Chronic stable angina
Chronic stable angina is reproducible, exertional chest discomfort from fixed coronary stenosis causing demand-related ischemia, relieved by rest or nitroglycerin. Diagnosis combines the typical anginal pattern with stress testing or coronary imaging, and treatment is antianginal and secondary-prevention medical therapy, with revascularization for refractory symptoms or high-risk anatomy.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
Definition: chronic stable angina is reproducible chest discomfort caused by demand-related myocardial ischemia from fixed obstructive coronary artery disease.
- Epidemiology
Common manifestation of coronary artery disease, increasing with age.
- Risk factors
Atherosclerotic risk factors: smoking, diabetes, hypertension, dyslipidemia, and family history.
- Pathophysiology
Fixed stenosis: a stable atherosclerotic plaque limits maximal coronary flow.
- Clinical features
Typical angina: substernal discomfort, provoked by exertion, relieved by rest or nitroglycerin (all three features).
- Differential diagnosis
Unstable angina: rest, new, or crescendo pattern signaling instability, distinguished from stable angina by symptoms at rest or a falling threshold without a troponin rise (unstable angina).
- Diagnosis
Establish from the typical anginal pattern plus objective ischemia or coronary stenosis: chronic stable angina is diagnosed by reproducible exertional discomfort relieved by rest or nitroglycerin…
- Management
First, start anti-ischemic therapy for symptom control: a beta-blocker (metoprolol) as first-line to reduce heart rate and demand, and sublingual nitroglycerin for acute episodes and before exertion.
- Complications
Progression to acute coronary syndrome. Heart failure from ischemic cardiomyopathy.
- Prognosis
Generally good with medical therapy: most patients are controlled medically, with revascularization reserved for refractory symptoms or prognostic anatomy.
- Prevention
Aggressive risk-factor control: high-intensity statin to LDL below 70 mg/dL, blood pressure below 130/80 mmHg, smoking cessation, and diabetes management.
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Unstable angina
Unstable angina is acute myocardial ischemia from a non-occlusive coronary thrombus causing rest, new, or crescendo angina without a troponin rise, placing it on the acute coronary syndrome spectrum just short of NSTEMI. Diagnosis is clinical with ischemic ECG changes and negative serial troponins, and management mirrors NSTE-ACS with antithrombotic therapy and risk-guided angiography.
- Non-ST-elevation myocardial infarction (NSTEMI)
Non-ST-elevation myocardial infarction is acute myocardial injury from partial or intermittent coronary occlusion, diagnosed by ischemic symptoms and a rising troponin without diagnostic ST elevation. Management is antiplatelet and anticoagulant therapy with risk stratification (TIMI or GRACE) guiding the timing of an invasive coronary strategy.
- Vasospastic (Prinzmetal) angina
Vasospastic (Prinzmetal) angina is angina from transient epicardial coronary artery spasm, causing rest chest pain with transient ST elevation, typically at night or in the early morning. Diagnosis rests on documenting spasm or reversible ST changes, and treatment is calcium channel blockers and nitrates while strictly avoiding non-selective beta-blockers and triggers.
- Aortic stenosis
Aortic stenosis is obstruction to left ventricular outflow from a narrowed aortic valve, most often calcific degeneration in older adults or a bicentric bicuspid valve earlier in life. Symptoms of angina, syncope, or heart failure mark a poor prognosis, and severe symptomatic disease is treated with valve replacement (surgical or transcatheter).
- Gastroesophageal reflux disease (GERD)
GERD is retrograde reflux of gastric contents into the esophagus causing heartburn and regurgitation, diagnosed clinically and confirmed by response to an empiric PPI trial, with endoscopy reserved for alarm features or refractory symptoms. Management proceeds from lifestyle measures through an 8-week once-daily PPI trial, dose escalation or agent switch for partial response, and fundoplication for medication-refractory or regurgitation-predominant disease.
- Pulmonary embolism
Pulmonary embolism is thrombus, usually from a lower-extremity deep vein thrombosis, obstructing the pulmonary arterial circulation and causing V/Q mismatch, right ventricular strain, and hypoxemia. Diagnosis follows Wells criteria (with PERC in low-risk patients) to sequence D-dimer, CT pulmonary angiography, and V/Q scanning, and management is risk-stratified anticoagulation escalating to thrombolysis or embolectomy for hemodynamic instability.