Stable Angina

Rapid Review·Cardiovascular

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Coronary Artery Disease

T1Must know

Focus on

Predictable chest pressure on exertion from a fixed coronary plaque. Confirm it with pretest probability and a stress test, relieve attacks with nitroglycerin, prevent them with a beta blocker, and protect life with aspirin, a statin and risk-factor control. Revascularize only for refractory symptoms or high-risk anatomy.

Key takeaways

What it is and who gets it

Coronary artery disease (CAD)

ischemic heart disease caused by atherosclerotic change in the coronary arteries.

It is generally silent until the plaque narrows the lumen by more than 75 percent.

Stable angina is the symptom of a fixed plaque

on exertion, oxygen demand exceeds what the narrowed artery can supply.

Plaque rupture with thrombus is a different disease (Acute Coronary Syndrome).
Spasm without plaque is Vasospastic Angina.

Smoking is the strongest risk factor

the others add up.

Obesity, dyslipidemia, hypertension, diabetes, chronic kidney disease (CKD).
Male sex, and age over 45 in men or over 55 (or post-menopause) in women.
Family history of premature CAD: a first-degree relative with CAD before 55 (male) or before 65 (female).

CAD equivalents are treated as if CAD is already present

diabetes mellitus, CKD, and non-coronary atherosclerosis (Peripheral Artery Disease, Carotid Artery Stenosis, Abdominal Aortic Aneurysm).

Clinical features

Exertional chest pain

comes on with exertion and is relieved by rest or nitroglycerin.

Pain can show in NBME as feeling pressure on the chest.

Three criteria define typical angina

count how many the pain meets.

Location and quality: substernal, diffuse pressure or squeezing.
Trigger: brought on by exertion or intense emotion.
Relief: relieved by rest or nitroglycerin.
Typical angina meets all three, atypical meets two, and non-cardiac chest pain meets one or none.

Atypical presentation

diabetics, the elderly and women may have silent ischemia.

In acute coronary syndrome (ACS) the pain may be absent or replaced by autonomic symptoms (nausea, diaphoresis).
Silent angina is also seen in patients with frequent repeated attacks.

Diagnosis and pretest probability

The diagnosis is clinical

classic symptoms plus risk factors.

Resting electrocardiogram (ECG) first

it is the best initial test and is done for every symptomatic patient.

It is usually normal or non-specific between attacks.

What this shows

Evaluation of stable chest pain by pretest probability of coronary artery disease. Low: no further testing. High: start drug therapy for CAD and refer for expert evaluation. Intermediate: if the patient can exercise and the ECG is normal, an exercise ECG test; if the ECG is abnormal, an exercise imaging test; if the patient cannot exercise, a pharmacologic stress imaging test. Any positive test leads to coronary angiography.

Then estimate the pretest probability

from age, sex and how typical the pain is.

Pretest probability decides the test
Probability	Clinical scenario	Next step
Low	Asymptomatic people of any age; atypical chest pain in a woman under 50	No additional testing
Intermediate	Men with atypical angina (any age); women with atypical angina over 50; women with typical angina aged 30 to 50	Stress test, or coronary computed tomography angiography (CCTA)
High	Typical angina in men aged 40 or more, or women aged 60 or more	Start pharmacologic therapy for CAD

A positive stress test or CCTA leads to invasive coronary angiography

the two are different tests.

CCTA is non-invasive.
Coronary angiography is the invasive digital subtraction study, and it is the route to revascularization.

Stress testing

Which stress test to perform

it depends on whether the patient can exercise.

Exercise ECG is first choice if the patient can exercise; echocardiography or nuclear perfusion imaging can be added.
Pharmacologic stress if the patient cannot exercise: a vasodilator (dipyridamole, adenosine, regadenoson) or dobutamine, always with imaging.

Two mechanisms

exercise and dobutamine work by raising oxygen demand; vasodilators work by coronary steal, dilating normal vessels more than diseased ones.

Hold before the test

some drugs blunt the result.

Beta blockers, calcium-channel blockers and nitrates.
Caffeine and other methylxanthines for 12 hours, and dipyridamole for 48 hours, before a vasodilator test.

What this shows

Reversible myocardial perfusion defect: tracer uptake falls in one wall during stress (top row) but is normal at rest (bottom row), the pattern of inducible ischemia.

