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{{DevelopmentPhase}}
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[[File:Heart_coronary_artery.jpg|thumb|400px|An epicardial coronary artery with a atherosclerotic narrowing]]
 
Stable angina (pectoris) is a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back, or arms, typically elicited by exertion or emotional stress and relieved
 
Stable angina (pectoris) is a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back, or arms, typically elicited by exertion or emotional stress and relieved
 
by rest or nitroglycerin. It can be attributed to myocardial ischemia which is most commonly caused by atherosclerotic coronary artery disease or aortic valve stenosis.  
 
by rest or nitroglycerin. It can be attributed to myocardial ischemia which is most commonly caused by atherosclerotic coronary artery disease or aortic valve stenosis.  
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==History==
 
==History==
 +
[[File:Chest_pain_areas.svg|thumb|Typical chest pain is retrosternal. Pain may radiate to the arms, jaw, and / or back.]]
 
Patients often describe angina pectoris as pressure, tightness, or heaviness located centrally in the chest, and sometimes as strangling, constricting, or burning. The pain often radiates elsewhere in the upper body, mainly arms, jaw and/or back. <Cite>REFNAME3</Cite> Some patients only complain about abdominal pain so the presentation can be aspecific. <Cite>REFNAME4</Cite>, <Cite>REFNAME5</Cite>
 
Patients often describe angina pectoris as pressure, tightness, or heaviness located centrally in the chest, and sometimes as strangling, constricting, or burning. The pain often radiates elsewhere in the upper body, mainly arms, jaw and/or back. <Cite>REFNAME3</Cite> Some patients only complain about abdominal pain so the presentation can be aspecific. <Cite>REFNAME4</Cite>, <Cite>REFNAME5</Cite>
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Depending on the characteristics, chest pain can be identified as typical angina, atypical angina or non-cardiac chest pain, see Table 1.   
 
Depending on the characteristics, chest pain can be identified as typical angina, atypical angina or non-cardiac chest pain, see Table 1.   
   −
{| class="wikitable" border="1" width="400px"
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{| class="wikitable" border="1" width="600px"
 
|-
 
|-
 
! align="center" colspan="2" | Table 1. Clinical classification of chest pain <Cite>REFNAME17</Cite>
 
! align="center" colspan="2" | Table 1. Clinical classification of chest pain <Cite>REFNAME17</Cite>
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*Substernal chest discomfort of characteristic quality and duration
 
*Substernal chest discomfort of characteristic quality and duration
 
*Provoked by exertion or emotional stress
 
*Provoked by exertion or emotional stress
*Relieved by rest and/or GTN
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*Relieved by rest and/or nitroglycerine
 
|-
 
|-
 
| valign="top"|Atypical angina (probable)
 
| valign="top"|Atypical angina (probable)
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The classification of chest pain in combination with age and sex is helpful in estimating the pretest likelihood of angiographically significant coronary artery disease, see Table 2.  
 
The classification of chest pain in combination with age and sex is helpful in estimating the pretest likelihood of angiographically significant coronary artery disease, see Table 2.  
   −
{| class="wikitable" border="1" width="95%"
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{| class="wikitable" border="1" width="600px"
 
|-
 
|-
! align="left" colspan = "7" | Table 2. Pretest Probabilities of >=50% Diameter Stenotic Coronary Artery Disease in Patients with Chest Pain as Shown in the American College of Cardiology/American Association Guidelines for Management of Chronic Stable Angina <Cite>REFNAME20</Cite>
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! align="left" colspan = "7" | Table 2. Clinical pre-test probabilities <sup>a</sup> in patients with stable chest pain symptoms. <Cite>REFNAME20</Cite>
 
|-  
 
|-  
| align="center" |
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| align="center"|
| align="center" colspan="2" | Nonanginal Chest Pain, %
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| align="center" colspan="2" bgcolor="#FFFFFF" | <b>Typical angina</b>
| align="center" colspan="2" | Atypical Angina, %
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| align="center" colspan="2" bgcolor="#FFFFFF" | <b>Atypical angina</b>
| align="center" colspan="2" | Typical Angina, %
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| align="center" colspan="2" bgcolor="#FFFFFF" | <b>Non-anginal pain</b>
 
|-
 
|-
| align="center" | Age, y
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! Age
| align="center" | Men
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! Men
| align="center" | Women
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! Women
| align="center" | Men  
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! Men  
| align="center" | Women
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! Women
| align="center" | Men
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! Men
| align="center" | Women
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! Women
 
