Stable Angina
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.
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Risk factors
- 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 |
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)
- Beta-blocker (metoprolol succinate, bisoprolol, carvedilol) — first-line antianginal; titrate to resting HR 55-60
- 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)
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