Angina

Angina develops when atherosclerosis affects the coronary arteries, leading to narrowing of the vessel lumen and reduced blood flow to the myocardium (heart muscle). When myocardial oxygen demand increases—such as during physical exertion—the compromised blood supply is unable to meet demand. This mismatch produces the characteristic symptoms of angina, most commonly a tight or constricting chest pain, which may radiate to the jaw, neck, shoulders, or arms.

Angina is described as stable when symptoms are consistently triggered by exertion and are reliably relieved by rest or glyceryl trinitrate (GTN).

It is considered unstable when chest pain occurs unpredictably or at rest. Unstable angina falls under the spectrum of acute coronary syndrome (ACS) and requires urgent medical treatment.

Investigations

All patients with suspected angina should undergo baseline assessment including:

• Clinical examination (e.g. heart sounds, signs of heart failure, blood pressure, and BMI)
• ECG (note that a normal ECG does not rule out stable angina)
• Full blood count (FBC) to assess for anaemia
• Urea and electrolytes (U&Es), required before initiating ACE inhibitors and other therapies
• Liver function tests (LFTs) prior to starting statins
• Lipid profile
• Thyroid function tests (to assess for hypo- or hyperthyroidism)
• HbA1c and fasting glucose to screen for diabetes

Cardiac Stress Testing

Stress testing evaluates cardiac function under increased workload. This can be achieved either through physical exercise (such as treadmill walking) or pharmacologically (for example, using dobutamine).

Cardiac response during stress may be assessed using:

• ECG
• Echocardiography
• Cardiac MRI
• Myocardial perfusion scanning (nuclear medicine imaging)

CT Coronary Angiography

CT coronary angiography involves intravenous contrast administration followed by CT imaging synchronised with the cardiac cycle. This technique provides high-resolution images of the coronary arteries, allowing identification and localisation of arterial narrowing.

Invasive Coronary Angiography

Invasive coronary angiography is performed in a catheter laboratory and is considered the gold standard for diagnosing coronary artery disease.

A catheter is inserted into either the brachial or femoral artery and advanced through the arterial system to the coronary arteries under X-ray guidance. Contrast dye is injected, allowing visualisation of the coronary arteries and detection of stenotic lesions on fluoroscopic imaging.

Management

The management approach outlined below is based on NICE clinical knowledge summaries on stable angina (August 2022), chest pain (October 2022), and the SIGN guidelines (2018).

Management can be remembered using the “RAMPS” mnemonic:

• R – Refer to cardiology
• A – Advise on diagnosis, treatment, and when to seek emergency care
• M – Medical therapy
• P – Procedural or surgical treatment
• S – Secondary prevention

Patients are typically referred to a rapid access chest pain clinic (RACPC).

Medical Management

Medical treatment has three main objectives:

1. Rapid relief of acute angina symptoms
2. Long-term reduction of symptom frequency and severity
3. Prevention of future cardiovascular events

Immediate Symptom Relief

Acute episodes are treated with sublingual glyceryl trinitrate (GTN), available as tablets or spray. GTN works by causing vasodilation, improving myocardial blood flow.

Patients should be advised to:

• Take GTN as soon as symptoms begin
• Repeat the dose after 5 minutes if pain persists
• Call an ambulance if pain continues 5 minutes after the second dose

Common adverse effects include headache and dizziness due to vasodilation.

Long-Term Symptom Control

First-line therapy consists of either (or both):

• Beta blockers (e.g. bisoprolol)
• Calcium channel blockers (e.g. diltiazem or verapamil, avoided in heart failure with reduced ejection fraction)

If symptoms persist, specialist input may lead to the addition of:

• Long-acting nitrates (e.g. isosorbide mononitrate)
• Ivabradine
• Nicorandil
• Ranolazine

Secondary Prevention Medications

Secondary prevention can be recalled using the “four As”:

• Aspirin 75 mg once daily
• Atorvastatin 80 mg once daily
• ACE inhibitor (if co-existing diabetes, hypertension, CKD, or heart failure)
• Already prescribed beta blocker for symptom control

Surgical and Procedural Management

Revascularisation is considered for patients with significant disease or persistent symptoms despite optimal medical therapy. The two main options are:

• Percutaneous coronary intervention (PCI)
• Coronary artery bypass grafting (CABG)

Percutaneous Coronary Intervention (PCI)

PCI involves inserting a catheter via the brachial or femoral artery and advancing it to the coronary circulation under X-ray guidance. Contrast dye highlights areas of narrowing.

Stenotic segments may be treated by:

• Balloon dilation (angioplasty)
• Placement of a stent to maintain vessel patency

This is commonly referred to as coronary angioplasty with stenting.

Coronary Artery Bypass Grafting (CABG)

CABG is typically reserved for patients with severe or complex coronary artery disease. The procedure involves a midline sternotomy to access the heart.

A graft vessel is connected beyond the narrowed coronary segment to bypass the obstruction. Common graft choices include:

• Saphenous vein (from the inner leg)
• Internal thoracic (internal mammary) artery
• Radial artery

PCI vs CABG Outcomes

Short- and medium-term outcomes are broadly similar between PCI and CABG. However, PCI is associated with:

• Faster recovery times
• Lower stroke risk
• Higher likelihood of requiring repeat revascularisation

TOM TIP: In OSCE examinations, inspect for scars that may indicate prior coronary interventions—such as a midline sternotomy scar (CABG), brachial or femoral scars (PCI), or inner leg scars from saphenous vein harvesting.

Cardiac Syndrome X

Cardiac syndrome X presents with angina-like chest pain despite normal coronary arteries on angiography. It most commonly affects women during the peri- or post-menopausal period, typically between ages 45 and 55.

The underlying mechanism is unclear but may involve:

• Dysfunction of the coronary microvasculature
• Heightened myocardial pain sensitivity with a reduced pain threshold

This condition is a diagnosis of exclusion, made only after comprehensive investigation has ruled out coronary artery disease and other causes. Symptomatic treatment mirrors standard medical therapy for angina.

Last updated January 2026