Ischaemic heart disease: stable angina

Stable angina is a clinical syndrome reflecting inadequate myocardial perfusion – typically, but not always caused by atherosclerotic coronary disease. A detailed history is important to establish the diagnosis, presence of risk factors and unstable symptoms. Stress-ECG or stress-imaging techniques should ideally be used to determine the presence and extent of myocardial ischaemia. Multidetector CT is now able accurately to detect and localize significant coronary stenoses, but the gold standard remains invasive coronary angiography. Appropriate drug therapy should be started in all patients, and can significantly improve symptoms and prognosis. Risk stratification should be performed by clinical evaluation, response to stress testing, quantification of left ventricular function, and coronary angiography where appropriate. Revascularization improves symptoms in the majority of patients, and those at high risk (as determined by the extent of disease and ischaemic burden) may derive additional prognostic benefits. The choice of revascularization method (percutaneous coronary intervention or coronary artery bypass graft) is influenced by the extent and complexity of disease; presence of diabetes; co-morbidities that increase surgical risk; ability to take dual antiplatelet therapy; and patient preference.