Stable angina

Quick Overview

Stable angina is predictable chest discomfort due to reversible myocardial ischaemia during exertion/stress. NICE CG126 emphasises clinical assessment, CT coronary angiography (CTCA) as first-line imaging, and structured anti-anginal therapy. Key goals: symptom control, cardiovascular risk reduction, and appropriate revascularisation when indicated.

Core Facts & Concepts

📊 Diagnostic Pathway (NICE CG126)

• Clinical assessment: Typical angina requires 3 features-constricting chest discomfort, provoked by exertion, relieved by rest/GTN within 5 minutes
  • Atypical angina = 2 features; Non-anginal = ≤1 feature
• First-line investigation: CT coronary angiography (CTCA) for all with typical/atypical angina (unless revascularisation already planned)
  • Invasive coronary angiography if CTCA shows severe disease (≥70% stenosis) or equivocal results

• Functional testing: Exercise ECG no longer recommended as first-line (low sensitivity/specificity)
• Cardiovascular risk management: All patients require statin (atorvastatin 80mg), aspirin 75mg, BP control (<140/90mmHg)

💊 Anti-Anginal Medication Ladder

• 🚩 β-blocker contraindications: Asthma, severe peripheral vascular disease, heart block
• CCB choice: Verapamil/diltiazem (rate-limiting) vs amlodipine (non-rate-limiting)

Problem-Solving Approach

Step-by-Step Management

1. Confirm diagnosis: Clinical assessment → CTCA (identifies anatomy + severity)
2. Risk stratification: Consider invasive angiography if CTCA shows ≥70% stenosis in proximal vessels or left main stem disease
3. Initiate dual therapy: Anti-anginal (symptom control) + antiplatelet/statin (event prevention)
4. Optimise anti-anginals: Titrate to maximum tolerated dose before adding second agent
5. Revascularisation indications:
   • Persistent symptoms despite optimal medical therapy (OMT)
   • High-risk anatomy (left main stem, proximal LAD, 3-vessel disease)
   • Evidence of large ischaemic burden on functional imaging

🚩 Red Flags for Acute Coronary Syndrome

• Pain at rest, crescendo pattern, or lasting >15 minutes
• New-onset severe angina (<24 hours)
• Immediate 12-lead ECG and troponin required

Post-Revascularisation Antiplatelet Therapy

• PCI (stents): Dual antiplatelet therapy (DAPT) = aspirin 75mg + ticagrelor 90mg BD (or clopidogrel 75mg) for 12 months
• CABG: Aspirin 75mg lifelong (no routine DAPT unless specific indication)

⭐ Clinical Pearl: Always check renal function before CTCA (contrast nephropathy risk if eGFR <30ml/min)

Analysis Framework

Differentiating Chest Pain Types

Key Discriminators

• Troponin: Normal in stable angina (elevated in ACS)
• Timing: Stable angina = predictable exertional trigger; ACS = unpredictable/rest symptoms

Visual Aid

Anti-Anginal Optimisation Table

Key Points Summary

✓ CTCA is first-line imaging for suspected stable angina (NICE CG126)-identifies anatomy and guides revascularisation decisions

✓ Typical angina = 3 features: constricting discomfort, exertional provocation, relief with rest/GTN <5 minutes

✓ Anti-anginal ladder: Start β-blocker OR rate-limiting CCB (never combine both initially); add second agent if symptoms persist despite optimal dosing

✓ All patients need dual therapy: Anti-anginal for symptoms + aspirin 75mg + atorvastatin 80mg for event prevention

✓ Post-PCI DAPT: Aspirin + ticagrelor (or clopidogrel) for 12 months; post-CABG aspirin monotherapy lifelong

✓ Revascularisation indications: Symptoms despite optimal medical therapy, or high-risk anatomy (left main stem, proximal LAD, 3-vessel disease)

✓ 🚩 Red flag for ACS: Chest pain at rest, crescendo pattern, or >15 minutes duration-requires immediate ECG and troponin