Angina pectoris is characterised as chest pain/pressure caused by reduced blood flow to the heart muscles, lasting over 30 seconds; it is often a symptom of ischemic or coronary heart disease. It is recognised as a serious predictor of adverse cardiac events and it impedes the individual’s quality of life. Approximately 10 million individuals in the US suffer from angina. Overall, angina can be separated into stable (symptoms only occurring upon exertion) and unstable (symptoms occurring at rest).

Hermiz C & Sedhai Y (2022). Angina, StatPearls [Internet] Treasure Island (FL): StatPearls Publishing
Chronic Coronary Syndromes (CCS) remain a major health burden globally. A decline in mortality from acute events has been observed, but many patients progress to develop ischaemic heart failure. In the future, there will be an increase in chronic manifestations of CCS, such as stable angina, due to the ageing population and the obesity and diabetes epidemics. Chronic stable angina, in its various clinical presentations, can be caused by obstruction of large epicardial arteries or by non-obstructive mechanisms, including coronary epicardial spasm and coronary microvascular dysfunction. This dysfunction can be caused by both functional and structural alterations. Obstructive coronary artery disease, coronary spasm and coronary microvascular dysfunction can coexist in the same patients. This is why angina can persist after successful coronary revascularization in many patients.
  1. Kaski JC, Crea F, Gersh BJ, et al. Reappraisal of Ischemic Heart Disease. Circulation 2018;138:1463-1480.
  2. Cannon RO, 3rd, Watson RM, Rosing DR, et al. Angina caused by reduced vasodilator reserve of the small coronary arteries. J Am Coll Cardiol 1983;1:1359-1373.
  3. Crea F. Doctor, I feel microvascular chest pain. Eur Heart J 2020;41:3219-3221.
  4. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020;41:407-477.
  5. Beltrame JF, Crea F, Kaski JC, et al. International standardization of diagnostic criteria for vasospastic angina. Eur Heart J 2017;38:2565-2568.
  6. Ong P, Camici PG, Beltrame JF, et al. International standardization of diagnostic criteria for microvascular angina. Int J Cardiol 2018;250:16-20.
The 2019 guidelines of the European Society of Cardiology (ESC) recognise that chronic coronary diseases may have many different facets. These are a dynamic process of plaque accumulation and functional changes in coronary circulation that can be modified by lifestyle changes, pharmacological therapies and revascularisation. Implementation programmes are needed because it has been shown that the thorough application of clinical recommendations may favourably influence the outcome of the disease.

Some of the key changes in the updated guidelines are:

  • Revision to focus on chronic coronary syndromes (CCS) instead of stable CAD.
  • The prevalence of CAD in symptomatic populations has decreased, leading to a lower pre-test probability of disease. This has a significant impact on the use of diagnostic testing.
  • Imaging has advanced – both anatomy and function are available invasively and non-invasively. The role of CT is increasing.
  • New evidence on intensified antithrombotic therapy. However, these guidelines have important limitations, especially regarding applicability. It seems they are aimed at rich countries.
  1. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020;41:407-477.
Angina treatment should be tailored according to guidelines and the “Diamond” approach. The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial published in 2007 demonstrated that an initial strategy of percutaneous coronary intervention (PCI) added to optimal medical therapy (OMT) did not reduce death, myocardial infarction, or other major cardiovascular events compared with OMT alone. So OMT remains a key component of therapy and should involve:
  • Adequate timing of intervention
  • Proper identification of high-risk patients
  • Taking into account regional differences and cultural specificities
Aims of pharmacological management Reduce angina symptoms and exercise-induced ischaemia Prevent cardiovascular events Optimal treatment Treatment that satisfactorily controls symptoms and prevents cardiac events With maximal patient adherence and minimal adverse events
  1. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020;41:407-477.
  2. Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356:1503-1516.
  3. Boden WE. Interpreting the results of the COURAGE trial: a non-interventionalist perspective. Rev Cardiovasc Med 2009;10 Suppl 2:S34-44.
  4. Boden WE, Hartigan PM, Mancini J, et al. Risk Prediction Tool for Assessing the Probability of Death or Myocardial Infarction in Patients With Stable Coronary Artery Disease. Am J Cardiol 2020;130:1-6.
Angina is multifactorial, and medical therapy for its control should be tailored according to the guidelines and the “Diamond” approach. A key step is the initial risk stratification of suspected coronary artery disease (CAD). The main diagnostic pathways are described here:
  1. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. 2018;67:328-57
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