What is the approach to evaluate stable angina?

From the Guidelines

The evaluation of stable angina should begin with a thorough clinical assessment, including a detailed history of chest pain characteristics, physical examination, and risk factor assessment, as recommended by the European Society of Cardiology 1. The initial diagnostic testing should include a 12-lead ECG, complete blood count, lipid profile, fasting blood glucose, and cardiac biomarkers if acute coronary syndrome is suspected. Non-invasive functional testing is recommended for most patients, with options including exercise stress testing, stress echocardiography, nuclear perfusion imaging, or cardiac MRI. The choice of test depends on the patient's ability to exercise, baseline ECG abnormalities, and local expertise. Some key points to consider in the evaluation of stable angina include:

• A carefully taken history and physical examination, a comprehensive risk factor evaluation, and a resting electrocardiogram should be performed for every patient with suspected stable angina 1.
• An initial non-invasive strategy, using exercise ECG, stress echo, or myocardial perfusion scintigraphy, is most appropriate to confirm the diagnosis and plan further management 1.
• The exercise ECG should be interpreted with attention to haemodynamic response, workload achieved, and clinical features of the individual, as well as symptoms and ST-segment response 1.
• For patients with high pre-test probability or those with positive non-invasive tests, coronary angiography (invasive or CT-based) should be performed to define coronary anatomy. Risk stratification is essential to guide management decisions, considering factors such as symptom severity, extent of ischemia, left ventricular function, and comorbidities. This systematic approach allows for accurate diagnosis, assessment of disease severity, and appropriate treatment planning, which typically includes lifestyle modifications, anti-anginal medications (like beta-blockers, calcium channel blockers, and nitrates), and consideration of revascularization in selected patients with significant obstructive coronary artery disease.

From the FDA Drug Label

In the CARISA (Combination Assessment of Ranolazine In Stable Angina) trial, statistically significant (p <0. 05) increases in modified Bruce treadmill exercise duration and time to angina were observed for each Ranolazine Extended-Release Tablets dose versus placebo, at both trough (12 hours after dosing) and peak (4 hours after dosing) plasma levels, with minimal effects on blood pressure and heart rate. The effects of Ranolazine Extended-Release Tablets on angina frequency and nitroglycerin use are shown in Table 2. Exercise treadmill results showed no increase in effect on exercise at the 1000 mg dose compared to the 750 mg dose

To evaluate stable angina, the approach includes:

• Modified Bruce treadmill exercise duration to assess the effect of treatment on exercise capacity
• Time to angina to evaluate the effect of treatment on angina symptoms
• Angina frequency and nitroglycerin use to assess the effect of treatment on angina episodes and the need for rescue medication
• Exercise treadmill results to compare the effects of different doses of treatment on exercise capacity 2 2 Key points:
• Ranolazine Extended-Release Tablets have been shown to increase exercise duration and time to angina, and decrease angina frequency and nitroglycerin use, in patients with chronic stable angina
• The evaluation of stable angina should include a combination of these assessments to determine the effectiveness of treatment.

From the Research

Evaluation Approach

To evaluate stable angina, the following steps can be taken:

• Identify patients with suspected stable ischemic heart disease and determine the prevalence of angiographically significant coronary artery disease (CAD) according to gender and chest pain character 3
• Use coronary computed tomographic angiography as a first-line diagnostic test due to its higher sensitivity and comparable specificity compared with imaging-based stress testing 3
• Consider exercise treadmill testing or stress echocardiography for patients who cannot undergo coronary computed tomographic angiography, with stress echocardiography being more accurate for ruling in or out obstructive CAD in patients aged ≥ 70 years with atypical angina and non-anginal pain 4
• Evaluate the effect of angina on a patient's quality of life and integrate this into the clinic encounter to assist with the decision to proceed with revascularization 3

Diagnostic Tests

Diagnostic tests for stable angina include:

• Coronary computed tomographic angiography: allows detection of nonobstructive atherosclerosis and improves risk assessment 3
• Exercise treadmill testing: has a sensitivity of 79% and specificity of 82% for detecting obstructive CAD in patients with atypical angina and non-anginal pain 4
• Stress echocardiography: has a sensitivity of 89% and specificity of 95% for detecting obstructive CAD in patients with atypical angina and non-anginal pain 4

Management

The management of stable angina involves:

• Optimizing lifestyle factors, such as exercise, diet, and avoiding toxic habits 5
• Initiating optimal medical therapy, including treatment to prevent cardiovascular events and drugs for the control of myocardial ischemia and angina tailored to the patient's comorbidities 5
• Considering myocardial revascularization when indicated, with an emphasis on shared decision-making with an informed patient 3, 5
• Focusing on patient education, managing residual angina, and reducing cardiovascular risk 5