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Stable Angina

NICE Clinical guideline [CG95] Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis. Last updated: Nov 2016 NICE Clinical guideline [CG126] Stable angina: management. Last updated: Aug 2016

Background Information

Stable angina is the most common clinical manifestation of CADCoronary artery disease:
  • Defined as pain / constricting discomfort in the chest / neck / shoulder / jaw / arm caused by insufficient myocardial perfusion

CADCoronary artery disease can manifest clinically as either stable angina or as ACS:
 

CAD manifestation Pathophysiology Clinical presentation
Stable angina Stable, fixed coronary artery stenosis causing ischaemia on exertion Predictable symptoms on exertion and relieved by rest or nitrates
ACS Plaque rupture + acute thrombosis causing sudden reduction of myocardial perfusion Sudden onset symptoms at rest, or symptoms that do not improve with rest or nitrates

Be aware that stable angina is NOT the same as unstable angina. Unstable angina falls under the category of ACS.

Stable angina is caused by myocardial ischaemia resulting from an imbalance between myocardial oxygen supply and demand. [ref]

Factors reducing oxygen supply: [ref]
  • Coronary artery atherosclerosis - most common
  • Coronary artery vasospasms (classically caused by cocaine use)
  • ↑ Heart rate
  • Anaemia

Factors increasing oxygen demand: [ref]
  • ↑ Heart rate (e.g. physical exertion, emotional stress)
  • ↑ Afterload (e.g. hypertension)

Major risk factors (for developing CADCoronary artery disease, thus stable angina): [ref]
  • Old age
  • Male
  • Smoking
  • Hypertension
  • Hyperlipidaemia (esp. ↑ LDL and ↓ HDL)
  • Diabetes mellitus
  • Obesity (esp. central obesity)
  • Family history of premature CAD

Main complications are:
  • ACS
  • Heart failure
  • Increased overall risk of cardiovascular death

Diagnosis Guidelines

Stable angina presents as repetitive and reversible attacks. Characteristic features:

  • 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.

  Chest pain that is brought on at rest, chest pain that doesn't improve with rest or GTN should warrant immediate exclusion of ACS.

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.

Immediately perform a 12-lead ECG
  • To exclude ACSAcute coronary syndrome 
  • NB ECG cannot diagnose or exclude stable angina

Diagnostic tests:
  • 1st line: CT coronary angiography 
 
  • 2nd line: non-invasive functional imaging
    • Stress echocardiography (dobutamine / exercise)
    • Cardiac MRI
    • Nuclear perfusion imaging (myocardial perfusion scintigraphy)
 
  • 3rd line: invasive coronary angiography 

Management Guidelines

All patients should all the following:
  • Drugs to prevent / manage angina attacks
  • Long-term medications
    • Anti-anginal drugs
    • Secondary prevention drugs

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 the pain is not relieved after 5 minutes after using the 2nd dose → call an ambulance

  • Step 1: monotherapy of beta blocker (atenolol / bisoprolol / metoprolol / propranolol) / rate-limiting CCB (verapamil / diltiazem)
    • Avoid beta blockers in asthmatic
    • In heart failure, beta blockers are preferred and rate-limiting CCB should be avoided
 
  • Step 2: dual therapy of beta blocker (atenolol / bisoprolol / metoprolol / propranolol) + dihydropyridine CCB (e.g. amlodipine, felodipine, nifedipine)
 
  • Step 3: 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).

Contraindications and cautions for beta blocker and rate-limiting CCB:

  • Heart rate <50 bpm
  • High-degree AV block (2nd / 3rd degree) without a pacemaker
  • Sick sinus syndrome without a pacemaker

All patients:
  • Aspirin 75mg OD
  • Atorvastatin 80 mg OD

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 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: 16/09/25