|-
 
|-
| align="center" | 30-39
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! 30-39
| align="center" | 4
+
| align="center" bgcolor="#F0F8FF" | 59
| align="center" | 2
+
| align="center" bgcolor="#F0F8FF" | 28
| align="center" | 34
+
| align="center" bgcolor="#F0F8FF" | 29
| align="center" | 12
+
| align="center" bgcolor="#FFFFFF" | 10
| align="center" | 76
+
| align="center" bgcolor="#F0F8FF" | 18
| align="center" | 26
+
| align="center" bgcolor="#FFFFFF" | 5
 
|-
 
|-
| align="center" | 40-49
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! 40-49
| align="center" | 13
+
| align="center" bgcolor="#FFCCCC" | 69
| align="center" | 3
+
| align="center" bgcolor="#F0F8FF" | 37
| align="center" | 51
+
| align="center" bgcolor="#F0F8FF" | 38
| align="center" | 22
+
| align="center" bgcolor="#FFFFFF" | 14
| align="center" | 87
+
| align="center" bgcolor="#F0F8FF" | 25
| align="center" | 55
+
| align="center" bgcolor="#FFFFFF" | 8
 
|-
 
|-
| align="center" | 50-59
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! 50-59
| align="center" | 20
+
| align="center" bgcolor="#FFCCCC" | 77
| align="center" | 7
+
| align="center" bgcolor="#F0F8FF" | 47
| align="center" | 65
+
| align="center" bgcolor="#F0F8FF" | 49
| align="center" | 31
+
| align="center" bgcolor="#F0F8FF" | 20
| align="center" | 93
+
| align="center" bgcolor="#F0F8FF" | 34
| align="center" | 73
+
| align="center" bgcolor="#FFFFFF" | 12
 
|-
 
|-
| align="center" | 60-69
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! 60-69
| align="center" | 27
+
| align="center" bgcolor="#FFCCCC" | 84
| align="center" | 14
+
| align="center" bgcolor="#F0F8FF" | 58
| align="center" | 72
+
| align="center" bgcolor="#F0F8FF" | 59
| align="center" | 51
+
| align="center" bgcolor="#F0F8FF" | 28
| align="center" | 94
+
| align="center" bgcolor="#F0F8FF" | 44
| align="center" | 86
+
| align="center" bgcolor="#F0F8FF" | 17
 +
|-
 +
! 70-79
 +
| align="center" bgcolor="#FF69B4" | 89
 +
| align="center" bgcolor="#FFCCCC" | 68
 +
| align="center" bgcolor="#FFCCCC" | 69
 +
| align="center" bgcolor="#F0F8FF" | 37
 +
| align="center" bgcolor="#F0F8FF" | 54
 +
| align="center" bgcolor="#F0F8FF" | 24
 +
|-
 +
! >80
 +
| align="center" bgcolor="#FF69B4" | 93
 +
| align="center" bgcolor="#FFCCCC" | 76
 +
| align="center" bgcolor="#FFCCCC" | 78
 +
| align="center" bgcolor="#F0F8FF" | 47
 +
| align="center" bgcolor="#F0F8FF" | 65
 +
| align="center" bgcolor="#F0F8FF" | 32
 +
|-
 +
| colspan = "7" bgcolor="#FFFFFF"|
 +
|-
 +
! colspan = "7" | ECG = electrocardiogram; PTP = pre-test probability; SCAD = stable coronary artery disease.
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|-
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| colspan = "7" bgcolor="#FFFFFF" | <b><sup>a</sup></b> Probabilities of obstructive coronary disease shown reflect the estimates for patients aged 35, 45, 55, 65, 75 and 85 years.
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*Groups in <i>white boxes</i> have a PTP <15% and hence can be managed without further testing.
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*Groups in <i>blue boxes</i> have a PTP of 15–65%. They could have an exercise ECG if feasible as the initial test. However, if local expertise and availability permit a non-invasive imaging based test for ischaemia this would be preferable given the superior diagnostic capabilities of such tests. In young patients radiation issues should be considered.
 +
*Groups in <i>light pink boxes</i> have PTPs between 66–85% and hence should have a non-invasive imaging functional test for making a diagnosis of SCAD.
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*In groups in <i>dark pink boxes</i> the PTP is >85% and one can assume that SCAD is present. They need risk stratification only.
 
