Predictable exertional chest pain from fixed coronary stenosis, relieved by rest or nitrates.
Also known as: stable angina, chronic stable angina, exertional angina, angina pectoris, CAD
Overview
Reproducible chest discomfort precipitated by exertion or emotional stress, lasting <10 minutes, and relieved by rest or sublingual nitroglycerin. Reflects fixed coronary artery stenosis (typically ≥70% luminal narrowing) with demand-supply mismatch during exertion.
Try two board-style Stable Angina questions
Real questions from the FirstPassPA bank, with the full explanation. Pick an answer — no signup, no email.
Question 1CardiovascularMedium
A 45-year-old man reports several weeks of substernal chest pressure brought on by brisk walking and relieved within a few minutes by rest. Resting ECG is normal. An exercise stress test reproduces his typical symptoms and shows 1.5 mm of horizontal ST-segment depression at a moderate workload, with normal recovery. Which of the following is the most appropriate therapy to relieve an acute angina episode?
ADaily low-dose aspirin
BSublingual nitroglycerin
CLong-acting amlodipine
DOral metoprolol succinate
Reveal answer & full explanation
Correct answer: B — Sublingual nitroglycerin
ADaily low-dose aspirin
BSublingual nitroglycerin✓
CLong-acting amlodipine
DOral metoprolol succinate
Why Sublingual nitroglycerin is correct
Exertional substernal pressure relieved by rest with reproducible ST-segment depression on stress testing is chronic stable angina from fixed coronary stenosis.
Sublingual nitroglycerin aborts an acute anginal episode within 1-3 minutes through venodilation (preload reduction) and coronary vasodilation, rapidly lowering myocardial oxygen demand.
It is the guideline-recommended agent for immediate relief of an acute anginal episode (per ACC/AHA chronic coronary disease guidance).
Why the others are wrong
Daily low-dose aspirin — lowers thrombotic and MI risk in coronary disease but has no antianginal effect and no role in aborting an acute episode. Trap: buzzword-matching 'chest pain to aspirin' from the ACS reflex.
Long-acting amlodipine — a calcium-channel blocker for chronic anti-anginal prevention; its slow onset cannot relieve an episode in progress. Trap: right-diagnosis-wrong-step (a prevention agent chosen when abortive therapy is asked for).
Oral metoprolol succinate — a beta-blocker for long-term angina prevention and rate control, not acute relief. Trap: right-diagnosis-wrong-step (prevention vs abortive therapy).
Question 2CardiovascularEasy
A 55-year-old man with stable coronary artery disease has had no change in his anginal symptoms for the past year on aspirin, a statin, a beta-blocker, and a long-acting nitrate. He exercises without limiting chest pain. Coronary angiography performed for risk stratification shows a single 70% stenosis of the mid left anterior descending artery, with no left main or proximal disease and preserved left ventricular function. Which of the following is the most appropriate management?
AContinue optimal medical therapy
BCoronary artery bypass grafting
CPercutaneous coronary intervention
DAdd clopidogrel to the regimen
Reveal answer & full explanation
Correct answer: A — Continue optimal medical therapy
AContinue optimal medical therapy✓
BCoronary artery bypass grafting
CPercutaneous coronary intervention
DAdd clopidogrel to the regimen
Why Continue optimal medical therapy is correct
This is stable coronary artery disease with symptoms well controlled for a year and only single-vessel, non-left-main disease with preserved left ventricular function: a low-risk anatomy.
In stable coronary disease, revascularization (PCI or CABG) relieves angina but does NOT lower myocardial infarction or mortality compared with optimal medical therapy (COURAGE and ISCHEMIA trials); guideline-directed medical therapy is first-line (per ACC/AHA chronic coronary disease guidance).
Because symptoms are already controlled, continuing and optimizing medical therapy with risk-factor control is the most appropriate step.
Why the others are wrong
Coronary artery bypass grafting — reserved for left main or multivessel disease (especially with reduced ejection fraction or diabetes), not an isolated single-vessel lesion with controlled symptoms. Trap: over-treating an anatomic stenosis number.
Percutaneous coronary intervention — relieves refractory angina but offers no mortality or MI benefit in stable disease, and there is nothing to gain when symptoms are already controlled. Trap: the oculostenotic reflex (stenting a 70% lesion just because it is seen).
Add clopidogrel to the regimen — dual antiplatelet therapy is indicated after stenting or acute coronary syndrome, not for stable medically managed disease, where it only adds bleeding risk. Trap: buzzword-matching — reflexively escalating antiplatelet therapy whenever the stem says coronary disease.
🔒 Free preview limit reached
Keep reading — start your free trial
You've read your 2 free diagnosis previews. Create your free account to unlock the full Stable Angina outline — plus all 514 diagnoses, 6,500+ board-style questions, flashcards, and an AI tutor. Your 7-day free trial includes everything, and there's no credit card required.
Same as ACS: smoking, diabetes, hypertension, dyslipidemia, family history, age, male sex
Microvascular angina (women > men): cardiac risk factors + normal coronaries on angiography
Pathophysiology
Stable atherosclerotic plaque progressively narrows the coronary lumen. At rest, autoregulation maintains perfusion; with exertion, myocardial oxygen demand exceeds supply → transient ischemia → pain. Pain resolves when demand drops below the stenosis-limited supply.
