Ischaemic heart disease: stable angina

Stable angina is a clinical syndrome reflecting inadequate myocardial perfusion. This is typically, but not always, caused by atherosclerotic coronary artery disease. A detailed history is important to establish the diagnosis, presence of risk factors and unstable symptoms. A range of tests is available to investigate patients with stable angina. Anatomical tests, include CT coronary angiography and invasive coronary angiography, aim to assess the presence and extent of atheroma in the coronary arteries. Functional tests, including stress echocardiography, stress MRI and nuclear perfusion, aim to detect the presence and extent of reversible myocardial ischaemia. The gold standard test to detect coronary disease remains invasive coronary angiography with the addition of fractional flow reserve to assess the significance of stenosis. Appropriate drug therapy significantly improves symptoms and prognosis. Risk stratification requires clinical evaluation, assessment of the presence and extent of myocardial ischaemia, quantification of left ventricular function and coronary angiography where appropriate. Revascularization improves symptoms in most patients with stable angina, and improves prognosis in those with a high ischaemic burden. The choice of revascularization method (percutaneous coronary intervention or coronary artery bypass graft) is influenced by the extent and complexity of disease, presence of co-morbidities, surgical risk, bleeding risk and patient preference.