Stable ischaemic heart disease and angina — KFP-style written assessment

KFP 1 (10 marks)

A 61-year-old man presents with three months of central chest tightness on climbing his driveway hill, easing within five minutes of rest. Episodes occur two or three times weekly. He smokes 10/day, takes amlodipine for hypertension, and his father had bypass surgery at 60. Resting ECG is normal. ^{[7] [9]}

1. Classify his pain using the three-feature taxonomy. (2) ^[7]
2. What is your first-line investigation and why? (4) ^[9]
3. His CTCA shows a proximal LAD stenosis of intermediate severity. Name the functional assessment options that follow. (4) ^[10]

Model answers

1. Typical angina — all three features present (substernal character, exertional provocation, rest relief). Typical pain carries the highest pre-test probability in a 61-year-old male smoker. ^[7]
2. CT coronary angiography — ANZ/NICE first-line for typical/atypical pain with intermediate probability; high negative predictive value; SCOT-HEART showed CTCA reclassified the coronary diagnosis in 27% of patients at 6 weeks versus 1% with standard care. His normal resting ECG excludes nothing. ^[9]
3. Functional confirmation before revascularisation decisions: CT fractional flow reserve on the existing scan, stress echocardiography or myocardial perfusion scintigraphy, or invasive FFR at angiography — FAME 2 showed only functionally significant stenoses (FFR 0.80 or less) carried urgent-revascularisation risk that PCI reduced (composite 4.3% vs 12.7%). ^[10]