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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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)
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