Stable anginaMANAGEMENT

CARDIOVASCULAR PRESENTATIONS · 12 SECTIONS

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454 items

☷ Legend

01Approach to the Critical Patient/attcp39

Immediate safety screen

›Rule out unstable features

›Rest pain

›Crescendo pattern

›New onset severe limitation

›Pain with syncope

›Pain with hypotension

›Pain with acute dyspnea

›Pain with diaphoresis

›Pain with vomiting

›New neurologic deficit

›Suspected aortic syndrome features

›Suspected pulmonary embolism features

›Suspected pericarditis features

›If unstable features present, manage as acute coronary syndrome pathway

Monitoring and access

›Monitoring and access

›Cardiac monitor

›Ischemic symptoms during observation

›Arrhythmia during observation

›Blood pressure both arms

›Marked interarm difference

›Symptom reproduction with exertion

›IV access

›If ongoing pain, analgesia and anti-ischemic therapy

›If hemodynamic instability, escalation to resuscitation setting

Early diagnostics and risk framing

›Early diagnostics and risk framing

›12 lead ECG

›If dynamic ischemic changes, treat as acute coronary syndrome

›Baseline abnormalities limiting stress ECG interpretation

›High sensitivity troponin strategy if active symptoms or uncertainty

›If elevated with rise or fall, treat as acute coronary syndrome

›If normal with stable pattern and stable symptoms, outpatient pathway possible

›Pretest probability estimate for obstructive CAD

›Age

›Sex

›Symptom typicality

›Risk factor burden

›Shared decision making framing

›Goal of testing is event risk reduction and symptom guidance

›Goal of therapy is symptom control and long term prevention

02History/hx44

Symptom pattern and triggers

›Chest discomfort pattern

›Exertional trigger

›Predictable threshold

›Relief with rest

›Relief with nitroglycerin

›Typical location

›Radiation pattern

›Pressure tightness heaviness

›Duration minutes

›Frequency per week

›Recent change in threshold

›Associated dyspnea

›Associated fatigue

›Associated diaphoresis

Functional limitation and classification

›Functional limitation

›Activities that trigger symptoms

›Baseline exercise capacity

›Canadian Cardiovascular Society class estimate

›Occupational safety implications

›Driving safety implications

Cardiovascular history and risk

›Atherosclerotic risk context

›Hypertension

›Diabetes

›Dyslipidemia

›Tobacco use

›Chronic kidney disease

›Family history premature CAD

›Prior MI

›Prior PCI

›Prior CABG

›Prior stroke or TIA

›Peripheral arterial disease

Medication and contraindication screen

›Medication context

›Current antiplatelet use

›Current anticoagulant use

›Beta blocker use

›Calcium channel blocker use

›Nitrate use

›PDE5 inhibitor use within 24 to 48 hours

›Statin use and tolerance

›ACE inhibitor or ARB use

›Asthma or bronchospasm history

›Bradycardia history

›Hypotension history

03Physical Exam/exam24

Cardiovascular and perfusion

›Cardiovascular and perfusion

›Vital signs trend

›Orthostatic symptoms

›Peripheral pulses symmetry

›Capillary refill

›Jugular venous pressure

›New murmur

›S3 gallop

›Peripheral edema

Pulmonary and alternate causes

›Pulmonary and alternate causes

›Work of breathing

›Lung crackles

›Wheeze

›Pleural rub

›Chest wall tenderness reproducibility

High risk comorbidity findings

›High risk comorbidity findings

›Signs of heart failure

›Signs of anemia

›Signs of thyroid disease

›Signs of peripheral arterial disease

›Neurologic deficits

PITFALLS

›Pitfalls

›Normal exam does not exclude coronary ischemia

›Reproducible tenderness does not exclude concurrent ischemia

04Differential Diagnosis/ddx23

Life threatening and must not miss

›Must not miss causes of chest pain

›Acute coronary syndrome

›Unstable angina ICD-10 I20.0

›NSTEMI ICD-10 I21.4

›STEMI ICD-10 I21.0 to I21.3

›Aortic dissection ICD-10 I71.0

›Pulmonary embolism ICD-10 I26

›Tension pneumothorax ICD-10 J93

›Esophageal rupture ICD-10 K22.3

›Pericardial tamponade ICD-10 I31.4

Stable ischemic syndromes and mimics

›Stable ischemic syndromes and mimics

›Stable angina pectoris ICD-10 I20.8

›Chronic ischemic heart disease ICD-10 I25

›Microvascular angina

›Vasospastic angina

›Hypertrophic cardiomyopathy

›Aortic stenosis

›Anemia related supply demand mismatch

›Hyperthyroidism related demand mismatch

›GERD

›Esophageal spasm

›Costochondritis

›Panic disorder