Reading the perfusion scan

a technetium-99m tracer (sestamibi or tetrofosmin) enters perfused muscle; rest and stress images are compared.

Normal uptake at rest and stress: no ischemia.
Reversible defect (reduced with stress, normal at rest): inducible ischemia.
Fixed defect (reduced at both): scar.

High-risk stress features go to angiography

ST depression at low workload, a fall in systolic blood pressure, poor capacity, ventricular arrhythmia.

Management

During an attack

sublingual nitroglycerin is first line.

Long term, symptom control

beta blocker is first line.

If beta blockers are contraindicated: a non-dihydropyridine calcium-channel blocker (CCB) or a long-acting nitrate.
Add a CCB or long-acting nitrate if symptoms persist; ranolazine for refractory angina.

Prevent progression

aspirin and a high-intensity statin for every patient with atherosclerotic cardiovascular disease (ASCVD); both reduce mortality.

Control hypertension and diabetes.
Add an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) with hypertension, diabetes, CKD or a left ventricular ejection fraction (LVEF) of 40 percent or less.

Lifestyle

smoking cessation is the most important step, then regular moderate exercise, weight loss and a healthy diet.

The Mediterranean diet (fresh fruit, vegetables, legumes) reduces cardiovascular morbidity and mortality with or without established CAD.

Revascularization

indicated when function stays impaired despite medical therapy, or for high-risk anatomy.

Percutaneous coronary intervention (PCI) is preferred unless coronary artery bypass grafting (CABG) is indicated.
After a stent, dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) for 6 to 12 months, then aspirin for life.

CABG indications

three anatomies.

Three-vessel disease: left anterior descending (LAD), right coronary artery (RCA) and left circumflex (LCx).
Left main stem disease.
Two-vessel disease involving the LAD in a patient with diabetes.

A vasodilator perfusion scan shows reduced tracer uptake in the anterior wall during stress that is normal at rest. What does that mean, and what should the patient have avoided before the test?

A reversible defect means inducible ischemia (a fixed defect would mean scar). Before a vasodilator test the patient should hold caffeine and other methylxanthines for 12 hours and dipyridamole for 48 hours, as well as beta blockers, calcium-channel blockers and nitrates.

How it's tested

A 55-year-old man with typical exertional angina, a normal resting ECG, and able to walk on a treadmill: exercise ECG stress test.

Same man with a baseline LBBB: vasodilator perfusion imaging or stress echocardiography; the exercise ECG is uninterpretable.

A 58-year-old with claudication and no cardiac symptoms: peripheral artery disease is a CAD equivalent; aspirin, a high-intensity statin and smoking cessation now.

Stable angina in a patient with asthma and a heart rate of 52: amlodipine or a long-acting nitrate; a beta blocker and verapamil or diltiazem are both wrong.

Angina persists on a beta blocker and a nitrate; what improves survival: aspirin and the statin already do; revascularization improves survival only for left main, three-vessel or diabetic multivessel disease.

Diabetic with three-vessel disease and an EF of 35 percent: CABG, not multivessel PCI.

A man on sildenafil takes nitroglycerin for chest pain: profound hypotension; the classic contraindication.

Go deeper

Guidelines: 2023 AHA/ACC Chronic Coronary Disease Guideline

Related Step 2 pages: Acute Coronary Syndrome, Vasospastic Angina, Hyperlipidemia, Coronary Artery Bypass Grafting, Approach to Chest Pain, Approach to Stress Testing

High-yield images2

Evaluation of stable chest pain by pretest probability of coronary artery disease. Low: no further testing. High: start drug therapy for CAD and refer for expert evaluation. Intermediate: if the patient can exercise and the ECG is normal, an exercise ECG test; if the ECG is abnormal, an exercise imaging test; if the patient cannot exercise, a pharmacologic stress imaging test. Any positive test leads to coronary angiography.

Reversible myocardial perfusion defect: tracer uptake falls in one wall during stress (top row) but is normal at rest (bottom row), the pattern of inducible ischemia.

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# What is the likely diagnosis in a young patient with a smoking history that presents with episodic chest pain that resolves spontaneously and is associated with transient ST-segment elevation during the episodes?

(...)

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