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Key Clinical Updates in Chronic Stable Angina Pectoris (Chronic Coronary Syndromes)
The role of routine functional stress testing following PCI to improve patient outcomes was analyzed in a randomized study of 1706 patients. There was no difference in all-cause death, MI, or hospitalization for unstable angina between those assigned to surveillance stress testing at 1 year following PCI or those receiving standard care, strongly arguing against a role for routine stress testing in asymptomatic patients post-PCI.
Park DW et al; POST-PCI Investigators. N Engl J Med. [PMID: 36036496]
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ESSENTIALS OF DIAGNOSIS
Precordial chest pain, usually precipitated by stress or exertion, relieved rapidly by rest or nitrates.
ECG or scintigraphic evidence of ischemia during pain or stress testing.
Angiographic demonstration of significant obstruction of major coronary vessels.
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GENERAL CONSIDERATIONS
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Angina pectoris is the manifestation of stable CAD or chronic coronary syndromes, and it is usually due to atherosclerotic heart disease. Coronary vasospasm may occur at the site of a lesion or, less frequently, in apparently normal vessels. Other unusual causes of coronary artery obstruction, such as congenital anomalies, emboli, arteritis, or dissection, may cause ischemia or infarction. Angina may also occur in the absence of coronary artery obstruction as a result of severe myocardial hypertrophy, severe aortic stenosis or regurgitation, or in response to increased metabolic demands, as in hyperthyroidism, marked anemia, or paroxysmal tachycardias with rapid ventricular rates. Rarely, angina occurs with angiographically normal coronary arteries and without other identifiable causes. This presentation has been labeled syndrome X and is most likely due to inadequate flow reserve in the resistance vessels (microvasculature). Syndrome X remains difficult to diagnose. Although treatment is often not very successful in relieving symptoms, the prognosis of syndrome X is good.
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The diagnosis of angina pectoris principally depends on the history, which should specifically include the following information: circumstances that precipitate and relieve angina, characteristics of the discomfort, location and radiation, duration of attacks, and effect of nitroglycerin.
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1. Circumstances that precipitate and relieve angina
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Angina occurs most commonly during activity and is relieved by resting. Patients may prefer to remain upright rather than lie down, as increased preload in recumbency increases myocardial work. The amount of activity required to produce angina may be relatively consistent under comparable physical and emotional circumstances or may vary from day to day. The threshold for angina is usually lower after meals, during excitement, or on exposure to cold. It is often lower in the morning or after strong emotion; the latter can provoke attacks in the absence of exertion. In addition, discomfort may occur during sexual activity, at rest, or at night as a result of coronary spasm.
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2. Characteristics of the discomfort
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Patients often do not refer to angina ...