What is the next step in managing a patient with persistent anginal pain but normal troponin (cardiac enzyme) and electrocardiogram (ECG) results?

From the Guidelines

For a patient with persistent anginal pain despite normal troponin and ECG results, the next step should be a non-invasive stress test such as exercise stress testing, stress echocardiography, or myocardial perfusion imaging. This approach is based on the guidelines from the American College of Physicians 1 and helps evaluate for inducible ischemia that may not be apparent on resting studies. While awaiting this test, the patient should be started on anti-anginal therapy including:

• Aspirin 81-325mg daily
• A beta-blocker (such as metoprolol 25-50mg twice daily)
• Sublingual nitroglycerin 0.4mg as needed for chest pain A high-intensity statin like atorvastatin 40-80mg daily should also be initiated. If stress testing reveals abnormalities suggesting coronary artery disease, referral for coronary angiography would be appropriate. This approach is recommended because angina with normal initial testing may still indicate significant coronary disease that requires further evaluation, as resting ECG and troponin can miss coronary stenosis that only causes ischemia during increased myocardial oxygen demand. The management of acute coronary syndromes without persistent ST-segment elevation, as outlined in the European Heart Journal 1, also supports the use of aspirin, clopidogrel, beta-blockers, and nitrates in patients with suspected coronary artery disease. However, the most recent and highest quality study 1 prioritizes the use of non-invasive stress testing and anti-anginal therapy as the next step in managing patients with persistent anginal pain and normal initial test results.

Some key points to consider in the management of these patients include:

• The classification of chest pain as typical angina, atypical angina, or noncardiac chest pain
• The use of risk stratification to identify high-risk and low-risk patients
• The importance of evaluating for inducible ischemia using non-invasive stress testing
• The role of anti-anginal therapy, including aspirin, beta-blockers, and nitrates, in managing patients with suspected coronary artery disease. Overall, the goal of management is to reduce morbidity, mortality, and improve quality of life for patients with persistent anginal pain, and the approach outlined above is based on the most recent and highest quality evidence available 1.

From the FDA Drug Label

The effectiveness of 5 to 10 mg/day of amlodipine in exercise-induced angina has been evaluated in 8 placebo-controlled, double-blind clinical trials of up to 6 weeks duration involving 1038 patients (684 amlodipine, 354 placebo) with chronic stable angina In 5 of the 8 studies, significant increases in exercise time (bicycle or treadmill) were seen with the 10 mg dose. Amlodipine 10 mg also increased time to 1 mm ST segment deviation in several studies and decreased angina attack rate.

The next step in managing a patient with persistent anginal pain but normal troponin and electrocardiogram (ECG) results is to consider optimizing medical therapy, including the use of calcium channel blockers such as amlodipine, as it has been shown to be effective in reducing angina symptoms and improving exercise tolerance in patients with chronic stable angina 2.

• Dose titration: The dose of amlodipine can be titrated up to 10 mg/day to achieve optimal symptom control.
• Combination therapy: Amlodipine can be used in combination with other anti-anginal medications, such as nitrates and beta-blockers, to achieve better symptom control. However, it is essential to note that the management of angina should be individualized and guided by the patient's clinical presentation, medical history, and response to treatment.

From the Research

Next Steps in Managing Persistent Anginal Pain

• The patient's symptoms and normal troponin and ECG results should be taken into consideration when determining the next steps in management 3, 4.
• The use of coronary computed tomographic angiography as a first-line diagnostic test may be considered to evaluate the patient's coronary arteries and detect any nonobstructive atherosclerosis 4.
• The patient's risk factors and clinical characteristics should be assessed using a cardiac risk score, such as the HEART score, to predict the risk of major adverse cardiac events (MACE) 5.
• The patient's lifestyle factors and preventive medications, such as lipid-lowering and antiplatelet agents, should be optimized to reduce the risk of cardiovascular events and death 4.
• Antianginal medications, such as β-blockers, nitrates, or calcium channel blockers, may be initiated to improve angina symptoms 3, 4.
• Revascularization with percutaneous coronary intervention may be considered if the patient's angina symptoms negatively impact their quality of life, generally after a trial of antianginal medical therapy 4.

Considerations for Diagnostic Testing

• The variability of exercise-induced ST changes and left ventricular parameters in patients with anginal attacks but normal coronary arteriograms should be taken into account when interpreting diagnostic test results 6.
• Disparities in ECG and troponin testing among emergency department patients with chest pain or anginal-equivalent symptoms should be recognized, with lower testing rates observed in female and non-white patients 7.