AKT · Cardiovascular/Coronary & ischaemic

Stable angina (ischaemic heart disease)

Fixed coronary atheroma → demand-led myocardial ischaemia

Overview

Chest pain caused by reversible myocardial ischaemia from fixed coronary artery atheroma — pain on exertion, relieved by rest or GTN. Diagnosis rests on the classic triad and is confirmed with CT coronary angiography (NICE first-line). Managed with secondary prevention (antiplatelet + statin), an anti-anginal (beta-blocker or CCB first-line), and revascularisation for refractory symptoms.

Recognise

Constricting central chest discomfort, may radiate to jaw/arm, brought on by exertion/emotion and RELIEVED by rest or GTN within minutes
Typical angina = all 3 features; atypical = 2; non-anginal = ≤1
Risk factors: smoking, diabetes, hypertension, hyperlipidaemia, family history; signs of vascular disease

Red flags

Pain at rest, crescendo pattern, or lasting >15 min with sweating/nausea → suspect ACS, not stable angina → troponin + ECG
New angina with severe symptoms or LV dysfunction → urgent cardiology

Differentials & how to tell them apart

Acute coronary syndromepain at rest/prolonged, dynamic ECG/troponin rise

GORD / oesophageal spasmrelation to food/posture, acid taste, responds to PPI

Pericarditispleuritic, positional, relieved sitting forward, diffuse saddle ST elevation

Musculoskeletal / costochondritisreproducible on palpation, localised

Investigations

CT coronary angiography is NICE first-line for diagnosing stable angina. Resting 12-lead ECG (often normal; may show prior MI/LVH). FBC (anaemia), lipids, HbA1c, TFTs, U&Es. Functional imaging (stress echo/perfusion MRI) or invasive angiography if CTCA inconclusive or revascularisation considered.

Management

GTN + aspirin + statin; beta-blocker or rate-limiting CCB first-line anti-anginal

1Confirm with CT coronary angiography. Start GTN PRN, aspirin 75 mg and a high-intensity statin, and address risk factors. First anti-anginal = beta-blocker OR rate-limiting CCB.Gate: If a CCB is combined with a beta-blocker, it MUST be a dihydropyridine (amlodipine) — verapamil or diltiazem + beta-blocker risks complete heart block and severe bradycardia.
2If symptoms persist, use a beta-blocker + dihydropyridine CCB; then add a long-acting nitrate, ivabradine, nicorandil or ranolazine.Gate: If symptoms remain limiting despite optimal medical therapy → coronary angiography for revascularisation (PCI vs CABG).
3Revascularise: PCI for focal disease; CABG for left-main/triple-vessel or diabetes with multivessel disease.

GTN spray (PRN) + secondary prevention: aspirin 75 mg + high-intensity statin (atorvastatin) — all patients; GTN for symptom relief and pre-emptive use; treat hypertension/diabetes

First-line anti-anginal: beta-blocker OR rate-limiting calcium-channel blocker — if CCB monotherapy use a rate-limiter (verapamil/diltiazem); if combining with a beta-blocker use a dihydropyridine (amlodipine) — never verapamil + beta-blocker

Add long-acting nitrate / ivabradine / nicorandil / ranolazine — if symptoms persist on two agents or one not tolerated

Revascularisation (PCI or CABG) — for symptoms refractory to optimal medical therapy; CABG favoured in left-main/triple-vessel disease, especially with diabetes/LV dysfunction

Key points

Exertional constricting chest pain relieved by rest/GTN = stable angina → CTCA to confirm, aspirin + statin for everyone, beta-blocker or rate-limiting CCB first. Never combine verapamil/diltiazem with a beta-blocker.

Monitor & prognosis

Symptom frequency/GTN use; BP, lipids, HbA1c; review anti-anginal tolerability.

Good with risk-factor control; angina marks coronary disease that can progress to ACS.

Source: NICE CG126 (stable angina); NG238 (CVD risk)