From the Guidelines
The workup for angina should begin with a thorough history and physical examination, followed by an ECG and cardiac biomarkers to rule out acute coronary syndrome, as recommended by the European Society of Cardiology 1. The initial evaluation should include assessment of cardiovascular risk factors, including smoking, hyperlipidemia, diabetes mellitus, hypertension, family history of premature CAD, and postmenopausal status in women, as suggested by the American College of Physicians 1. Some key points to consider in the workup for angina include:
- A carefully taken history and physical examination to determine the characteristics of the chest pain, including quality, location, duration, and triggering factors
- A comprehensive risk factor evaluation, including assessment of cardiovascular risk factors
- A resting electrocardiogram (ECG) to evaluate for signs of ischemia or infarction
- Stress testing, such as exercise ECG, stress echocardiography, or nuclear perfusion imaging, to confirm the diagnosis and assess the severity of coronary artery disease
- Consideration of coronary angiography in high-risk patients or those with positive non-invasive tests The goal of the workup is to determine the underlying cause of the angina, assess the severity of coronary artery disease, and guide treatment decisions to improve symptoms and reduce the risk of adverse outcomes, as emphasized by the European Society of Cardiology 1. Key aspects of treatment include:
- Aspirin and statin therapy to reduce the risk of myocardial infarction and death
- Anti-anginal medications, such as beta-blockers, calcium channel blockers, or nitrates, to control symptoms
- Risk factor modification, including smoking cessation, blood pressure control, diabetes management, and lifestyle changes, to reduce the risk of progression of coronary artery disease.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Diagnostic Approach
The diagnostic approach for a patient with angina (chest pain) involves a combination of clinical evaluation, physical examination, and diagnostic tests.
- Key questions to ask the patient in establishing a diagnosis of angina pectoris include those related to the characteristics of the chest pain, such as its location, duration, and triggers 2.
- Physical examination signs to look for include those indicative of cardiovascular disease, such as hypertension or signs of heart failure 2.
- Diagnostic tests that may be used include resting and exercise stress electrocardiograms (ECG), which can help identify signs of ischemia or infarction 2, 3.
Diagnostic Tests
- Exercise testing is recommended as a first-line diagnostic test for patients with stable angina pectoris 3.
- Stress speckle tracking, which uses ultrasound to evaluate myocardial strain, may also be useful in diagnosing coronary artery disease (CAD) in patients with stable angina pectoris 3.
- High-sensitivity C-reactive protein (hs-CRP) levels may be elevated in patients with CAD and can be used as a marker of coronary stenosis 3.
- Coronary angiography may be used to visualize the coronary arteries and identify any blockages or stenosis 4, 5.
Risk Assessment
- Risk scores, such as the History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) score and the Thrombolysis in Myocardial Infarction (TIMI) score, can be used to estimate the probability of acute coronary syndrome (ACS) in patients with chest pain 6.
- These risk scores incorporate factors such as the patient's medical history, ECG findings, and troponin levels to provide a more accurate assessment of risk 6.
- The HEART score and TIMI score have been shown to perform well in diagnosing ACS, with high sensitivity and specificity 6.
Management
- Management of angina pectoris may involve medical therapy, such as nitrates, which can help relieve chest pain by increasing coronary artery blood supply and decreasing cardiac preload and afterload 4.
- Invasive coronary function testing may be used to guide medical therapy and improve outcomes in patients with angina pectoris 5.
- Stratified medical therapy, guided by invasive coronary vascular function testing, has been shown to lead to marked and sustained angina improvement and better quality of life at 1 year following invasive coronary angiography 5.