What is Stable Angina?

by

Dr Zaid Ismail

Stable angina is a type of chest pain or discomfort that occurs when the heart muscle doesn’t get enough oxygen-rich blood, usually during physical exertion or emotional stress.

Stable angina significantly impacts quality of life and poses risks of cardiovascular complications.

Key Features of Stable Angina:

  • Predictable: The pain happens with exertion or stress and follows a consistent pattern.
  • Relieved by rest or GTN: Symptoms typically go away within minutes of stopping the activity or taking glyceryl trinitrate (GTN).
  • Chest pain: Often described as pressure, heaviness, tightness, or squeezing, usually behind the sternum. It may radiate to the arms, neck, jaw, or back.
  • Short duration: Usually lasts less than 10 minutes.

Triggers:

  • Physical exertion (e.g., climbing stairs)
  • Emotional stress
  • Cold weather
  • Heavy meals

Diagnosis

Suspect stable angina based on:

  • Typical chest pain (constricting discomfort, triggered by exertion or stress, relieved by rest or GTN)
  • Risk factors (e.g., smoking, hypertension, diabetes)
  • Referral to the rapid access chest pain clinic (RACPC)

Confirm diagnosis with:

  • Clinical assessment
  • 12-lead ECG (to identify underlying cardiac abnormalities)
  • Refer for diagnostic tests (e.g., CT Coronary Angiography or Functional Imaging)

Lifestyle Advice

Advise patients on lifestyle changes to reduce angina symptoms and cardiovascular risks:

  • Smoking cessation
  • Healthy, balanced diet
  • Regular moderate-intensity exercise
  • Weight management
  • Limit alcohol intake
  • Stress reduction techniques

Pharmacological Treatment

Immediate symptom relief:

  • Sublingual Glyceryl Trinitrate (GTN)

First-line prevention therapy:

  • Beta-blocker or calcium channel blocker (CCB)

Combination therapy:

  • Beta-blocker and CCB if symptoms uncontrolled on monotherapy
  • Long-acting nitrates, ivabradine, nicorandil, or ranolazine if beta-blocker/CCB contraindicated or not tolerated

Secondary Prevention

  • Aspirin 75 mg daily (or clopidogrel if aspirin contraindicated)
  • Statin therapy (atorvastatin 80 mg recommended)
  • Antihypertensive treatment if required
  • Optimal diabetes control if diabetic

Referral to Specialist Care

Consider referral for specialist evaluation and possible revascularization (PCI/CABG) if:

  • Symptoms uncontrolled despite optimal medical therapy
  • Diagnostic uncertainty
  • High-risk features on non-invasive testing

Monitoring and Follow-up

  • Regular follow-up to assess symptom control, medication adherence, and side effects
  • Annual cardiovascular risk review
  • Review medication and dosage regularly

Summary

  • Confirm diagnosis using clinical assessment and appropriate investigations.
  • Lifestyle modification is fundamental.
  • Follow NICE-recommended medication protocols for symptom relief and secondary prevention.
  • Refer patients with uncontrolled symptoms or high-risk features.

References

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