Stable angina

Angina, formally known as angina pectoris, is a common symptom of myocardial ischaemia, with an estimated prevalence of 3–4% in adults in the UK (Ford and Berry, 2020). Angina is defined by the National Institute for Health and Care Excellence (NICE, 2016a) as the presence of:

• pain or constricting discomfort in the front of the chest, neck, shoulders, jaw or arms and
• precipitated by physical exertion or emotional stress and
• relieved by rest or sublingual nitrate therapy within approximately 5 minutes of pain onset

Presenting with two of the above is classified as ‘atypical’ pain, while presence of one of the above is classified as ‘non-anginal’ pain.

Angina is typically caused by an identifiable event, such as physical activity, emotional stress, exposure to cold temperatures or after eating a heavy meal (Kloner and Chaitman, 2017). The most common symptom is chest pain, manifesting in an activity-pain-rest-relief sequence.

The pain is usually described as a central, tight pressure, aching or burning in the middle of the chest, which may radiate to the jaw, neck, shoulder or arm, typically lasting 2–5 minutes and relieved by rest.

Atypical symptoms of angina include:

• gastrointestinal discomfort
• dyspnoea
• nausea and vomiting
• upper back pain

Associated symptoms of angina include:

• anxiety or fear
• tachycardia
• pallor

Numerous studies have shown gender-specific differences in symptoms of stable angina. Women tend to experience more severe anginal symptoms, and present with atypical symptoms more often than men (Sharma et al, 2022). Atypical symptoms seen more often in women include prodromal symptoms, such as fatigue, sleep disturbances and

Angina is caused by reduced coronary blood flow, resulting in a temporary imbalance between myocardial oxygen supply and demand. Oxygen demand briefly exceeds supply, causing temporary and reversible myocardial ischaemia, often resulting in symptoms.

Atherosclerotic coronary artery disease is the most common cause of a supply–demand imbalance in myocardial oxygen resulting in angina (Kloner and Chaitman, 2017). Hypermetabolic conditions, including physical exercise, thyrotoxicosis, stimulant use (ie cocaine or methamphetamine) and emotional stress, can also increase myocardial oxygen demand and lead to angina.

Other issues that can affect blood and oxygen supply, causing angina, include:

• aortic valve disease
• microvascular coronary dysfunction
• heart failure
• pulmonary diseases
• oeseophageal spasm and reflux
• anaemia

The diagnosis of angina is based on taking a thorough history and physical examination. A detailed medical history (including the presence of cardiovascular risk factors or heart disease), family history, chest pain and symptom history should be taken (NICE, 2016b). Physical examination should be conducted to identify risk factors for cardiovascular disease, in addition to an examination for signs of other cardiovascular disease and non-coronary causes of angina (ie severe aortic stenosis or hypertrophic cardiomyopathy) (NICE, 2016b).

Laboratory tests, such as high-sensitive troponin I or T, assist in the diagnosis of angina caused by obstructive coronary artery disease (Adamson et al, 2018). They can also help to determine the presence of cardiovascular risk factors, such as elevated blood glucose levels or an abnormal lipid profile (Norhammar et al, 2010). Common diagnostic tests used to assess for coronary artery disease and angina include:

• electrocardiography
• cardiac computed tomography (CT)
• angiography
• stress electrocardiography

The primary aim of angina management is to:

• stop or alleviate symptoms
• improve quality of life
• reduce long-term morbidity
• reduce risk of myocardial infarction
• reduce risk of death (Knuuti et al, 2020)

Optimal anti-anginal drug therapy should be offered, in addition to medications for secondary prevention of coronary artery disease in line with current NICE guidelines (NICE, 2016a).

The patient must be given clear information on stable angina, including factors that can provoke angina, health promotion strategies and risk-factor management. Risk-factor management should include lifestyle advice, such as:

Strategies such as activity pacing and goal setting should also be incorporated to help patients successfully manage their risks (Harwell et al, 2022).

Angina commonly causes feelings of anxiety as a result of the pain and associated symptoms. Instances of anxiety should be explored and addressed, and patients should be provided

Adamson PD, Hunter A, Madsen DM, et al. High-sensitivity cardiac troponin I and the diagnosis of coronary artery disease in patients with suspected angina pectoris. Circ Cardiovasc Qual Outcomes. 2018;11(2):e004227. https://doi.org/10.1161/CIRCOUTCOMES.117.004227

Dancy L, O'Gallagher K, Milton P, Sado D. New NICE guidelines for the management of stable angina. Br J Gen Pract. 2018;68(669):202-203. https://doi.org/10.3399/bjgp18X695693

DeVon HA, Burke LA, Vuckovic KM, et al. Symptoms suggestive of acute coronary syndrome: when is sex important?. J Cardiovasc Nurs. 2017;32(4):383-392. https://doi.org/10.1097/JCN.0000000000000351

Ford TJ, Berry C. Angina: contemporary diagnosis and management. Heart. 2020;106(5):387-398. https://doi.org/10.1136/heartjnl-2018-314661  

Goldfarb MJ, Bechtel C, Capers Q 4th, et al. Engaging families in adult cardiovascular care: a scientific statement from the american heart association. J Am Heart Assoc. 2022;11(10):e025859. https://doi.org/10.1161/JAHA.122.025859

Harwell SM, Tomlinson JS, Brady AJ. Diagnosis and management of stable angina in primary care. InnovAiT. 2022;15(6):362-369. https://doi.org/10.1177/17557380221084730

King-Shier K, Quan H, Kapral MK, et al. Acute coronary syndromes presentations and care outcomes in white, South Asian and Chinese patients: a cohort study. BMJ Open. 2019;9(3):e022479.