From the Guidelines
Diagnosing angina primarily relies on a careful history taking, focusing on the characteristics of chest pain, including its location, character, duration, and relationship to exertion and other factors, as outlined in the 2013 ESC guidelines on the management of stable coronary artery disease 1. To diagnose angina, healthcare providers should consider the following key points:
- Location of the discomfort: usually in the chest, near the sternum, but may radiate to other areas such as the arms, jaw, or back 1.
- Character of the discomfort: often described as pressure, tightness, or heaviness, and may be accompanied by shortness of breath, fatigue, or other less-specific symptoms 1.
- Duration of the discomfort: typically brief, lasting no more than 10 minutes, and often relieved by rest or nitroglycerin 1.
- Relationship to exertion and other factors: symptoms may be triggered or worsened by physical activity, emotional stress, or other factors, and may be relieved by rest or nitroglycerin 1. Physical examination and diagnostic tests, such as electrocardiogram (ECG), stress testing, and coronary CT angiography, may also be necessary to confirm the diagnosis, exclude alternative diagnoses, and assess the severity of underlying disease 1. A therapeutic trial with sublingual nitroglycerin (0.4 mg) that relieves pain within minutes can support an angina diagnosis, as buccal or sublingual nitrates rapidly relieve angina, as noted in the 2013 ESC guidelines 1.
From the Research
Diagnostic Tests for Angina
To diagnose angina, several tests can be used, including:
- Computed tomography coronary angiography (CTCA) 2, 3
- Stress electrocardiography (ECG) 2, 4, 5, 6
- Stress echocardiography 4
- Exercise stress test 5
- Dipyridamole thallium-201 single photon emission tomography (SPECT) 6
- Intracoronary methylergonovine testing 6
Role of Each Test
- CTCA is a first-line diagnostic test for stable angina, with higher sensitivity and comparable specificity to imaging-based stress testing 3
- Stress ECG is associated with endothelial dysfunction, but not microvascular dysfunction or myocardial bridge 4
- Stress echocardiography is not associated with any occult coronary abnormalities 4
- Exercise stress test can be used to assess prognosis in patients with unstable angina 5
- Intracoronary methylergonovine testing can be used to diagnose coronary spasm in patients with a positive noninvasive stress test result and no hemodynamically significant CAD 6
Limitations of Diagnostic Tests
- Conventional stress testing is insufficient for identifying occult coronary abnormalities in patients with angina in the absence of obstructive CAD 4
- A normal stress test does not rule out a non-obstructive coronary etiology of angina 4
- Noninvasive stress testing can be positive in patients with coronary spasm, even in the absence of hemodynamically significant CAD 6