopidogrel is an antiplatelet agent that acts by blocking the ADP receptor and resulting platelet aggregation Unlike its older congener ticlopidine, clopidogrel does not cause agranulocytosis but may rarely induce thrombotic thrombocytopenic purpura Clopidogrel reduces vascular events in patients with stable vascular disease (as an alternative to aspirin) and in patients with acute coronary syndromes (in addition to aspirin) Thus, it is also a good alternative in aspirinintolerant patients 9 Risk reduction As discussed above, patients with coronary disease should undergo aggressive risk factor modification This approach, with a particular focus on statin treatment, treating hypertension, stopping smoking, and exercise and weight control (especially for patients with metabolic syndrome or at risk for diabetes), may markedly improve outcome 10 Revascularization The indications for coronary artery revascularization and the choice of procedure are discussed below.

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