Initial Workup for Stable Angina

Clinical Assessment

The American College of Cardiology and European Heart Society recommend determining the characteristics of chest pain to classify it as typical angina, atypical angina, or non-cardiac chest pain based on quality, location, and duration of pain, factors that trigger and relieve the pain, and response to nitroglycerin 1, 2, 3, 4
Typical angina meets all three criteria: substernal chest discomfort of characteristic quality and duration, provoked by exertion or emotional stress, and relieved by rest and/or nitroglycerin 2, 3
The Canadian Cardiovascular Society Classification assesses severity of symptoms, with Class I being ordinary activity does not cause angina, Class II being slight limitation of ordinary activity, Class III being marked limitation of ordinary activity, and Class IV being inability to carry out any physical activity without discomfort 3, 5
Evaluate cardiovascular risk factors, including smoking, hyperlipidemia, diabetes mellitus, hypertension, family history of premature CAD, and postmenopausal status in women 1, 4, 6, 7

Obtain a 12-lead ECG at rest to look for ST-segment depression, T-wave inversions, or Q waves suggesting previous MI 1, 2, 4
Laboratory tests should include complete blood count, fasting blood glucose and HbA1c, fasting lipid profile, serum creatinine for renal function, and thyroid function tests if clinically indicated 1, 4, 7
Cardiac biomarkers, such as troponin or CK-MB, should be used to exclude acute myocardial injury 3
Chest X-ray is particularly useful in patients with suspected heart failure, valvular disease, or pulmonary disease 3

Patients should be categorized into low, intermediate, or high-risk groups based on clinical features, ECG findings, and biomarker results 2, 4
High-risk features requiring prompt coronary angiography include abnormal ECG consistent with ischemia, positive cardiac biomarkers, hemodynamic instability, and severe symptoms (CCS class III) despite maximal medical therapy 4, 5, 6

Exercise ECG testing is the standard initial test for patients with normal resting ECG, ability to exercise, and no digoxin use 1, 4, 5, 8
Stress imaging, such as echocardiography, nuclear, or MRI, is preferred for patients with abnormal resting ECG, previous revascularization, inability to exercise, or equivocal exercise ECG results 1, 5, 8, 9
Coronary CT angiography may be appropriate for patients with intermediate pretest probability of CAD, normal or nondiagnostic ECG, and normal cardiac biomarkers 4, 8, 10

Echocardiography is indicated for assessment of left ventricular function, evaluation of suspected heart failure, assessment of valvular disease, and patients with abnormal ECG, prior MI, or clinical evidence of heart failure 1, 5, 9

Direct referral for coronary angiography is indicated for patients with high-risk features on non-invasive testing, severe symptoms (CCS class III) despite maximal medical therapy, survivors of sudden cardiac death, congestive heart failure, and special occupational requirements 1, 5, 6, 9

Failing to distinguish between stable and unstable angina, as management pathways differ significantly 2, 10
Overlooking comorbid conditions that may precipitate "functional" angina, such as increased myocardial oxygen demand or decreased myocardial oxygen supply 7, 9
Performing unnecessary repeat testing in patients with known stable CAD and no change in symptoms 5, 9
Neglecting to assess for non-coronary causes of chest pain that may mimic angina 2, 3