Investigation and Management of Stable Angina

Initial Diagnostic Approach

• The European Society of Cardiology recommends exercise ECG as the initial non-invasive test of choice to confirm diagnosis and assess prognosis in patients with suspected stable angina 1
• A comprehensive history and physical examination focusing on character, duration, and triggers of chest pain, cardiovascular risk factors, and family history of premature coronary disease is essential 1

Diagnostic Testing

• Resting 12-lead ECG is recommended in all patients with suspected stable angina 1
• Fasting lipid panel and glucose are recommended to assess metabolic risk factors 5, 6

Management Strategy

• The American College of Cardiology recommends aspirin 75-100 mg daily for all patients without contraindications 1, 2, 4, 3
• High-intensity statin therapy is recommended to target LDL-C <70 mg/dL when possible 1, 2, 3
• ACE inhibitors are indicated for patients with coexisting ventricular dysfunction, hypertension, diabetes, or prior MI with LV dysfunction 1, 2, 4, 3

Symptomatic Anti-Anginal Therapy

• Beta-blockers are the preferred initial anti-anginal agent due to mortality benefits in post-MI patients and proven symptom control 1, 2, 4, 3
• Calcium channel blockers can be added or substituted if beta-blockers are contraindicated, not tolerated, or symptoms persist despite optimal dosing 1, 3

Aggressive Risk Factor Modification

• Smoking cessation, Mediterranean diet, aerobic exercise, weight reduction, blood pressure control, and strict glycemic control are mandatory interventions 1, 2, 4, 3, 6

Coronary Revascularization

• Coronary arteriography should be undertaken when symptoms are not satisfactorily controlled by medical therapy with two anti-anginal drugs at optimal doses 2, 4, 3
• CABG reduces mortality in specific high-risk subgroups, including left main stenosis ≥50%, three-vessel disease, especially with impaired LV function, and two-vessel disease with proximal LAD stenosis 2, 4, 3, 6

Follow-Up Monitoring

• Routine follow-up every 4-6 months is recommended to assess angina frequency, nitroglycerin use, functional capacity, medication adherence, and physical examination 5, 6
• Repeat stress testing is indicated when there is a significant change in symptoms, new symptoms suggesting progression, or before revascularization 5, 6