|}
 
|}
    
The severity of complaints can be classified according to the Canadian Cardiovascular Society as shown in Table 3
 
The severity of complaints can be classified according to the Canadian Cardiovascular Society as shown in Table 3
   −
{| class="wikitable" border="1" width="95%"
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{| class="wikitable" border="1" width="600px"
 
|-
 
|-
 
! colspan="2" | Table 3. Classification of angina severity according to the Canadian Cardiovascular Society
 
! colspan="2" | Table 3. Classification of angina severity according to the Canadian Cardiovascular Society
 
|-
 
|-
| width="100" align="left" | ''Class''
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! width="100"| ''Class''
| align="left" | ''Level of Symptoms''
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| ''Level of Symptoms''
 
|-
 
|-
| valign="top" align="left" | Class I
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! valign="top"| Class I
| align="left" | 'Ordinary activity does not cause angina'
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| 'Ordinary activity does not cause angina'
 
Angina with strenuous or rapid or prolonged exertion only
 
Angina with strenuous or rapid or prolonged exertion only
 
|-
 
|-
| valign="top" align="left" | Class II
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! valign="top"| Class II
| align="left" | 'Slight limitation of ordinary activity'
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| 'Slight limitation of ordinary activity'
 
Angina on walking or climbing stairs rapidly, walking uphill or exertion after meals, in cold weather, when under emotional stress, or only during the first few hours after awakening
 
Angina on walking or climbing stairs rapidly, walking uphill or exertion after meals, in cold weather, when under emotional stress, or only during the first few hours after awakening
 
|-
 
|-
| valign="top" align="left" | Class III
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! valign="top"| Class III
| align="left" | 'Marked limitation of ordinary physical activity'
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| 'Marked limitation of ordinary physical activity'
 
Angina on walking one or two blocks on the level or one flight of stairs at a normal pace under normal conditions
 
Angina on walking one or two blocks on the level or one flight of stairs at a normal pace under normal conditions
 
|-
 
|-
| valign="top" align="left" | Class IV
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! valign="top"| Class IV
| align="left" | 'Inability to carry out physical activity without discomfort' or 'angina at rest'
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| 'Inability to carry out physical activity without discomfort' or 'angina at rest'
 
|}
 
|}
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==Stress Testing in Combination with Imaging==
 
==Stress Testing in Combination with Imaging==
Some patients are unable to perform physical exercise. Furthermore, in patients with resting ECG abnormalities the exercise ECG is associated with low sensitivity and specificity. If the ECG made during exercise testing does not show any abnormalities myocardial ischemia becomes unlikely as cause of the complaints. If the diagnosis is still in doubt, the following additional tests may be performed.  
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Some patients are unable to perform physical exercise. Furthermore, in patients with resting ECG abnormalities the exercise ECG is associated with low sensitivity and specificity.  
 +
 
 +
{| class="wikitable" border="1" width="600px"
 +
|-
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|colspan = "7" | <b>Table 4. Characteristics of tests commonly used to diagnose the presence of coronary artery disease. <Cite>REFNAME20</Cite></b>
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|-
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| bgcolor="#FFFFFF" rowspan="2"|
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|align="center" colspan="2" bgcolor="#FFFFFF" | <b>Diagnosis of CAD</b>
 +
|-
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| align="center" bgcolor="#FFFFFF" | <b>Sensitivity (%)</b>
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| align="center" bgcolor="#FFFFFF" | <b>Specificity (%)</b>
 +
|-
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| <b>Exercise ECG <sup>a, 91, 94, 95</sup></b>
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!45–50
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!85–90
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|-
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| <b>Exercise stress echocardiography <sup>96</sup></b>
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!80–85
 +
!80–88
 +
|-
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| <b>Exercise stress SPECT <sup>96-99</sup></b>
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!73–92
 +
!63–87
 +
|-
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| <b>Dobutamine stress echocardiography <sup>96</sup></b>
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!79–83
 +
!82–86
 +
|-
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| <b>Dobutamine stress MRI <sup>b,100</sup></b>
 +
!79–88
 +
!81–91
 +
|-
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| <b>Vasodilator stress echocardiography <sup>96</sup></b>
 +
!72–79
 +
!92–95
 +
|-
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| <b>Vasodilator stress SPECT <sup>96, 99</sup></b>
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!90–91
 +
!75–84
 +
|-
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| <b>Vasodilator stress MRI <sup>b,98, 100-102</sup></b>
 +
!67–94
 +
!61–85
 +
|-
 +
| <b>Coronary CTA <sup>c,103-105</sup></b>
 +
!95–99
 +
!64–83
 +
|-
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| <b>Vasodilator stress PET <sup>97, 99, 106</sup></b>
 +
!81–97
 +
!74–91
 +
|-
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| colspan="3" bgcolor="#FFFFFF"| <b>CAD</b> = coronary artery disease; <b>CTA</b> = computed tomography angiography; <b>ECG</b> = electrocardiogram; <b>MRI</b> = magnetic resonance imaging; <b>PET</b> = positron emission tomography; <b>SPECT</b> = single photon emission computed tomography.
 +
|-
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| colspan="3"|<b><sup>a</sup></b> Results without/with minimal referral bias.
 +
 
