Angina Pectoris


Chest pain. Central, heavy chest pin radiating to the left arm and jaw. Typically episodes of angina occurring upon exertion and relieved by rest and nitrates (GTN). Pain lasting <20 minutes
Dyspnoea and palpitations also common. Nausea and sweating.
Generally few symptoms between episodes of pain.


Features of pain - SOCRATES - sight, onset, character, radiation, associated features (autonomic features), time course, exacerbating/relieving factors (breathing, position, exertion, eating) and severity (0-10)
Recent trauma? If pain is worse with movement then think MSK, but do not rule out angina.
Does the patient have a GTN spray and has it helped their symptoms? - generally good response
Does the patient have any risk factors for developing vascular disease - Hypertension, hypercholesterolaemia, obesity, diabetes, previous acute coronary event/stroke, smoker, lifestyle/occupation, family history of ischaemic heart disease?
PMHx - consider other causes for the presenting symptoms, such as gastric, respiratory problems, MSK
Medications - cardiac or respiratory medications, antacids, anticoagulants

Vital signs / observations



Cool and sweaty 'clammy', Palor. Tachycardia
Normal after episode of pain

Bedside tests

ECG - ST depression during ischaemia, inverted or flat T waves; subsequent evolution of changes + T wave inversion. Non-specific changes. ECG may be normal. Signs of previous MI.

If bedside ECG normal, consider exercise tolerance test

Laboratory investigations

FBC, U&E, LFT, lipids, glucose, lactate
Cardiac Markers - various cardiac markers so check locally which you should send at what time-points after the onset of chest pain. Troponin I or T will show an increase 6 hour post-pain and remain raised for up to 14 days. Typically blood test taken on presentation and 12h after worst pain.
cardiac markers not elevated in stable angina
Diagnosis is based upon history in the presence of ECG changes, but without subsequent elevation of cardiac markers
Consider ABG if patient acutely unwell

Radiological investigations

CXR - cardiomegaly, signs of LV failure (pulmonary oedema)

CT Coronary angiography 1st line may be useful to view narrowing of the coronary vessels.
Stress echo may detect changes in regional wall motion seen during ischaemia.
Coronary Calcium score measure with CT is a strong predictor of coronary artery disease


Immediate management

GTN (400mcg sublingual spray)
If the pain is lasting for >20 minutes then treat as NSTEMI/unstable angina

Prior to discharge

Aim to reduce modifiable risk factors such as smoking, obesity, control of diabetes, blood pressure and cholesterol.


Smoking cessation, dietary advice


Optimal drug treatment includes one or two anti-anginal medication and secondary prevention for cardiovascular risk

Secondary Prevention

  • ACE inhibitor - eg ramipril. Start on low dose for example Ramipril 2.5mg daily, then increase to either 5mg then maximally 10mg
  • Statin, eg atorvastatin 10-80mg PO ON
  • Aspirin - 75mg OD for life. Reduces mortality by 34%.

Symptomatic Treatment

GTN Spray - advice to patient about using immediately before planned exercise or exertion. Side effects such as facial flushing, headache and light headedness. Repeat after 5 minutes if the pain has not gone away - phone an ambulance if persists after a further 5 minutes

Follow up

Beta Blocker (eg atenolol 100mg OD or 50mg BD) or Calcium Channel blocker for 1st line treatment with angina. If one is not tolerated then consider switching to the other option. If the patient is not adequately controlled on a single agent consider switching or using a combination of the 2 drugs.
(When combining a calcium channel blocker with a beta blocker, use a dihydropyridine calcium channel blocker, for example, slow release nifedipine, amlodipine or felodipine.)

If the person cannot tolerate beta blockers and calcium channel blockers or both are contraindicated, consider monotherapy with one of the following drugs:

  • a long-acting nitrate or
  • ivabradine or
  • nicorandil or
  • ranolazine.

Add additional drugs when symptoms not controlled on mono therapy:

  • a long-acting nitrate or
  • ivabradine or
  • nicorandil or
  • ranolazine.

Do not offer a third anti-anginal drug to people whose stable angina is controlled with two anti-anginal drugs.
Consider adding a third anti-anginal drug only when:

  • the person's symptoms are not satisfactorily controlled with two anti-anginal drugs and
  • the person is waiting for revascularisation or revascularisation is not considered appropriate or acceptable.

Consider revascularisation when people with stable angina not controlled on optimal drug therapy. Offer Coronary angiography to guide treatment options
Both CABG and PCI are effective at relieving symptoms. CABG may be advantageous to patients with multi-vessel disease

++Follow up

Review in clinic dependant on how symptomatic patient is


STEMI, Heart Failure, LV dysfunction


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