05Laboratory Tests/lt30

Baseline cardiometabolic risk labs

›Baseline cardiometabolic profile

›Lipid panel mmol/L

›LDL cholesterol mmol/L for treatment targets

›Non HDL cholesterol mmol/L for treatment targets

›Hemoglobin A1c percent

›Diabetes diagnosis and control

›Prediabetes risk framing

›Creatinine and eGFR

›Medication dosing

›Contrast planning

›Electrolytes

›Potassium optimization for arrhythmia risk

›Magnesium optimization when indicated

Ischemia and acute change screen

›Ischemia and acute change screen

›High sensitivity troponin strategy when symptoms recent or atypical

›Serial pattern for rise or fall

›Chronic elevation pattern in CKD consideration

›BNP or NT proBNP when heart failure suspected

›Supports volume and structural disease evaluation

›Does not localize ischemia

Contributing condition screen

›Contributing conditions

›Complete blood count for anemia

›Symptom threshold lowering with low hemoglobin

›Bleeding risk context for antiplatelet therapy

›TSH when thyroid disease suspected

›Demand mismatch contributor

›Rate control implications

›Liver enzymes baseline when high intensity statin planned

›Pre existing liver disease context

›Persistent symptoms evaluation if later transaminitis

06Diagnostic Tests/dt69

Scoring Systems

›Structured risk and symptom scales

›Canadian Cardiovascular Society angina class

›Class I ordinary activity no angina

›Class II slight limitation

›Class III marked limitation

›Class IV angina at rest or minimal activity

›Duke Treadmill Score for exercise ECG

›Exercise time minutes

›ST deviation mm

›Angina index

›Low risk score 5 or higher

›Intermediate risk score minus 10 to 4

›High risk score minus 11 or lower

›Pretest probability model for obstructive CAD

›Age

›Sex

›Typicality typical atypical non anginal

MRI

›Cardiac MRI options

›Stress perfusion MRI

›When intermediate pretest probability and need ischemia assessment

›Avoids ionizing radiation

›Viability assessment

›Late gadolinium enhancement for scar

›Guides revascularization benefit assessment in select cases

›Contraindications and cautions

›Non MRI compatible devices

›Severe claustrophobia

›Advanced CKD and gadolinium risk context

›Coronary CT angiography

›Best fit scenarios

›Low to intermediate pretest probability

›Need anatomic assessment

›Non diagnostic or uninterpretable resting ECG for stress ECG

›Practical requirements

›Heart rate control goal

›Beta blocker protocol per local pathway

›Limitations

›High coronary calcium burden

›Inability to hold breath

›Contrast allergy

›Advanced CKD contrast risk

›Coronary artery calcium score option

›Risk refinement in selected asymptomatic or equivocal cases

›Does not localize stenosis severity reliably

Ultrasound

›Cardiac ultrasound adjuncts

›Point of care echo when alternative diagnosis suspected

›LV systolic function estimate

›Pericardial effusion screen

›Stress echo

›Exercise or pharmacologic

›Wall motion ischemia detection

›Vascular ultrasound

›Carotid disease screening only when clinically indicated

›Peripheral arterial disease assessment when symptoms present

Functional ischemia testing

›Functional ischemia tests

›Exercise ECG treadmill

›Interpretable baseline ECG requirement

›Adequate exercise ability requirement

›Nuclear perfusion imaging

›When baseline ECG uninterpretable

›When inability to exercise and pharmacologic needed

›Stress echo

›When radiation avoidance preferred

›Valve and structure evaluation combined benefit

Invasive coronary angiography

›Invasive angiography pathways

›High risk noninvasive test findings

›Refractory symptoms despite guideline directed therapy

›Suspected left main disease

›Ventricular dysfunction with ischemia concern

07Disposition/dispo24

Emergency versus outpatient pathway

›Site of care decision

›Emergency management triggers

›Rest pain within 24 hours

›Dynamic ECG ischemia

›Troponin rise or fall

›Hemodynamic instability

›Ventricular arrhythmia

›Suspected alternate life threat diagnosis

›Outpatient management criteria

›Predictable exertional symptoms

›No rest symptoms

›Stable ECG without dynamic changes

›No biomarker evidence of myocardial injury when checked

Follow up and testing timelines

›Follow up and testing

›Cardiology follow up expedited for high symptom burden

›Noninvasive testing selection based on pretest probability and ECG interpretability

