Stable Angina

Use the stable-angina pathway only when symptoms are predictably provoked and unchanged in frequency and severity over time; one review defines chronic stable angina as symptoms unchanged for at least 2 months. Escalating exertional threshold, new rest symptoms, prolonged episodes, or a clinically unstable presentation should instead trigger an acute coronary syndrome evaluation pathway. AHA Journals+1AHA Journals2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the ...ScienceDirectIschaemic heart disease: stable angina - ScienceDirect

Do not assume exertional chest discomfort is obstructive epicardial CAD. Stable angina reflects inadequate myocardial perfusion, most commonly from atherosclerotic CAD but not invariably so; chronic coronary disease also encompasses nonobstructive CAD and chronic angina syndromes with variable causes. A normal or nonobstructive anatomic study therefore changes the diagnostic question from obstructive lesion localization to alternative ischemic mechanisms or noncoronary causes. jacc+1jacc2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the ... - JACCScienceDirectIschaemic heart disease: stable angina - ScienceDirect

Coronary CTA is an anatomic test: it assesses coronary atheroma, stenosis, and structural coronary abnormalities. In a meta-analysis using invasive FFR as reference, coronary CTA had the highest sensitivity for functionally significant lesions at 88% (95% CI, 85%–90%). This makes it useful when excluding significant coronary disease is the near-term decision; a positive CTA does not by itself establish that a stenosis causes ischemia. ScienceDirect+1ScienceDirectIschaemic heart disease: stable angina - ScienceDirectScienceDirectDiagnostic performance of non-invasive imaging for stable coronary artery disease: A meta-analysis - ScienceDirect

Use stress imaging when the management question is inducible ischemia rather than coronary anatomy alone. In the same meta-analysis, stress CMR and combined coronary CTA plus stress myocardial CT perfusion had the highest vessel-based specificity, while PET, stress CMR, stress echocardiography, and SPECT each provide functional evidence of ischemia. Test selection should also reflect exercise ability, ECG interpretability, local availability, and expertise. ScienceDirect+1ScienceDirectDiagnostic performance of non-invasive imaging for stable coronary artery disease: A meta-analysis - ScienceDirectPubMedChest Pain Evaluation: Diagnostic Testing - PMC

Exercise ECG remains a practical option when the resting ECG is interpretable and the patient can exercise adequately, but contemporary national and international guidance has downgraded it to a Class II indication. Its residual value is direct symptom correlation and assessment of exercise capacity, chronotropic response, and exercise blood-pressure response. PubMedPubMedChest Pain Evaluation: Diagnostic Testing - PMC

Reserve invasive coronary angiography for patients in whom noninvasive findings, symptom burden, or clinical risk make coronary anatomy actionable. Direct invasive testing is generally less cost-effective than noninvasive functional testing for new stable angina, although a decision model found direct angiography with FFR became cost-effective when the value assigned to a correct diagnosis exceeded £24,000. BMJBMJCost-effectiveness in diagnosis of stable angina patients: a decision-analytical modelling approach | Open Heart

When invasive angiography identifies an intermediate or otherwise uncertain lesion, add FFR to determine functional significance before revascularization. FFR-guided care has been associated with better outcomes than management based on angiography alone, and invasive FFR is described as the reference standard for revascularization decision-making in stable CAD. BMJ+1BMJCost-effectiveness in diagnosis of stable angina patients: a decision-analytical modelling approach | Open HeartScienceDirectIntegration of fractional flow reserve derived from CT into clinical practice - ScienceDirect

Integrate coronary distribution and disease complexity with ventricular function, comorbidity, bleeding risk, and patient preference when selecting PCI versus CABG. Neither procedure should be framed as a default response to an angiographic stenosis; both are revascularization approaches with different procedural strategies and limitations. jacc+1jaccACC/AHA/ACP-ASIM guidelines for the management of patients with ...ScienceDirectIschaemic heart disease: stable angina - ScienceDirect

Use the chronic coronary disease framework rather than the older isolated label of stable ischemic heart disease. The 2023 multisociety guideline defines chronic coronary disease broadly to include obstructive and nonobstructive CAD, prior MI or revascularization, ischemic heart disease diagnosed only by noninvasive testing, and chronic angina syndromes with varying causes. This classification should prompt longitudinal reassessment of symptoms, testing results, and treatment goals rather than discharge after a single negative or positive study. jacc+1jacc2023 Chronic Coronary Disease Guideline-at-a-Glancejacc2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the ... - JACC

For antianginal symptom treatment, beta-blockers and calcium-channel blockers are established initial classes; if both are contraindicated or not tolerated, NICE guidance advises considering monotherapy with another antianginal option. Ranolazine has trial evidence for prolonging exercise duration and time to angina as monotherapy or in combination therapy, but the available evidence excerpt does not provide a dose or a specific sequencing rule. BMJ+2BMJManagement of stable angina: summary of NICE guidance - The BMJOxford AcademicClinical implications of inhibition of the late sodium current: ranolazineOxford AcademicTreatment of stable ischaemic heart disease: the old and the new

Treat hypertension and modifiable cardiovascular risk factors as part of coronary disease management. Older ACC/AHA guidance notes that hypertension in chronic stable angina confers high cardiovascular morbidity and mortality risk and supports beginning with nonpharmacologic measures, adding antihypertensive therapy when lifestyle and dietary measures do not adequately lower blood pressure. jaccjaccACC/AHA/ACP-ASIM guidelines for the management of patients with ...

For patients with type 2 diabetes and chronic coronary disease, the 2023 AHA/ACC multisociety guideline recommends an SGLT2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit. Select the individual agent, dose, renal constraints, and monitoring plan from current product labeling and diabetes-specific guidance. jaccjacc2023 Chronic Coronary Disease Guideline-at-a-Glance

If coronary CTA is negative for obstructive disease but exertional symptoms persist, reconsider whether the syndrome is nonobstructive chronic coronary disease, another ischemic mechanism, or a noncoronary exercise-limiting disorder. Functional testing can clarify whether inducible ischemia is present, while exercise testing may reveal chronotropic incompetence, hypertensive response, or poor exercise capacity that changes the competing diagnosis. jacc+2jacc2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the ... - JACCScienceDirectDiagnostic performance of non-invasive imaging for stable coronary artery disease: A meta-analysis - ScienceDirectPubMedChest Pain Evaluation: Diagnostic Testing - PMC

If CTA shows stenosis but stress imaging is negative or symptoms are atypical, avoid treating anatomy alone as a mandate for intervention. CT-derived FFR or invasive FFR is the next discriminator when defining lesion-level flow limitation would determine whether catheterization or revascularization is appropriate. ScienceDirect+1ScienceDirectIntegration of fractional flow reserve derived from CT into clinical practice - ScienceDirectpubs rsnaCoronary CT Angiography-derived Fractional Flow Reserve Testing in Patients with Stable Coronary Artery Disease: Recommendations on Interpretation and Reporting

Repeat noninvasive risk stratification in patients with known stable angina who become asymptomatic on therapy according to older ACC/AHA coronary angiography guidance, while using the current chronic coronary disease framework for longitudinal follow-up. A recurrence, reduced exertional threshold, or change in symptom quality should restart the assessment at the stability-versus-acute-coronary-syndrome decision point. jacc+2jacc2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the ... - JACCAHA JournalsACC/AHA Guidelines for Coronary Angiography: Executive ...AHA Journals2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the ...