Angina
Exam Tips
- Use the 3-feature rule: typical angina has all of (constricting chest/arm/jaw discomfort, precipitated by exertion, relieved by rest/GTN in about 5 minutes); two features = atypical angina.
- A normal resting ECG does not exclude stable angina; exercise ECG is not recommended to rule in/out stable angina in people without known CAD.
- In an OSCE, always safety-net GTN use clearly: stop and rest, take GTN, repeat once after 5 minutes, call 999 if pain persists 5 minutes after the second dose or if symptoms worsen.
- Differentiate stable from unstable angina: new-onset, crescendo, or rest pain is an ACS red flag requiring urgent hospital assessment.
- Remember prevention aims: anti-anginals reduce symptoms; antiplatelet/statin/ACE inhibitor strategy reduces future cardiovascular events.
Definition
Stable angina is a chronic coronary syndrome in which transient myocardial ischaemia causes episodic chest discomfort when oxygen demand exceeds coronary supply, usually because of atherosclerotic narrowing of epicardial coronary arteries. Symptoms are classically reproducible with exertion or emotional stress, last minutes rather than hours, and improve promptly with rest or sublingual glyceryl trinitrate (GTN).
Pathophysiology
Most cases are due to fixed atherosclerotic coronary stenosis (often flow-limiting at higher workloads), so myocardial oxygen delivery cannot rise adequately during exertion, cold exposure, heavy meals, or adrenergic stress. Ischaemia is typically subendocardial and reversible, producing pain via metabolic and neural signalling without myocyte necrosis (unlike myocardial infarction). Plaque inflammation, endothelial dysfunction, and vasomotor tone abnormalities can further reduce flow reserve; less common non-atherosclerotic causes include aortic stenosis, hypertrophic obstructive cardiomyopathy, and severe hypertension-related demand mismatch. See coronary atherosclerosis and myocardial oxygen supply-demand diagrams in standard UK undergraduate cardiology texts (e. g, Kumar & Clark, ischaemic heart disease chapter).
Risk Factors
- Increasing age
- Male sex
- Smoking
- Diabetes mellitus
- Hypertension
- Dyslipidaemia (especially raised LDL cholesterol)
- Family history of premature coronary heart disease
- Chronic kidney disease
- Obesity and physical inactivity
- Established coronary artery disease (previous MI or revascularisation)
Clinical Features
Symptoms
- Constricting/heavy chest discomfort (central or left-sided), possibly radiating to neck, jaw, shoulders, or arms
- Provoked by exertion, emotional stress, cold weather, or large meals
- Relieved within about 5 minutes by rest or GTN
- Episodes usually short (commonly less than 10 minutes)
- Atypical presentations may include breathlessness, epigastric discomfort, or nausea
Signs
- Examination may be normal between episodes
- Possible evidence of cardiovascular risk states (e. g, hypertension, obesity)
- Signs suggesting alternative or contributing pathology: aortic stenosis murmur, hypertrophic cardiomyopathy signs, heart failure signs, anaemia
Investigations
Management
Lifestyle Modifications
- Smoking cessation with behavioural and pharmacological support
- Cardioprotective diet (Mediterranean-style), weight optimisation, and regular graded aerobic activity
- Control of blood pressure, glycaemia, and lipids; treat comorbidities
- Education on trigger avoidance, pacing, and when to call 999 (persistent pain despite two GTN doses 5 minutes apart, or earlier if deteriorating)
- Address anxiety/depression and impact on work, driving, sexual activity, and quality of life
Pharmacological Treatment
Short-acting nitrate for immediate relief
- Glyceryl trinitrate sublingual spray 400 micrograms (1-2 sprays) when pain occurs; repeat after 5 minutes if needed
- Glyceryl trinitrate sublingual tablet 300-600 micrograms PRN
Use at symptom onset or before predictable exertion. Common adverse effects: headache, flushing, light-headedness. Contraindicated with phosphodiesterase-5 inhibitors (e. g, sildenafil, tadalafil) due to severe hypotension risk.