›Symptom reassessment interval

›Medication titration interval

Admission considerations

›Admission considerations

›New heart failure signs

›Syncope with exertional chest pain

›Severe anemia

›Significant arrhythmia

›Inadequate outpatient support

08Treatment/t104

Anti ischemic symptom control

›Symptom control strategy

›Short acting nitrate

›Nitroglycerin SL 0.4 mg

›If persistent symptoms, repeat every 5 minutes

›Maximum 3 doses

›Avoid with PDE5 inhibitor recent use

›Sildenafil or vardenafil within 24 hours

›Tadalafil within 48 hours

›Common adverse effects

›Headache

›Hypotension

›Beta blocker first line when no contraindication

›Metoprolol tartrate PO 25 to 50 mg twice daily

›Titrate every 1 to 2 weeks

›Resting heart rate target 55 to 60 per minute if tolerated

›Bisoprolol PO 2.5 to 5 mg daily

›Titrate to 10 mg daily

›Bradycardia monitoring

›Contraindications and cautions

›Symptomatic bradycardia

›High grade AV block without pacing

›Decompensated heart failure

›Severe bronchospasm

›Calcium channel blocker option

›Amlodipine PO 5 mg daily

›Titrate to 10 mg daily

›Edema monitoring

›Diltiazem extended release PO 120 to 180 mg daily

›Titrate to 360 mg daily

›Avoid with reduced EF heart failure

›Verapamil extended release PO 120 to 180 mg daily

›Titrate to 480 mg daily

›Constipation monitoring

›Long acting nitrate option for persistent symptoms

›Isosorbide mononitrate extended release PO 30 mg daily

›Titrate to 60 mg daily

›Nitrate free interval to reduce tolerance

›Isosorbide dinitrate PO 10 to 20 mg three times daily

›Titrate as tolerated

›Headache and hypotension monitoring

›Ranolazine option for persistent symptoms

›Ranolazine PO 500 mg twice daily

›Titrate to 1000 mg twice daily

›QT prolongation monitoring

›Drug interaction screen

›Strong CYP3A inhibitors

›Significant hepatic impairment

Event prevention and disease modification

›Secondary prevention core

›Antiplatelet therapy

›Aspirin PO 75 to 100 mg daily

›Class I recommendation in chronic coronary disease secondary prevention

›Avoid if true aspirin allergy or active bleeding

›Clopidogrel PO 75 mg daily alternative

›For aspirin intolerance

›CYP2C19 interaction awareness

›Statin therapy

›Atorvastatin PO 40 to 80 mg daily

›LDL cholesterol reduction goal 50 percent or greater

›LDL cholesterol target individualized high risk often below 1.8 mmol/L

›Rosuvastatin PO 20 to 40 mg daily

›LDL cholesterol reduction goal 50 percent or greater

›Myopathy and liver enzyme symptom monitoring

›Add on therapy when targets not met

›Ezetimibe PO 10 mg daily

›LDL cholesterol further reduction

›PCSK9 inhibitor per local formulary

›Very high risk and persistent LDL elevation

›ACE inhibitor or ARB when indicated

›Ramipril PO 2.5 mg daily

›Titrate to 10 mg daily

›Indications diabetes CKD hypertension reduced EF

›Losartan PO 25 to 50 mg daily

›Titrate to 100 mg daily

›Hyperkalemia monitoring

›Blood pressure control

›Target systolic blood pressure individualized often below 130 mmHg

›Target diastolic blood pressure individualized often below 80 mmHg

›Avoid excessive lowering with symptomatic hypotension

›Diabetes risk reduction

›SGLT2 inhibitor in diabetes with ASCVD per local guideline

›GLP1 receptor agonist in diabetes with ASCVD per local guideline

›Renal function and contraindication screening

Lifestyle and rehabilitation

›Lifestyle and rehab

›Smoking cessation

›Nicotine replacement therapy options

›Varenicline option if appropriate

›Exercise prescription

›Cardiac rehabilitation referral

›Gradual aerobic progression without provoking angina

›Nutrition pattern

›Mediterranean style eating pattern

›Sodium reduction for hypertension

›Weight management

›Waist circumference risk framing

›Sleep apnea screen when suggested

Revascularization and referral triggers

›Revascularization considerations

›High risk ischemia on testing

›Large territory ischemia

›Left main equivalent patterns

›Refractory angina despite optimized therapy

›Frequent nitroglycerin use

›Persistent CCS class III to IV limitation

›LV dysfunction with ischemia concern

