Chronic stable angina

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💡 In people with angiographically normal coronary arteries and continuing anginal symptoms, consider a diagnosis of Cardiac Syndrome X (microvascular angina).

📖 About

• Angina is usually a sign of underlying atherosclerosis 🫀.
• Can also be caused by microvascular dysfunction (syndrome X) or valvular disease (e.g. severe aortic stenosis).

🧬 Aetiology

• Fixed coronary stenosis >70% limits blood flow.
• Microvascular angina without epicardial stenosis.
• Secondary to conditions increasing oxygen demand (e.g. severe aortic stenosis, anaemia, thyrotoxicosis).

📊 Canadian Cardiovascular Society (CCS) Angina Score

• Class I: Angina only with strenuous/prolonged activity.
• Class II: Slight limitation, angina on vigorous exertion.
• Class III: Moderate limitation; angina with daily activities.
• Class IV: Angina at rest or minimal activity 🚨.

⚠️ Risk Factors

• Age >65 👵
• Male sex ♂️ (earlier onset risk)
• Family history of premature CAD 👨‍👩‍👧
• Smoking 🚬
• Hypertension 💉
• Dyslipidaemia 🍳
• Diabetes mellitus 🍭
• Obesity ⚖️
• Physical inactivity 🛋️

🔑 These are modifiable targets for prevention. “Triple risk” 🚭 + BP + lipids control = huge impact.

🩺 Clinical Features

• Central chest pain/pressure on exertion 🏃.
• Relieved by rest or GTN 💊.
• May radiate to jaw/arm/back.
• Look for associated signs: S3 gallop, cardiomegaly, murmurs (aortic stenosis), peripheral vascular disease (carotid/renal bruits).

🔥 Precipitants

• Exertion, heavy meals 🍽️, cold weather ❄️.
• Emotional stress (anger, excitement) 😡.
• Physiological stressors: anaemia, thyrotoxicosis.

🔍 Differentials

• Aortic stenosis 💔
• Anaemia 🩸
• Hypertrophic obstructive cardiomyopathy (HOCM)
• Non-cardiac chest pain (e.g. GORD, MSK)

🧪 Investigations

• Bloods: FBC, U&E, lipids, glucose, thyroid.
• ECG: May show ST depression with pain; often normal.
• Exercise stress test: ST depression with exertion 🏃.
• Echocardiography: LV function, valve disease.
• Stress echo / perfusion scan: Ischaemia localisation.
• CT coronary angiography: Non-invasive calcium score & anatomy.
• Coronary angiogram: Gold standard but invasive; risks include stroke/death.

📈 Risk Stratification

• High risk 🚨: Post-MI angina, poor LV function, left main/triple-vessel disease.
• Low risk ✅: Predictable exertional angina, good exercise tolerance, single-vessel disease.

💊 Management

• Lifestyle: 🚭 Smoking cessation, 🏃 regular exercise (within limits), ⚖️ weight loss, 🥗 healthy diet, BP & diabetes control.
• Medication:
  • 🩸 Antiplatelet: Aspirin 75 mg OD.
  • 💊 Short-acting nitrates (GTN spray): for acute attacks.
  • ⏳ Long-acting nitrates: Isosorbide mononitrate, GTN patch.
  • 🧡 Beta-blockers: e.g. Bisoprolol.
  • 🔓 Calcium-channel blockers: e.g. Diltiazem, Amlodipine.
  • 💊 Nicorandil, Ivabradine, Ranolazine: 2nd-line add-ons.
  • 🧴 Statins for lipid lowering.
  • 💉 ACE inhibitors if diabetes, HTN, or LV dysfunction.
• Revascularisation:
  • PCI with stenting if refractory symptoms.
  • CABG for triple-vessel/left main disease (internal mammary or radial grafts; mortality ~1–2%).

💡 Clinical Pearls

• Stable angina is predictable & exertional vs unstable angina (at rest, new-onset, or crescendo) 🚨.
• “Cardiac Syndrome X” = angina + normal coronaries, usually microvascular dysfunction.
• Always optimise medical therapy before considering PCI/CABG.

📚 References

• NICE CG95: Chest pain of recent onset (last updated 2016).
• ESC Guidelines for the management of stable coronary artery disease.

📝 Revisions

• Updated with emojis and expanded management pearls (05/09/2025).