First-line anti-anginal maintenance (choose one class initially)
- Bisoprolol 5 mg once daily, titrate to 10 mg once daily
- Amlodipine 5 mg once daily, titrate to 10 mg once daily
- Diltiazem MR 120 mg once daily, titrate according to preparation/response
Choose beta-blocker or rate-limiting/non-rate-limiting CCB based on comorbidity and tolerance. Avoid combining beta-blocker with verapamil (risk of bradycardia/heart block). Beta-blockers: caution in asthma/COPD, bradycardia, AV block, decompensated HF.
Alternative monotherapy if beta-blocker/CCB not tolerated or contraindicated
- Isosorbide mononitrate MR 25-60 mg once daily (or standard-release divided dosing with nitrate-free interval)
- Nicorandil 10 mg twice daily, titrate up to 20-30 mg twice daily
- Ivabradine 5 mg twice daily, titrate to 7.5 mg twice daily
- Ranolazine MR 375 mg twice daily, titrate to 500-750 mg twice daily
Ivabradine requires sinus rhythm and adequate resting heart rate; avoid in AF and significant conduction disease. Nicorandil can rarely cause severe GI/skin ulceration. Ranolazine may prolong QT and interacts with CYP3A inhibitors.
Secondary prevention
- Aspirin 75 mg once daily
- Clopidogrel 75 mg once daily (if aspirin not suitable, or already indicated for stroke/PAD)
- Atorvastatin 80 mg once daily (adjust if intolerance/drug interactions)
- Ramipril 2.5 mg once daily, titrate to 10 mg once daily where indicated/tolerated
Balance antiplatelet benefit against bleeding risk; consider gastroprotection if GI risk. ACE inhibitors are particularly indicated with diabetes, hypertension, CKD, LV dysfunction, heart failure, or prior MI. Monitor renal function and potassium after ACE inhibitor initiation/titration.
Surgical / Interventional
- Percutaneous coronary intervention (PCI) for persistent symptoms despite optimal medical therapy or suitable high-risk coronary anatomy
- Coronary artery bypass grafting (CABG) for prognostically significant multivessel/left main disease or when anatomy/diabetes favours surgery
Complications
- Unstable angina
- Myocardial infarction
- Stroke
- Sudden cardiac death
- Heart failure due to progressive ischaemic cardiomyopathy
- Anxiety, depression, and reduced quality of life
Prognosis
Stable angina is usually chronic but manageable, with many patients becoming symptom-free within a year when risk factors and medication are optimised. Prognosis worsens with extensive coronary disease, impaired left ventricular function, limited exercise tolerance, and major comorbidities; there remains an ongoing risk of acute coronary events and mortality.
Sources & References
💊BNF Drug References(37)
- Acebutolol[contraindications]
- Acebutolol[management.pharmacological]
- Alemtuzumab[contraindications]
- Amlodipine[management.pharmacological]
- Apraclonidine[cautions]
- Atenolol[management.pharmacological]
- Atenolol[contraindications]
- Bisoprolol fumarate[contraindications]
- Bisoprolol fumarate[management.pharmacological]
- Carvedilol[contraindications]
- Carvedilol[management.pharmacological]
- Celiprolol hydrochloride[contraindications]
- Co-tenidone[contraindications]
- Diltiazem hydrochloride[management.pharmacological]
- Esmolol hydrochloride[contraindications]
- Felodipine[management.pharmacological]
- Glyceryl trinitrate[management.pharmacological]
- Isosorbide dinitrate[management.pharmacological]
- Isosorbide mononitrate[management.pharmacological]
- Labetalol hydrochloride[contraindications]
- Landiolol hydrochloride[contraindications]
- Metoprolol tartrate[management.pharmacological]
- Metoprolol tartrate[contraindications]
- Nadolol[contraindications]
- Nadolol[management.pharmacological]
- Nebivolol[contraindications]
- Nicardipine hydrochloride[management.pharmacological]
- Nifedipine[management.pharmacological]
- Pindolol[contraindications]
- Pindolol[management.pharmacological]
- Propranolol hydrochloride[management.pharmacological]
- Propranolol hydrochloride[contraindications]
- Selegiline hydrochloride[cautions]
- Sotalol hydrochloride[contraindications]
- Timolol maleate[management.pharmacological]
- Timolol maleate[contraindications]
- Verapamil hydrochloride[management.pharmacological]
✅NICE Guidelines(1)
- Angina[overview]
📖Textbook References(5)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1726)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1725, 1726)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1726)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 131)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 844)[context]