Chronic Stable Angina

Richard A. Lange, MD, MBA, FACP
L. David Hillis, MD, FACP
University of Texas Health Science Center, San Antonio, TX

Definition/Key Clinical Features

• A pattern of chest pain or discomfort caused by myocardial ischemia
  • No appreciable change in frequency or severity for ≥ 2 mo
  • Pain is provoked by exertion or stress of similar intensity
  • Relieved by rest or nitroglycerin
• Initial manifestation of coronary heart disease in half of cases; the other half initially experience unstable angina, MI, or sudden death

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Differential Diagnosis

• Nonischemic heart disease
• Arrhythmias (typical or atypical angina)
• Valvular heart disease (typical angina, often exertional)
• Aortic dissection ("tearing" pain, often beginning abruptly)
• Pericarditis (pleuritic pain; relieved by sitting up and leaning forward)
• Pulmonary disease
  • Pulmonary embolus (pleuritic pain; associated dyspnea)
  • Pneumothorax (acute onset, pleuritic pain, associated dyspnea)
  • Pneumonia (pleuritic pain)
• Gastrointestinal disease
• Gastroesophageal reflux (may be indistinguishable from angina)
• Acid peptic disease (may be indistinguishable from angina)
• Biliary disease (RUQ pain that radiates to back or scapula)
• Pancreatitis ("boring" epigastric pain, may radiate to back)
• Chest wall or dermatologic pain (characteristically reproduced with palpation or movement)
• Costochondritis
• Rib fracture
• Sternoclavicular arthritis
• Herpes zoster (pain may precede rash)
• Fibrositis (characteristic point tenderness)
• Psychiatric disorders (may be indistinguishable from angina)
• Anxiety disorders
• Affective disorders (e.g., depression)
• Somatoform disorders
• Thought disorders (e.g., fixed delusions)
• Factitious disorders (e.g., Münchausen syndrome)

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Best Tests

• Patient history
• Use to estimate pretest probability of significant ischemic heart disease (> 70% stenosis of one or more coronary arteries) based on symptom characteristics and risk factors
• Symptoms of typical angina
• Retrosternal pain; may radiate to neck, jaw, shoulder, arms
• Dull, aching, pressurelike in character; difficult to localize precisely
• Typically < 5 min in duration
• Exacerbated by exertion or emotional stress; relieved by rest or nitroglycerin
• May be associated with diaphoresis, nausea, palpitations, light-headedness, dyspnea
• Risk factors
• Older age
• Male gender; for women, status post menopause
• Cigarette smoking
• Abnormal lipids (high LDL, low HDL cholesterol, elevated lipoprotein(a))
• Diabetes mellitus
• Hypertension
• Sedentary lifestyle
• Obesity
• Family history of premature coronary artery disease
• Metabolic syndrome
• Physical examination
• Often normal
• Signs of hypertension
• Elevated blood pressure
• Enlarged or laterally displace point of maximum impulse
• S₄ gallop
• Retinal vascular changes
• Stigmata of genetic dyslipidemia syndromes (e.g., xanthelasma)
• Possible findings during episode of angina
• S₄ or S₃ gallop
• Mitral regurgitation murmur
• Paradoxically split S₂
• Bibasilar crackles
• Chest wall heave
• Resting 12-lead ECG
• ECG normal in 50% of patients with chronic stable angina
• ST depression, T wave inversion, or "pseudonormalization" of these abnormalities during chest pain strongly suggests cardiac ischemia
• Pathologic Q waves strongly suggests ischemic heart disease (IHD)
• Isolated Q waves in lead III or QS pattern in V1 and V2 nonspecific
• Laboratory tests
• Serum hemoglobin
• Fasting glucose
• Fasting lipid panel
• Total cholesterol
• HDL cholesterol
• Triglycerides
• Calculated LDL cholesterol
• Imaging studies
• Chest radiograph or CT if signs or symptoms of the following:
• Congestive heart failure
• Valvular heart disease
• Pericardial disease
• Aortic dissection
• Aortic aneurysm
• Echocardiography or multigated equilibrium radionuclide angiography if suspected left ventricular impairment
• Noninvasive testing
• Objectives
• Ascertain probability of clinically important IHD
• Estimate risk of a serious cardiovascular event (e.g., MI or sudden death)
• Most likely to influence clinical decisions when pretest probability of IHD is intermediate; also useful to assess risk and prognosis when probability is high
• Sensitivity reduced by beta blockade (withhold beta blockers for four half-lives [~ 48 hr] before testing)
• ECG exercise testing (sensitivity, 68%; specificity, 77%)
• First-choice diagnostic test for average patient with intermediate pretest probability of IHD and normal resting ECG
• Widely available; inexpensive
• Generally safe
• Exercise capacity strong prognostic indicator
• Sensitivity reduced by digoxin (causes resting ST segment depression)
• Contraindications
• Inability to exercise
• Previous coronary revascularization
• ECG abnormalities that interfere with interpretation of exercise ECG
• Stress radionuclide myocardial perfusion imaging
• Greater diagnostic sensitivity than ECG exercise testing (range, 80%–85%)
• Requires specialized setting
• Exercise or pharmacologic agents to induce stress, with latter for patients unable or unwilling to exercise to near-maximal capacity
• Preferred in patients with ECG abnormalities that interfere with interpretation of ECG
• May be considered after nondiagnostic exercise ECG
• Stress echocardiography
• Alternative choice in patients with ECG abnormalities that interfere with ECG exercise testing
• Exercise or pharmacologic agents to induce stress
• Sensitivity, 80%–85%; specificity marginally higher than other noninvasive tests
• Computed tomography
• Electron beam CT (EBCT) detects coronary arterial calcification
• Multislice CT used to assess coronary anatomy
• High negative predictive value (96%-100%) for excluding CHD in patients with chest pain
• Compared to conventional angiography, only 85% sensitivity for detecting clinically important CHD
• Not currently recommended as screening tool for CHD
• Invasive testing
• Coronary angiography
• "Gold standard" for identifying or excluding CHD
• Provides prognostic information
• Expensive
• Unable to assess functional stability and significance of lesions
• May underestimate the severity of stenosis when coronary arteries are diffusely diseased
• Indications
• High probability of high-risk IHD
• Survival of sudden death
• Urgency to confirm or refute diagnosis of IHD
• Nondiagnostic noninvasive testing
• Inability to undergo noninvasive testing
• Suspected nonatherosclerotic angina
• High pretest probability of left main coronary or three-vessel IHD