›Expedited cardiology evaluation

09Special Populations/sp27

Pregnancy

›Pregnancy considerations

›Rare presentation and high stakes evaluation

›Spontaneous coronary artery dissection risk consideration

›Preeclampsia and demand mismatch consideration

›Medication safety constraints

›Avoid ACE inhibitor and ARB

›Avoid statins

›Anti ischemic options

›Beta blocker selection per obstetric guidance

›Nitrates for symptom control if blood pressure stable

Geriatric

›Geriatric considerations

›Atypical symptoms

›Dyspnea as angina equivalent

›Fatigue and weakness presentations

›Polypharmacy risks

›Hypotension and falls

›Bradycardia and conduction disease

›Testing selection

›Exercise limitation and need for pharmacologic stress imaging

›CKD and contrast risk with CT

Pediatrics

›Pediatrics considerations

›True atherosclerotic stable angina uncommon

›Congenital coronary anomalies consideration

›Kawasaki disease sequelae consideration

›Specialist pathway

›Pediatric cardiology referral

›Advanced imaging selection per pediatric protocols

10Background/b29

Epidemiology

›Epidemiology

›Stable angina reflects chronic coronary disease spectrum

›Increasing prevalence with age

›Higher risk with diabetes and CKD

›Major adverse cardiovascular event risk

›Risk modified by symptom burden and ischemia extent

›Risk reduced with guideline directed therapy

Pathophysiology

›Pathophysiology

›Supply demand mismatch from fixed coronary stenosis

›Increased demand during exertion

›Reduced supply with stenosis

›Endothelial dysfunction contribution

›Microvascular dysfunction mechanisms

›Vasospasm mechanisms

›Ischemia consequences

›Subendocardial ischemia

›Arrhythmia vulnerability

Therapeutic Considerations

›Therapeutic considerations

›Symptom relief mechanisms

›Beta blockers reduce heart rate and contractility

›Nitrates reduce preload and improve coronary perfusion

›Calcium channel blockers reduce afterload and spasm

›Disease modification mechanisms

›Statins stabilize plaque and lower LDL cholesterol

›Antiplatelets reduce thrombotic events

›ACE inhibitor benefits in high risk vascular disease

›Guideline aligned strategy

›Class I secondary prevention for ASCVD risk reduction

›Class I antianginal therapy individualized to comorbidities

11Patient Discharge Instructions/pdi27

Copy discharge instructions

›Discharge instructions

›Diagnosis explanation

›Stable angina is exertional chest discomfort from reduced coronary blood flow

›Stable pattern means predictable with similar triggers

›Medication plan

›Nitroglycerin SL use

›Sit or lie down before dose

›If pain persists after 1 dose, emergency services activation

›Activity guidance

›Avoid exertion that triggers symptoms until treatment optimized

›Gradual return with rehab plan

›Risk reduction

›Smoking cessation

›Daily walking plan within symptom limits

›Heart healthy diet pattern

›Return to ED now

›Chest pain at rest

›Chest pain lasting more than 10 minutes

›Chest pain not relieved after 1 nitroglycerin dose

›Severe shortness of breath

›Fainting

›New weakness or trouble speaking

›Palpitations with dizziness

›Follow up

›Primary care appointment within 1 week

›Cardiology appointment timeline per risk

›Testing appointment scheduling instructions

12References/r14

Clinical Guidelines and consensus

›Guideline sources

›ACC AHA chronic coronary disease guideline

›Secondary prevention Class I recommendations

›Antianginal medication sequencing guidance

›ESC chronic coronary syndromes guideline

›Pretest probability and testing selection framework

›Medical therapy and revascularization indications

Evidence based sources

›Evidence based sources

›Trials supporting statins in chronic coronary disease

›High intensity statin risk reduction outcomes

›Trials supporting antiplatelet therapy in stable CAD

›Aspirin event reduction outcomes

›Trials comparing PCI plus medical therapy versus medical therapy alone

›Symptom relief and event outcomes frameworks

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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