Chapter

Management of stable angina

Adam D. Timmis

in Oxford Textbook of Medicine

Fifth edition

Published on behalf of Oxford University Press

Published in print May 2010 | ISBN: 9780199204854
Published online May 2011 | e-ISBN: 9780199570973 | DOI: http://dx.doi.org/10.1093/med/9780199204854.003.161304_update_001

Series: Oxford Textbooks

Management of stable angina

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Angina—the pain provoked by myocardial ischaemia—is usually caused by obstructive coronary artery disease that is sufficiently severe to restrict oxygen delivery to the cardiac myocytes. Quality of life is impaired in direct proportion to the severity of symptoms.

Clinical history remains the most useful basis for diagnosis and referral decisions to specialist services, the commonest indications being (1) new-onset angina, (2) exclusion of angina in high-risk individuals with atypical symptoms, (3) worsening angina in a patient with previously stable symptoms, (4) new or recurrent angina in a patient with history of myocardial infarction or coronary revascularization, (5) assessment of occupational fitness (e.g. airline pilots).

Investigation—noninvasive testing is used primarily for diagnosis, but whatever test is employed—exercise ECG, myocardial perfusion imaging, stress echocardiography, or multidetector CT—the incremental diagnostic value is greatest for patients with an intermediate pretest probability of coronary artery disease in whom uncertainty is greatest. Such tests also have a role in risk assessment to inform decisions about the urgency and aggressiveness of treatment in individual cases.

Medical treatment of angina involves (1) dealing with exacerbating comorbidities, (2) secondary prevention by lifestyle modification (smoking cessation, exercise training, Mediterranean-style diet, etc.) and drugs (aspirin, statins, angiotensin-converting enzyme (ACE)-inhibitors, etc.), (3) antianginal drugs (most commonly β-blockers, short acting nitrates, and calcium channel blockers).

Patients with continuing moderate or severe stable angina despite optimal medical treatment should undergo coronary angiography, as should those identified as being at high risk on noninvasive testing. In symptomatic patients, revascularization is generally indicated if one or more of the major coronary arteries—or their large branches—have flow-limiting stenoses (>70% luminal narrowing) or occlusions. Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) produce comparable symptomatic benefit. With regard to life expectancy, PCI does not produce survival benefit in patients with stable angina. By contrast, studies more than 20 years ago showed that CABG produced small gains in life expectancy in some patients.

With current management strategies, patients with angina are living longer, but a few remain symptomatic with poor quality of life despite optimal medical treatment and having exhausted revascularization options. Psychological support is important to treat anxiety and depression and improve confidence, and neuromodulatory techniques are sometimes employed.

Chapter.  6548 words.  Illustrated.

Subjects: Cardiovascular Medicine

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