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Stable angina -assessment and diagnosis

Stable angina –Occurs predictably with physical exertion or emotional stress , last for no more than 10 mins ( usually less ) and is relieved within minutes of rest as well as s/l nitrates

Chest pain is very common 1 % of GP visits 5 % of A&E visits 25 % of emergency hospital admissions Coronary artery disease ( CAD ) – one of biggest cause of mortality in the UK causing around 80 000 deaths/ year

Acute coronary syndrome –Includes range of conditions as Unstable angina ST segment myocardial infarction ( STEMI ) non-ST segment MI

CACS- coronary artery calcium score CAD- coronary artery disease CTCA- Computed tomography coronary angiography CMR -cardiac magnetic resonance DSE- dobutamine stress echocardiography ExSE – exercise stress echocardiography ICA- invasive coronoary angiography MPS-SPECT -Myocardial perfusion scintigraphy – single positron emission 
computed tomography

History- Age , sex Pain characteristic including
○ location
○ radiation
○ severity
○ duration
○ frequency
○ provoking factors and factors that relive the pain Previous hx which indicates established CAD as
○ history of angina
○ history of myocardial infarction
○ coronary revascularization Other cardiovascular disease CV risk factors
 Examination -Identify risk factors for CV disease Signs of other CV disease Non con-coronary causes of angina as
severe aortic stenosis
guideline does not provide any guidance on their investigative or diagnostic pathways Exclude other causes of chest pain

Angina pain-Constricting discomfort in the front of chest or in neck , shoulders , jaw or arms precipitated by physical exertion relieved by rest or GTN within about 5 minutes

typical angina , atypical angina , non-anginal chest pain

Angina pain more likely-Age Male sex CV risk factors including
○ smoking history
○ diabetes
○ hypertension
○ dyslipidaemia
○ family history of premature CAD Other CV disease Known established CAD as
○ previous MI
 Less likely-Continuous or very prolonged
and / or unrelated to activity and/ or brought on by breathing and/ or associated with symptoms as dizziness , palpitations , tingling or difficulty swallowing

NICE recognises that it will not be always easy to stratify patients based on history / examination only- who have or not CAD and provides some helpful tips.If low likelihood of CAD and typical angina like pain consider investigation for alternative causes as hypertrophic cardiomyopathy . The guidance does not elaborate further which specific investigations to consider for eg ECG/ Echo.Request blood tests for eg to R/O anaemia in any patient who is being investigated for stable angina.ECG – routinely requested in all . NICE suggests that ECG should be 
done as soon as possible after presentation when clinical assessment alone is not enough to exclude angina. Note that following changes indicate CAD and may indicate ischaemia or previous infarction.NICE reminds us that a normal resting ECG does not r/o stable angina.
It recommends provides guidance- which pts should be selected for further diagnostic testing.pathological Q waves LBBB ST-segment and T wave abnormalities
( eg flattening or inversion )

In patients with confirmed CAD ( eg h/o MI , stents ,previous angiography ) and stable angina cannot be ruled out by clinical assessment alone – refer for non-invasive functional testing.Offer aspirin if stable angina suspected until diagnosis and manage as per current guidance while awaiting opinion/ investigations

Before 2016 the NICE guidance on investigations of stable
 chest pain involved Determining the Pre-test likelihood ( PTL ) of CAD using a modified Diamond- Forrester model Cardiologists used various parameters to determine who qualified for which investigations or doesn’t need any CACS was also used in patients with low PTL as guidance for further investigations.NICE update in 2016 now recommends Cardiac CT as the 
first line test for Coronary Artery Disease
.The reason behind this update appears to be Cardiac CT is non-invasive , low cost , high-sensitivity Cardiac CT offers detailed anatomical assessment of coronary artery disease comparable to invasive coronary angiography Randomised trials have shown that cardiac CT improves diagnostic certainty when incorporated into chest pain pathways ICA ( invasive coronary angiography ) is expensive and exposes individuals to the highest risk of procedural complications Diagnostic testing with functional testing has a high rate of false positive results.So NICE recommends that a 64-slice or above CT should be offerred
 Suspected typical or atypical angina Non-anginal chest pain but resting ECG shows ST-T changes-,Q waves

Details of further investigations are not covered here as it will be a decision made by the cardiology team as per NICE guidance


Pennine Acute Hospitals NHS Trust on Stable Angina

American Heart Association on Angina

British Heart Foundation on angina ( with an explainer video )

A detailed PIL on angina from BUPA

NHS Inform Scot on angina

A 56 page PIL Living with Angina from Chest Heart and Stroke Scotland



  1. Skinner JS, Smeeth L, Kendall JM on behalf of the Chest Pain Guideline Development Group, et al NICE guidance. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin Heart 2010;96:974-978.
  2. Guidance update- latest NICE guidelines on chest pain Dr Ivan Benett and Toni Hazell GP Online via
  3. GP Online How to manage angina and when to refer as an emergency. By Dr Vinoda Sharma and consultant cardiologist Dr Robert Henderson
  4. NICE Pathways- Managing stable angina
  5. Moss, Alastair J et al. “The Updated NICE Guidelines: Cardiac CT as the First-Line Test for Coronary Artery Disease.” Current cardiovascular imaging reports vol. 10,5 (2017): 15. doi:10.1007/s12410-017-9412-6
  6. Angina CKS NHS revised Jan 18
  7. Stable angina: management Clinical guideline [CG126]Published date:  Last updated: 


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