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<b><sup>b</sup></b> Results obtained in populations with medium-to-high prevalence of disease without compensation for referral bias.
 +
 
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<b><sup>c</sup></b> Results obtained in populations with low-to-medium prevalence of disease.
 +
|}
 +
 
 +
[[File:Algorithm_for_the_initial_evaluation_of_patients_with_clinical_symptoms_of_angina.svg|thumb|right|500px|Figure 1. Algorithm for the initial evaluation of patients with clinical symptoms of angina]]
 +
 
 +
If the ECG made during exercise testing does not show any abnormalities myocardial ischemia becomes unlikely as cause of the complaints. If the diagnosis is still in doubt, the following additional tests may be performed.  
 
#Exercise echocardiography means that an echocardiography is made before and during different stages up to peak exercise in order to identify wall motion abnormalities. <Cite>REFNAME12</Cite> An alternative is pharmacological stress testing using dobutamine.
 
#Exercise echocardiography means that an echocardiography is made before and during different stages up to peak exercise in order to identify wall motion abnormalities. <Cite>REFNAME12</Cite> An alternative is pharmacological stress testing using dobutamine.
 
#Myocardium Perfusion Scintigraphy (MPS) is able to show the perfusion of the heart during exercise and at rest based on radiopharmaceutical tracer uptake . <Cite>REFNAME13</Cite>
 
#Myocardium Perfusion Scintigraphy (MPS) is able to show the perfusion of the heart during exercise and at rest based on radiopharmaceutical tracer uptake . <Cite>REFNAME13</Cite>
 
#Magnetic Resonance Imaging can be done with vasodilatory adenosine or stimulating dobutamine to detect wall motion abnormalities induced by ischemia during pharmacological stress. <Cite>REFNAME14</Cite>  
 
#Magnetic Resonance Imaging can be done with vasodilatory adenosine or stimulating dobutamine to detect wall motion abnormalities induced by ischemia during pharmacological stress. <Cite>REFNAME14</Cite>  
   −
The findings on stress testing can be used to determine the choice between medical therapy only or medical therapy and invasive assessment of the coronary anatomy in patients with stable angina. Coronary angiography is recommended based upon the severity of symptoms, likelihood of ischemic disease, and risk of the patient for subsequent complications including mortality based on risk scores. <Cite>REFNAME15</Cite> For the algorithm for the initial evaluation of patients with clinical symptoms of angina see Figure 1
+
The findings on stress testing can be used to determine the choice between medical therapy only or medical therapy and invasive assessment of the coronary anatomy in patients with stable angina. Coronary angiography is recommended based upon the severity of symptoms, likelihood of ischemic disease, and risk of the patient for subsequent complications including mortality based on risk scores. <Cite>REFNAME15</Cite> For the algorithm for the initial evaluation of patients with clinical symptoms of angina see Figure 1.
  −
[[File:Figure_1_-_algorithm_for_the_initial_evaluation_of_patients_with_clinical_symptoms_of_angina.png|thumb|right|500px|Figure 1. Algorithm for the initial evaluation of patients with clinical symptoms of angina]]
      
==Coronoary Angiography==
 
==Coronoary Angiography==
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#REFNAME18 pmid=3925741
 
#REFNAME18 pmid=3925741
 
#REFNAME19 pmid=9355934
 
#REFNAME19 pmid=9355934
#REFNAME20 pmid=12515758
+
#REFNAME20 pmid=23996286
 
</biblio>
 
</biblio>
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