Chronic Stable Angina

Paul R. Sutton, M.D., Ph.D., F.A.C.P.
Stephan D. Fihn, M.D., M.P.H., F.A.C.P.
University of Washington School of Medicine

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 exertions or stresses of similar intensity
• Precedes MI in about half of cases; common afterward

back to top

Differential Diagnosis

• Nonischemic heart disease
  • Arrhythmias (palpitations or typical angina)
  • Aortic stenosis (typical angina, often exertional)
  • Aortic dissection ("tearing" pain, often of abrupt onset)
  • Pericarditis (often pleuritic pain but may be anginal; often relieved by sitting up and leaning forward)
• Pulmonary disease
  • Pulmonary embolus (usually no chest pain but may cause 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
  • Myofascial pain
• Psychiatric disorders (may be distinguishable from angina)
  • Anxiety disorders
  • Affective disorders (e.g., depression)
  • Somatoform disorders
  • Thought disorders (e.g., fixed delusions)
  • Factitious disorders (e.g., Münchausen syndrome)

back to top

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
    • Substernal 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)
  • Diabetes
  • Sedentary lifestyle
  • Hypertension
  • Cerebrovascular disease
  • Peripheral vascular disease
  • Family history of premature coronary artery disease
• 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
  • Pathologic Q waves pathognomonic for ischemic heart disease (IHD)
    • Isolated Q waves in lead III or QS pattern in V1 and V2 nonspecific
  • ST depression, T wave inversion, and left ventricular hypertrophy favor diagnosis of angina
  • ECG normal in 50% of patients with chronic stable angina
• 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 perform exercise
      • Previous coronary revascularization
      • ECG abnormalities that would 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
    • Preferred in patients with ECG abnormalities that interfere with interpretation of ECG exercise testing
    • May be considered after nondiagnostic exercise ECG
    • Allows estimation of left ventricular systolic size and function
  • 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; less sensitive in very obese patients
• Invasive testing
  • Coronary angiography
    • Unequaled coronary artery detail
    • Powerful prognostic tool
    • Expensive
    • Risk of plaque rupture
    • Inconsistent assessment of functional stability and significance of lesions
    • 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

---

back to top

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 atherosclerotic occlusion or coronary tree
  • 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 min/day, 5–7 days/wk)
• Dietary modification (calorie restricted if overweight; high in fresh fruits and vegetables; high in fiber; low in saturated fats)

Drug Therapy to Reduce Cardiovascular Risk

• Antiplatelet agents
  • Aspirin
  • Aspirin alternatives
    • Clopidogrel
    • Ticlopidine (rarely used)
  • 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
  • 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

Invasive Therapy

• Revascularization
  • Percutaneous coronary intervention, with or without intracoronary stent
  • Coronary artery bypass graft

Follow-up

• Reassess patient periodically (4- to 12–month intervals) for the following:
  • 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

---

back to top

Best References

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): JAMA 285:2486, 2001 [PMID 11368702]

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

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

Grundy SM, et al: Circulation 100:1481, 1999 [PMID 10500053]

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

February 2006