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Best Therapy*

Risk Stratification in Chronic Stable Angina

• Categories
• Low risk (< 1% mortality/yr)
• Medical management without further noninvasive testing
• Intermediate risk (1%–3% mortality/yr)
• May require additional studies
• High risk (> 3% mortality/yr)
• May require additional studies
• Anatomic factors
• Left ventricular systolic function
• Extent and severity of coronary atherosclerotic occlusion
• Extent and severity of myocardial ischemia
• Plaque stability (i.e., risk of plaque rupture)
• Clinical factors
• Age
• Gender
• Presence of typical angina
• Diabetes
• Insulin use
• Prior MI

Nonpharmacologic Therapy to Reduce Cardiovascular Risk

• Smoking cessation
• Physical activity (moderate aerobic activity 30 to 60 min/day, 5–7 days/wk)
• Dietary modification (calorie restriction if overweight; rich in fresh fruits, vegetables, and omega-3 fatty acids; low in saturated fats and trans-fatty acids)

Drug Therapy to Reduce Cardiovascular Risk

• Antiplatelet agents
• Aspirin
• Aspirin alternatives
• Clopidogrel
• Lipid-lowering agents
• Therapeutic goal: serum LDL cholesterol < 100 mg/dl (perhaps < 70 mg/dl for selected high-risk patients)
• Statins
• Niacin
• Fibric acid derivatives
• Bile acid sequestrants
• Antihypertensive therapy
• Beta blockers (reduce cardiovascular risk in patients with cardiomyopathy or MI)
• ACE inhibitors

Drug Therapy for Anginal Symptoms

• Beta blockers
• Titrate dose to reduce resting heart rate to 55 to 60 beats/min
• Calcium channel blockers
• Nitrates and nitroglycerin
• Ranolazine

Invasive Therapy

• Revascularization
• Percutaneous coronary intervention, with or without intracoronary stent
• Coronary artery bypass grafting
• Improves symptoms in patients with angina despite optimal medical therapy
• Improves survival in certain individuals
• Left main disease
• Three vessel CHD and depressed LV ejection fraction (< 50%)
• Multivessel CHD, with > 75% stenosis of the proximal left anterior descending coronary artery

Follow-up

• Reassess patient periodically (4- to 12-month intervals) for
• Changes in level of activity
• Changes in frequency or severity of anginal symptoms
• Whether current therapy is well tolerated
• Patient success in modifying cardiac risk factors
• Development of new or worsening comorbid illnesses that may affect angina

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Best References

Lloyd-Jones D, et al: Circulation 119:480-6, 2009 [PMID 19171871]

Fraker TD, et al: Circulation 116:2762-72, 2007 [PMID 17998462]

Gibbons RJ, et al: Circulation 99:2829-48, 1999 [PMID 10351980]

Gibbons RJ, et al: J Am Coll Cardiol 41:159-68, 2003 [PMID 12570960]

Grundy SM, et al: J Am Coll Cardiol 44:720-32, 2004 [PMID 15358046]

Trikalinos TA, et al: Lancet 373:911-8, 2009 [PMID 19286090]

* To obtain additional drug information, click on the DrugInfo tab in the left column, or click on the following link: http://search.medscape.com/drug-reference-search?queryText=

July 2010