Stable angina is predictable chest discomfort that appears with exertion or stress and settles within minutes of rest or nitroglycerin. It happens when a fixed narrowing in a coronary artery cannot supply enough blood when the heart works harder.
Key symptoms
- Pressure, tightness or heaviness behind the breastbone during effort
- Pain spreading to the arm, neck, jaw or back
- Relief within about 5 minutes of rest or nitroglycerin
- Breathlessness or fatigue on effort, common in women, older adults and diabetes
What you find on exam
- Often normal between episodes
- Blood pressure, BMI and signs of vascular disease such as bruits or weak pulses
- Murmur of aortic stenosis as another cause of exertional pain
- Signs of high cholesterol such as xanthelasma
Tests
- Resting 12-lead ECG
- Lipid panel, HbA1c and kidney function
- Stress test (exercise ECG, stress echo or nuclear) or coronary CT angiography
- Coronary angiography if high risk or symptoms persist
Treatment basics
- Sublingual nitroglycerin as needed
- Beta blocker such as metoprolol, or a calcium channel blocker, to prevent attacks
- Aspirin and a high-intensity statin such as atorvastatin
- Control blood pressure, diabetes and smoking; regular exercise
- Revascularization with stent or bypass if symptoms persist or anatomy is high risk
Red flags
- Pain at rest or lasting more than 20 minutes
- Pain that is new, more frequent or comes with less effort
- Chest pain with fainting, heavy sweating or breathlessness
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.