Clinical presentation
Symptoms
Substernal chest pressure or tightness brought on by predictable triggers (exercise, emotional stress, cold weather, large meals)
Lasts 2-10 min, relieved by rest or sublingual NTG within minutes
May radiate to left arm, jaw, neck, or back
Atypical features more common in women, diabetics, elderly: dyspnea, fatigue, indigestion
Signs / physical exam
Often normal exam at rest
Possible S4 gallop during episode
Look for evidence of CAD risk: xanthomas, corneal arcus, peripheral vascular bruits
Differential diagnosis
Unstable angina / NSTEMI — Rest pain, prolonged duration (>20 min), or accelerating pattern — by definition not 'stable'; positive troponin separates NSTEMI from UA
Prinzmetal (vasospastic) angina — Rest or nocturnal pain, transient ST elevation that resolves, often younger patients; provoked by cocaine, triptans; treat with CCB ± nitrates, AVOID beta-blockers
Microvascular angina (cardiac syndrome X) — Typical exertional symptoms + positive stress test + normal coronaries on angiography; more common in women; treat as anginal equivalent
GERD — Burning quality, postprandial, worse supine, responds to acid suppression and antacids; not exertionally triggered
Esophageal motility disorder (e.g., diffuse esophageal spasm) — Squeezing chest pain, may paradoxically respond to nitrates; manometry diagnostic
Costochondritis / musculoskeletal — Reproducible with palpation, positional, no relation to exertion
Anxiety / panic disorder — Atypical pain, sense of impending doom, hyperventilation, paresthesias; usually <30 min; normal stress test
Diagnostic workup
Labs
Lipid panel, A1c, BMP, CBC, TSH
Resting troponin if presentation acute or pattern changing (to exclude ACS)
Imaging
Resting 12-lead ECG (often normal between episodes; may show old infarction, LVH, LBBB)
Stress testing — modality depends on baseline ECG and exercise capacity:
• Exercise treadmill ECG — first-line if normal baseline ECG and patient can exercise
• Stress echo or stress nuclear (SPECT/PET) — if baseline ECG uninterpretable (LBBB, paced, LVH with strain) or cannot exercise (pharmacologic stress with dobutamine, adenosine, or regadenoson)
• Coronary CTA — alternative in low-to-intermediate pretest probability
Invasive coronary angiography — gold standard; reserved for high-risk stress findings, refractory symptoms, or diagnostic uncertainty
Diagnostic algorithm
CCS Class
Activity Threshold
Limitation
I
Strenuous, prolonged exertion only
No limitation of ordinary activity
II
Walking >2 blocks or climbing >1 flight at normal pace
Slight limitation of ordinary activity
III
Walking 1-2 blocks or 1 flight at normal pace
Marked limitation of ordinary activity
IV
Any activity; may occur at rest
Inability to carry out activity without discomfort
Canadian Cardiovascular Society (CCS) Angina Severity Classification.
Treatment
First-line
Lifestyle: smoking cessation, Mediterranean/DASH diet, exercise 150 min/wk moderate intensity, weight loss, glycemic and BP control
Aspirin 81 mg daily (clopidogrel if ASA-intolerant)
High-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg)
Sublingual nitroglycerin 0.4 mg PRN — can repeat every 5 min × 3 doses; call 911 if not resolved
Second-line / adjunct
Calcium channel blocker if beta-blocker contraindicated, not tolerated, or symptoms persist — dihydropyridines (amlodipine, felodipine, nifedipine ER) or non-dihydropyridines (diltiazem, verapamil; avoid combining with beta-blocker due to AV block risk)
Long-acting nitrate — isosorbide mononitrate, isosorbide dinitrate, or transdermal nitroglycerin patch; requires nitrate-free interval of 10-12 h/day to prevent tolerance
Ranolazine — refractory angina; no effect on HR/BP; QT prolongation risk
Coronary revascularization (PCI or CABG) — symptom relief if refractory to optimal medical therapy, or prognostic indication (left main, multivessel disease with reduced LV function, proximal LAD disease)
Complications
Progression to ACS (plaque rupture)
Heart failure from ischemic cardiomyopathy
Arrhythmias (VT, sudden cardiac death)
Functional limitation, depression, reduced QOL
PANCE pearls
Canadian Cardiovascular Society (CCS) functional classification I-IV grades severity by activity limitation — used in clinical and board contexts.
Sildenafil (or other PDE5 inhibitor) within 24-48 h is an absolute contraindication to nitrates → severe hypotension.
A patient who can walk briskly on level ground without angina (METs ≥4) has lower pre-test probability of obstructive disease.
Microvascular angina (cardiac syndrome X): typical symptoms, positive stress test, normal coronaries. Treat with risk factor modification and beta-blockers or CCBs.
References
AHA/ACC 2023 — 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Chronic Coronary Disease (Virani et al., Circulation 2023)
ISCHEMIA Trial — Initial Invasive or Conservative Strategy for Stable Coronary Disease (Maron et al., NEJM 2020)
CCS Classification — Canadian Cardiovascular Society Functional Classification of Angina (Campeau, Circulation 1976)
COURAGE Trial — Optimal Medical Therapy with or without PCI for Stable Coronary Disease (Boden et al., NEJM 2007)
Practice Cardiovascular questions on FirstPassPA
Turn this outline into retention. 6,500+ board-style questions with an AI tutor that explains every answer — free to start, no card required.
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.