PassFinals
Cardiovascular

Stable Angina

Stable angina is predictable myocardial ischaemic pain from supply-demand mismatch, usually due to atherosclerotic coronary disease; new, worsening or rest pain is an ACS emergency until assessed.

In a nutshell

Stable angina is predictable exertional ischaemic pain. Diagnose through structured history, ECG and CT coronary angiography; treat episodes with GTN, prevent symptoms with beta-blocker or calcium-channel blocker, reduce cardiovascular risk and refer persistent/prognostically important disease for revascularisation.

Classic presentation

Predictable central pressure on exertion, relieved by rest or GTN, sometimes radiating to the arm, jaw or neck.

Key points

  • Stable angina is reproducible with exertion or stress and settles with rest; rest, prolonged or crescendo pain is ACS until proven otherwise.
  • A normal resting ECG does not exclude stable angina, and exercise ECG should not be used alone to diagnose or exclude it.
  • NICE recommends CT coronary angiography for typical or atypical angina unless unsuitable.
  • Offer short-acting nitrate for episodes and before predictable exertion; call an ambulance if pain persists after the second dose and interval.
  • Use a beta-blocker or calcium-channel blocker first line for prevention; choose alternatives according to comorbidity and interactions (see BNF/local protocol for medicines).
  • Statin and cardiovascular-risk management are prognostic; anti-anginal drugs mainly improve symptoms.
  • Persistent symptoms despite treatment or left-main/proximal-three-vessel anatomy warrant cardiology/revascularisation discussion.

First-line investigation

Structured history, resting ECG and CT coronary angiography through the NICE recent-onset chest-pain pathway.

Management

Exclude ACS and emergencies

  • Rest or crescendo pain, prolonged pain, haemodynamic compromise or acute ECG/troponin changes requires emergency ACS assessment.1,2,3

Confirm the stable-chest-pain pathway

  • Use structured history and resting ECG; offer CT coronary angiography for typical or atypical angina unless unsuitable.2,1

Treat episodes and prevent symptoms

  • Offer short-acting nitrate and use a beta-blocker or calcium-channel blocker as first-line regular therapy (see BNF/local protocol for medicines).1,5

Reduce cardiovascular risk

  • Offer statin and address smoking, activity, diet, weight, blood pressure and diabetes; consider aspirin after bleeding-risk assessment.1

Refer persistent or prognostically important disease

  • Discuss cardiology/revascularisation when symptoms persist despite optimal treatment or anatomy includes left-main-stem/proximal three-vessel disease.1

Reassess symptoms and diagnosis

  • Review response and adverse effects; reconsider non-ischaemic causes or microvascular disease if pain persists despite treatment.1,4

Exam traps

  • Stable angina can occur with a normal ECG.
  • Do not call chest pain stable if it is new, worsening, prolonged or occurs at rest.
  • GTN relieves symptoms but does not rule out ACS or prevent infarction.
  • Do not use the age-sex typicality estimate as a substitute for the current CTCA pathway.
  • Ivabradine and nicorandil have important safety cautions; check BNF and interactions.

Illustrations

Supply-demand mismatch in a fixed stenosisDiagram of a fixed coronary stenosis with a graph showing oxygen supply plateauing while demand rises with exertion, crossing an ischaemic threshold.PassFinals · original
Histological cross-section of a coronary artery: an eccentric atherosclerotic plaque narrows the lumen, the pathological basis of the stenosis sought on CT coronary angiography.CT coronary angiography image demonstrating an atherosclerotic narrowing of a coronary artery.Nephron, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. NICE CG126: Stable angina: management (Current recommendations on anti-anginal treatment, secondary prevention and revascularisation)Published 23 Jul 2011 | Updated 25 Aug 2016
  2. NICE CG95: Recent-onset chest pain of suspected cardiac origin (Current diagnostic pathway including CT coronary angiography and ECG)Published 25 Mar 2010 | Updated 30 Nov 2016
  3. NHS: Angina (Symptoms, emergency safety-netting and treatment information)
  4. NICE CKS: Angina (UK primary-care assessment and management topic)
  5. BNF: Glyceryl trinitrate (Current nitrate prescribing and patient-advice information)
  6. BNF: Ivabradine (Current contraindications, interactions and monitoring)
  7. BNF: Nicorandil (Current prescribing and ulceration cautions)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.