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Ischemic Heart Disease – Stable Angina

Written by: Thabet Zidan, M.D.

Overview

Ischemic Heart Disease (IHD) occurs when there is a reduced blood supply to the heart muscle due to narrowed or blocked coronary arteries, often caused by atherosclerosis. Stable angina, a common manifestation of IHD, presents as predictable chest pain triggered by exertion or emotional stress and relieved by rest or nitroglycerine. The diagnosis of stable angina involves clinical evaluation, stress testing, and coronary angiography. Management includes lifestyle modifications, pharmacological therapy, and in some cases, invasive procedures.

Buzzwords scenario: An elderly male presents to his primary care physician with complaints of chest pain that occurs during physical activity. The episodes last for about 5-10 minutes and are relieved by rest. ECG and cardiac enzymes are normal.

Keywords: Stable Angina, Ischemic Heart Disease, Atherosclerosis, Chest Pain, Stress Testing, Coronary Angiography

Definition

Stable Angina is a type of chest pain or discomfort that occurs with activity or stress and is relieved by rest or nitroglycerine.

Epidemiology

Ischemic Heart Disease:

● Gender: Males > Females.

● Age: More common in older age.

● Prevalence: 197.2 million people worldwide live with IHD; with 20.1 million people in the United States.

● Geographic distribution: Men in South Asia, particularly India and the Middle East, are highly affected.

Stable Angina:

● Gender: Males constitute ~70% of all patients with stable angina.

● Age: Typically males > 50 years and females >60 years.

Etiology

The most common cause of stable angina and ischemic heart disease is Atherosclerosis. Risk factors are divided into:

● Non-modifiable: Age, gender, family history, genetic predisposition.

● Modifiable: Hypertension, dyslipidemia, diabetes, smoking, obesity, sedentary lifestyle, poor diet.

Pathophysiology

● Atherosclerosis: Plaque buildup in coronary arteries narrows the lumen, reducing blood flow.

● Oxygen demand vs. supply: Angina occurs when myocardial oxygen demand exceeds supply, especially during exertion or stress.

Clinical Features

Table 1: Clinical features of stable angina.

Category	Description
Typical angina pain	− Retrosternal pain described as pressure, tightness, squeezing, or burning − Triggered by exertion or emotional stress − Relieved by rest and/or nitroglycerine − Pain may radiate to the jaw, neck, shoulders, or arms. − Duration: 2 – 5 minutes.
Anginal equivalents	− Dyspnea, nausea, fatigue, and faintness.
Physical examination	− Check for atherosclerotic signs, peripheral arterial disease.

NOTE: Anginal equivalents are more common in women, diabetics, and elderly.

Differential Diagnosis of Chest Pain

Table 2: Differential diagnoses of chest pain.

System/Condition	Onset and Description	Location & Associated Symptoms
Cardiac
Myocardial ischemia	Pressure, tightness, squeezing, or burning	Retrosternal; may spread to neck, jaw, shoulders, arms; sometimes to the epigastric region
Pericarditis	Sharp, pleuritic	Retrosternal or near the heart's apex; may radiate to left shoulder; relieved by sitting up and leaning forward
Vascular
Aortic dissection	Sudden; tearing, ripping, or knife-like pain	Anterior chest; can radiate to the back between shoulder blades; often associated with high blood pressure, aortic insufficiency, or loss of pulses
Pulmonary embolism	Sudden; pleuritic, with heaviness in severe cases	Lateral chest; may accompany shortness of breath, rapid breathing, fast heart rate, or low blood pressure
Pulmonary
Pneumonia or Pleuritis	Sharp and pleuritic	Unilateral, often localized; associated with shortness of breath, cough, fever, and abnormal lung sounds
Spontaneous pneumothorax	Sudden; sharp and pleuritic	Lateral chest; often associated with shortness of breath and reduced breath sounds
Gastrointestinal
Gastroesophageal reflux disease (GERD)	Burning sensation	Substernal; worsens when lying down after eating
Esophageal spasm	Pressure, tightness, or burning	Retrosternal; can resemble angina
Neuromuscular
Costochondritis	Aching	Sternal; may be swollen, tender, warm at the joint; localized pressure can reproduce the pain
Cervical disk disease	Aching, potentially with numbness	Arms and shoulders; worsens with neck movement
Trauma or Strain	Constant, aching	Limited to the strained area; pain can be triggered by movement or touch
Psychological
Psychiatric and Emotional Issues	Tightness, shortness of breath, or feelings of panic	Varies in location; may be retrosternal; often related to stress, previous panic attacks, or depression

Source: Morrow, D. A. (2022). Chest discomfort. In J. Loscalzo, A. Fauci, D. Kasper, S. Hauser, D. Longo, & J. L. Jameson (Eds.), Harrison's principles of internal medicine (21st ed., pp. 100-108). McGraw Hill.

