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Angina (stable)

NICE Clinical guideline [CG95] Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis. Published: Mar 2010. Last updated Nov 2016 NICE Clinical guideline [CG126] Stable angina: management. Published Jul 2011. Last updated Aug 2016 In this article, angina is being referred to angina pectoris.

Background Information

Simple definition: chest pain caused by insufficient blood supply to the myocardium
  • NICE defines it to be pain / constricting discomfort in the chest / neck / shoulder / jaw / arm (caused by insufficient blood supply to the myocardium)

Stable angina vs unstable angina:
  • Stable angina: <10 min chest pain brought on with physical exertion / emotional stress AND relieved with rest or sublingual nitrates. A stable presentation of coronary artery disease.
  • Unstable angina: chest pain that often occurs at rest and is NOT relieved with rest or sublingual nitrates. Suggestive of acute coronary syndrome.

Guidelines

Assess for the characteristic features of stable angina:

  • Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
  • Brought on by physical exertion 
  • Relieved by rest or GTNGlyceryl trinitrate within ~5min
 

Classification of chest pain

  • 3 features: typical angina 
  • 2 features: atypical angina 
  • 1 / 0 features: non-anginal chest pain

 

Other clinical features that often accompany stable angina, include dyspnoea, diaphoresis, nausea and vomiting.

 
Factors that make stable angina more likely: Factors that make stable angina unlikely:
  • Age
  • Male
  • Presence of cardiovascular risk factors
  • Presence of other cardiovascular diseases
  • Established coronary artery disease
 Chest pain / discomfort that is:
  • Continuous or very prolonged
  • Unrelated to activity
  • Brought on by breathing in (pleuritic chest pain)
  • Associated with dizziness / palpitation / tingling / difficulty swallowing
Consider GI causes or MSK pain.

1st line investigation: 12-lead ECG
  • To exclude ACSAcute coronary syndrome 
  • Note ECG is not diagnostic of stable angina

Diagnostic tests:
  • 1st line: CT coronary angiography 
  • 2nd line: non-invasive functional imaging - showing reversible myocardial ischaemia
    • Stress echo (dobutamine / exercise)
    • MPS with SPECT
    • Cardiac MRI +/- contrast
  • 3rd line: invasive coronary angiography 

All patients:
  • Drugs to prevent / manage episodes
  • Anti-anginal drugs 
  • Secondary prevention

Last resort: revascularisation

1st line: sublingual GTN as needed
  • Use to manage acute attacks or as a preventive measure  
  • Repeat dose after 5 minutes if pain persists
  • If pain not relieved after 5 minutes with use of 2nd dose → call an ambulance

  • 1st line: monotherapy of beta-blocker / rate-limiting CCB, depending on which is more appropriate
  • 2nd line: dual therapy of beta-blocker + dihydropyridine CCB
  • 3rd line: if dual therapy ineffective or inappropriate → replace one of the drugs with 1 of the following
    • Long-acting nitrate (e.g. isosorbide dinitrate, isosorbide mononitrate)
    • Ivabradine (If funny channel blocker → reduces cardiac oxygen demand)
    • Nicorandil (sodium channel blocker → reduces cardiac oxygen demand)
    • Ranolazine (potassium channel activator → coronary vasodilation)

Do not routinely give 3 anti-anginal drugs at the same time.

 

Never combine a beta blocker with rate-limiting CCB (i.e. verapamil and diltiazem).


  • Aspirin 75mg OD
  • High-intensity statin (e.g. atorvastatin 80mg)
  • Consider ACE inhibitors if there is concurrent diabetes mellitus. 

NICE specifically states NOT to offer vitamin or fish oil supplements to treat stable angina due to the lack of evidence


Revascularisation should only be considered if symptoms are not controlled with optimal medical treatment. 
 

2 main options of revascularisation:

  • Percutaneous coronary intervention (PCI)
  • Coronary artery bypass graft (CABG)
 

CABG is preferred over PCI if there is any of the following:

  • >65 y/o
  • Concurrent diabetes mellites 
  • Complex triple vessel disease +/- left main stem involvement

References

Author: Krish Patel, Adams Lau
Reviewer: TBC
Last Edited: 12/01/2025