What is the appropriate workup for a patient with worsening angina?

Workup of Worsening Angina

For patients with worsening angina, risk stratification with stress imaging (preferably) or exercise ECG testing should be performed promptly, followed by invasive coronary angiography with FFR/iwFR when appropriate based on high-risk features or refractory symptoms. 1

Initial Assessment

When a patient presents with worsening angina, the following evaluations should be conducted:

• 12-lead ECG: Immediately obtain to assess for ST-segment changes, which may indicate ongoing ischemia 1
• Cardiac biomarkers: Measure troponin levels to rule out myocardial infarction 1
• Risk stratification: Identify high-risk features that require expedited evaluation:
  • Recurrent chest pain or dynamic ST-segment changes
  • Elevated troponin levels
  • Hemodynamic instability
  • Major arrhythmias (ventricular tachycardia, ventricular fibrillation)
  • Early post-infarction unstable angina
  • Diabetes mellitus 1

Diagnostic Testing Algorithm

Step 1: Non-invasive Testing

• Stress imaging (preferred approach):
  • Stress echocardiography or nuclear perfusion imaging 1
  • Provides information on ischemic burden and functional significance of coronary lesions
• Exercise ECG testing (alternative if imaging unavailable):
  • Evaluates exercise tolerance and provokes ischemia
  • Less sensitive and specific than imaging-based tests 1

Step 2: Based on Non-invasive Results

• Low-risk findings: Consider medical therapy optimization
• High-risk findings: Proceed to invasive coronary angiography 1

Step 3: Invasive Assessment

• Coronary angiography with FFR/iwFR when appropriate:
  • Indicated for patients with:
    • Severe CAD
    • Symptoms refractory to medical treatment
    • High-risk clinical profile 1
    • Significant worsening of symptoms 1
  • Should be performed during initial hospitalization for high-risk patients 1

Special Considerations

• Timing of angiography:

  • For severe ongoing ischemia, major arrhythmias, or hemodynamic instability: within the first hour
  • For most high-risk patients: within 48 hours of presentation 1
  • For patients with deteriorating LV function: prompt evaluation 1

• Revascularization decisions:

  • Single-vessel disease: Percutaneous intervention of culprit lesion is first choice
  • Left main or triple-vessel disease: CABG is recommended, particularly with LV dysfunction
  • Double-vessel disease: Either PCI or CABG may be appropriate 1

Common Pitfalls to Avoid

1. Delayed evaluation: Worsening angina represents unstable disease with increased risk of progression to MI or death; prompt evaluation is essential 1

2. Inadequate risk stratification: Failure to identify high-risk features may lead to inappropriate management strategies 1

3. Overreliance on symptoms: The majority of deaths and major cardiovascular events are not preceded by warning symptoms, so objective testing is crucial 2

4. Neglecting medical therapy: While workup proceeds, ensure optimal medical therapy including:

   • Antiplatelet therapy (ASA 75-325 mg daily) 1
   • Beta-blockers 1
   • Nitrates for symptom relief 1
   • High-intensity statins 1

5. Missing vasospastic angina: Consider provocative testing in patients with episodic resting angina and no significant stenosis on angiography 1

By following this systematic approach to the workup of worsening angina, clinicians can effectively risk-stratify patients, identify those requiring urgent intervention, and implement appropriate management strategies to reduce morbidity and mortality.