Diagnosis

Diagnostic approach to patients with suspected stable angina:

1. History and Physical Examination: Suspect stable angina in a patient presenting with typical chest pain (increased with exertion, relieved by rest) who has atherosclerotic risk factors (e.g., hypertension, diabetes, dyslipidemia, smoking). Physical exam should focus on evaluating vital signs to look out for hemodynamic instability that could be caused by more serious conditions (e.g., myocardial infarction, arrhythmia, aortic dissection).

2. Electrocardiogram (ECG): Initial diagnostic test that should be done in all patients with suspected stable angina. It is essential to rule out more serious conditions (e.g., STEMI). May be normal or show signs of previous infarction (e.g., Q waves).

3. Stress Testing

Table 3: Stress test.

Category	Details
Purpose	Evaluate for ischemic heart disease (IHD) under exertional conditions.
Types	− Exercise stress testing (Figure 1) − Pharmacological stress testing (for those unable to exercise) − Imaging stress tests (for patients with abnormal baseline ECGs)
Indications	Used when there is suspicion of IHD based on symptoms or ECG findings.
Test termination criteria	− Chest pain − Significant shortness of breath − Dizziness − Extreme fatigue − ST-segment depression >2 mm − Drop in systolic BP >10 mmHg − Ventricular tachyarrhythmia
Positive findings	Down-sloping or horizontal ST depression >0.1 mV lasting >0.08 seconds (Figure 2).
Interpretation	It depends on patient’s characteristics; positive result in males > 50 years with history of angina correlates to 98% likelihood of having coronary artery disease.
Poor prognosis indicators	− Decreased blood pressure during the test − ST depression >0.2 mV (2 mm) at low workload − Chest pain during minimal exertion − ST depression lasting >5 minutes after the test
Contraindications	− Recent rest angina within last 48 hours − Unstable rhythm − Severe aortic stenosis − Acute myocarditis − Uncontrolled heart failure − Severe pulmonary hypertension − Active infective endocarditis

Abbreviations. ECG: electrocardiogram, BP: blood pressure.

4. Coronary Arteriography: Gold standards test for the diagnosis of stable angina and IHD. See the indications in Table 4. The list is not exhaustive, for more information refer to the source below.

Table 4: Indications of coronary angiography is stable angina patients.

Indication	Description
Severe symptoms despite medication	Patients with chronic stable angina who remain symptomatic despite optimal medical therapy and are candidates for revascularization (PCI or CABG).
Diagnostic uncertainty	Symptoms are challenging and there is a need to confirm or rule out ischemic heart disease (IHD).
Post-cardiac arrest	Patients with a history of angina or suspected angina who survived a cardiac arrest.
Ischemia with ventricular dysfunction	Evidence of ischemia on noninvasive testing and ventricular dysfunction.

Source: Antman, E. M., & Loscalzo, J. (2022). Ischemic heart disease. In J. Loscalzo, A. Fauci, D. Kasper, S. Hauser, D. Longo, & J. L. Jameson (Eds.), Harrison's principles of internal medicine (21st ed., p. 2038). McGraw Hill.

Figure 1. Exercise stress test.

Blue0ctane. (2006, October 28). Stress test [Image]. Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Stress_test.jpg

Figure 2. Stress-ECG of a patient with coronary heart disease: ST-segment depression (arrow) at 100 watts of exercise. A: at rest, B: at 75 watts, C: at 100 watts, D: at 125 watts.

Heuser, J. (2006, January 10). StressECG STDepression [Image]. Wikimedia Commons. https://commons.wikimedia.org/wiki/File:StressECG_STDepression.jpg

5. Routine tests:

● Urine Test: Check for diabetes and renal disease to assess atherosclerosis risk.

● Blood Tests: Measure lipids, glucose (HbA1C), creatinine, hematocrit, and thyroid function.

● High-sensitivity CRP: Independent IHD risk factor, guides hypolipidemic treatment.

● Chest X-ray: Identify cardiac enlargement, ventricular aneurysm, or heart failure.

