Stable Angina

• Angina is considered "stable" when symptoms only come on with exertion and are always relieved by rest or glyceryl trinitrate (GTN)
• Cardiac stress testing involves assessing the patient’s heart function during exertion
• During times of high demand, such as exercise, there is an insufficient supply of blood to meet the demand, causing symptoms of angina
• Unstable angina is a type of acute coronary syndrome (ACS) and requires immediate management
• Symptoms of angina typically include constricting chest pain, with or without radiation to the jaw or arms
• Angina is caused by atherosclerosis affecting the coronary arteries, narrowing the lumen and reducing blood flow to the myocardium
• Angina is considered "unstable" when symptoms appear randomly while at rest
• Investigations for patients with angina

  • Physical examination (e.g., heart sounds, signs of heart failure, blood pressure and BMI)
  • ECG (a normal ECG does not exclude stable angina)
  • FBC (anaemia)
  • U&Es (required before starting an ACE inhibitor and other medications)
  • LFTs (required before starting statins)
  • Lipid profile
  • Thyroid function tests (hypothyroidism or hyperthyroidism)
  • HbA1C and fasting glucose (diabetes)
  • Cardiac stress testing involves assessing the patient’s heart function during exertion. This can involve having the patient exercise (e.g., walking on a treadmill) or giving medication (e.g., dobutamine) to stress the heart. The options for assessing cardiac function during stress testing are an ECG, echocardiogram, MRI or a myocard
• Cardiac stress testing


  Assesses the patient’s heart function during exertion
• Referrals are usually sent to

  • Rapid access chest pain clinic (RACPC)
• Immediate symptomatic relief

  • Sublingual glyceryl trinitrate (GTN) in the form of a spray or tablets
• Assessing cardiac function during stress testing

  Exercise (e.g., walking on a treadmill) or giving medication (e.g., dobutamine) to stress the heart
• CT coronary angiography

  Injecting contrast and taking CT images timed with the heart contractions to give a detailed view of the coronary arteries, highlighting the specific locations of any narrowing
• Long-term symptomatic relief

  First-line with either, or a combination of: Beta blocker (e.g., bisoprolol), Calcium-channel blocker (e.g., diltiazem or verapamil – both avoided in heart failure with reduced ejection fraction). A specialist may consider other options for long-term symptomatic relief: Long-acting nitrates (e.g., isosorbide mononitrate), Ivabradine, Nicorandil, Ranolazine
• Surgical procedures are generally offered to patients with more severe disease and where medical treatments do not control symptoms
• Surgical Interventions

  • Percutaneous coronary intervention (PCI), Coronary artery bypass graft (CABG)
• Options for assessing cardiac function during stress testing

  • ECG
  • Echocardiogram
  • MRI
  • Myocardial perfusion scan (nuclear medicine scan)
• Medical Management

  1. Immediate symptomatic relief during episodes of angina

  2. Long-term symptomatic relief

  3. Secondary prevention
• GTN

  Causes vasodilation, improving blood flow to the heart muscle (myocardium)
• Invasive coronary angiography

  Inserting a catheter into the patient’s brachial or femoral artery, directed through the arterial system to the aorta and the coronary arteries under x-ray guidance, where contrast is injected to visualise the coronary arteries and identify any areas of stenosis using x-ray images. This is considered the gold standard for determining coronary artery disease
• Principles of management

  • Refer to cardiology
  • Advise them about the diagnosis, management and when to call an ambulance
  • Medical treatment
  • Procedural or surgical interventions
  • Secondary prevention
• Medications for secondary prevention

  • Aspirin 75mg once daily, Atorvastatin 80mg once daily, ACE inhibitor (if diabetes, hypertension, CKD or heart failure are also present), Already on a beta blocker for symptomatic relief
• Graft vessels for CABG

  • Saphenous vein (harvested from the inner leg)
  • Internal thoracic artery (internal mammary artery)
  • Radial artery
• PCI has

  • Faster recovery
  • Lower rate of strokes as a complication
  • Higher rate of requiring repeat revascularisation (further procedures)
• Percutaneous coronary intervention (PCI)

  Inserting a catheter into the patient’s brachial or femoral artery, feeding it through the arterial system to the coronary arteries, injecting contrast to visualise the arteries, identifying areas of stenosis, treating stenosis by dilating a balloon (angioplasty) and inserting a stent (coronary angioplasty and stenting)
• Coronary artery bypass graft (CABG)

  Opening the chest along the sternum with a midline sternotomy incision, attaching a graft vessel to the affected coronary artery to bypass the stenotic area
• Short and medium-term outcomes


  Similar between PCI and CABG
• When examining a patient suspected of coronary artery disease, check for scars: midline sternotomy scar (previous CABG), scars around the brachial and femoral arteries (previous PCI), and along the inner calves (saphenous vein harvesting scar) to determine procedures they may have had done