Management

Illustration 1. Algorithm for the management of ischemic heart disease.

Abbreviations. ASA: aspirin, EF: ejection fraction, ACS: acute coronary syndrome, PCI: percutaneous coronary intervention, CABG: coronary artery bypass graft.

*If the patient is intolerant to aspirin, clopidogrel can be used as an alternative.

Source: Antman, E. M., & Loscalzo, J. (2022). Ischemic heart disease. In J. Loscalzo, A. Fauci, D. Kasper, S. Hauser, D. Longo, & J. L. Jameson (Eds.), Harrison's principles of internal medicine (21st ed., pp. 2030-2046). McGraw Hill.

Lifestyle Modifications

● Encourage regular, moderate-intensity exercise.

● Adjust physical activities to avoid triggering angina (e.g., reducing intensity in the morning, after meals, or in cold weather).

● Promote weight loss and a balanced diet low in saturated and trans fats.

Risk Factor Modification

● Treat hypertension and diabetes aggressively.

● Ensure smoking cessation and manage dyslipidemia with statins or other lipid-lowering agents.

Pharmacological Therapy

Table 5: Pharmacological therapy in stable angina patients.

Medication	Description
Nitrates	Relieve and prevent angina; available in short-acting (sublingual nitroglycerin) and long-acting forms (isosorbide dinitrate).
Beta-blockers	First-line therapy to reduce heart rate, blood pressure, and myocardial oxygen demand; improves mortality rates.
Calcium channel blockers	Used if beta-blockers are contraindicated (e.g., asthma, heart block) or insufficient; effective in variant angina and peripheral vascular disease.
Antiplatelet agents	Aspirin (75-325 mg daily) reduces myocardial infarction risk; Clopidogrel is an alternative if aspirin intolerant.
Statins	Essential for dyslipidemia management; target LDL cholesterol <70 mg/dL.

Consideration of Revascularization

● Main indication: Patients with severe symptoms or high-risk features, despite optimal medical therapy.

● Percutaneous coronary intervention (PCI): Angioplasty with or without stent placement to open narrowed arteries. Relief of angina is achieved in ~95% of patients.

● Coronary artery bypass grafting (CABG): Indicated in severe cases with extensive coronary artery disease or when PCI is not feasible.

Complications

● Myocardial infarction

● Heart failure

● Arrhythmias

● Sudden cardiac death

Prognosis

Poor prognostic factors:

● New-onset or unstable angina

● Post-myocardial infarction angina

● Angina resistant to therapy

● Angina with heart failure symptoms

● Signs of heart failure (e.g., pulmonary edema, third heart sound, mitral regurgitation)

● Cardiac enlargement, reduced ejection fraction (<0.40)

● High-risk lesions: left main or proximal left anterior descending artery stenosis (>50%)

● Atherosclerotic plaques with fissuring or defects

● Impaired left ventricular function

Variant (Prinzmetal) Angina

Variant angina, also known as Prinzmetal angina, is characterized by episodic vasoconstriction of the coronary arteries. Unlike typical angina, which is often triggered by exertion or stress, variant angina usually occurs at rest and is frequently observed during the nighttime or early morning hours.

Epidemiology

● Gender: Females > Males

● Age: Younger adults.

Clinical Features:

● Timing: Occur at rest, most commonly from midnight to early morning.

● Chest pain: is often severe and may be associated with ST-segment elevation on ECG during episodes.

● Associations: Linked to smoking and cocaine abuse, which can provoke or exacerbate vasoconstriction. Other associations include Raynaud’s phenomenon and migraine headaches.

Diagnosis:

● Clinical Diagnosis: Identified by transient ST-segment elevation on ECG during rest pain.

● Coronary Angiography: Shows transient coronary spasm; ~50% have atherosclerotic plaques.

● Provocative Testing: Hyperventilation and acetylcholine can confirm diagnosis by inducing coronary stenosis or ST-segment elevation.

Treatment:

1. Lifestyle Modifications: Smoking cessation and avoiding cocaine use.

2. Pharmacological Therapy:

● CCBs: First-line of treatment, as they help to prevent coronary vasospasm.

● Nitrates: Used along CCBs.

● Beta blockers: Can be used if CCBs are not sufficient or if the patient also has a component of exertional angina; studies showed variable response.

Prognosis:

Long-Term Survival: ~90-95% survival at 5 years; up to 20% may experience a myocardial infarction (MI).