Stable ischaemic heart disease and angina

Also known as Stable angina · Chronic coronary syndrome · SIHD · Coronary artery disease

GP-fellowship guide to stable ischaemic heart disease and angina: typical, atypical and non-anginal pain definitions that set pre-test probability, CT coronary angiography as the first-line investigation in ANZ practice, the anti-anginal ladder from beta-blocker and calcium channel blocker to ranolazine and ivabradine, aspirin plus high-intensity statin secondary prevention with FOURIER and ODYSSEY PCSK9 add-ons, ACEI after myocardial infarction, cardiac rehabilitation evidence, what COURAGE and ISCHEMIA mean for revascularisation versus medical therapy, follow-up cadence, and safety-netting the acute change.

high15 referencesUpdated 21 Aug 20268 min readVerification in progress

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Key points

Stable ischaemic heart disease is diagnosed by the history: typical angina means substernal chest discomfort provoked by exertion or emotion and relieved within minutes by rest or glyceryl trinitrate — three features = typical, two = atypical, one or none = non-anginal.
CT coronary angiography is the first-line investigation in ANZ practice for typical or atypical pain with intermediate pre-test probability; a normal CTCA carries a high negative predictive value and SCOT-HEART showed it reclassified the diagnosis in 27% of patients at 6 weeks.
Optimal medical therapy — aspirin plus high-intensity statin, anti-anginals titrated to symptoms, blood pressure and diabetes control, smoking cessation, cardiac rehabilitation — is the foundation: COURAGE found no reduction in death or myocardial infarction from adding PCI (19.0% vs 18.5% at 4.6 years), and ISCHEMIA confirmed no benefit of an initial invasive strategy over conservative therapy in moderate-to-severe ischaemia.^[3]^[1]
Revascularisation earns its place for symptom control beyond medical therapy (COURAGE quality-of-life gains fading after ~2 years), functionally significant stenoses driving urgent revascularisation risk (FAME 2), and left main or high-burden anatomy.^[4]^[10]

Overview

Stable ischaemic heart disease is a chronic supply-demand mismatch: fixed epicardial stenoses limit flow so that exertion outstrips perfusion. The GP's job spans four decades of care — recognising the pattern, investigating proportionately, layering secondary prevention onto every year of life, keeping the patient stable, and catching the moment stability ends.^[7]

The evidence base reshaped practice twice. COURAGE showed that adding PCI to optimal medical therapy did not reduce death or myocardial infarction in stable disease.^[3] ISCHEMIA extended the message to patients with moderate-to-severe ischaemia on modern therapy: no outcome advantage from starting invasively.^[1] What revascularisation does deliver — earlier and better angina relief — matters to patients and is exactly what shared decision-making is for.^[4]

References15Show

[1]Maron DJ, Hochman JS, Reynolds HR, et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease N Engl J Med, 2020.PMID 32227755
[2]Bangalore S, Maron DJ, O'Brien SM, et al. Management of Coronary Disease in Patients with Advanced Kidney Disease N Engl J Med, 2020.PMID 32227756
[3]Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease N Engl J Med, 2007.PMID 17387127
[4]Weintraub WS, Spertus JA, Kolm P, et al. Effect of PCI on quality of life in patients with stable coronary disease N Engl J Med, 2008.PMID 18703470
[5]Sabatine MS, Giugliano RP, Keech AC, et al. Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease N Engl J Med, 2017.PMID 28304224
[6]Schwartz GG, Steg PG, Szarek M, et al. Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome N Engl J Med, 2018.PMID 30403574
[7]Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes Eur Heart J, 2020.PMID 31504439
[8]Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease N Engl J Med, 2015.PMID 25773919
[9]SCOT-HEART investigators CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial Lancet, 2015.PMID 25788230
[10]De Bruyne B, Pijls NH, Kalesan B, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease N Engl J Med, 2012.PMID 22924638
[11]Antithrombotic Trialists' (ATT) Collaboration, Baigent C, Blackwell L, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials Lancet, 2009.PMID 19482214
[12]Morrow DA, Scirica BM, Karwatowska-Prokopczuk E, et al. Effects of ranolazine on recurrent cardiovascular events in patients with non-ST-elevation acute coronary syndromes: the MERLIN-TIMI 36 randomized trial JAMA, 2007.PMID 17456819
[13]IONA Study Group Effect of nicorandil on coronary events in patients with stable angina: the Impact Of Nicorandil in Angina (IONA) randomised trial Lancet, 2002.PMID 11965271
[14]Long L, Anderson L, Dewhirst AM, et al. Exercise-based cardiac rehabilitation for adults with stable angina Cochrane Database Syst Rev, 2018.PMID 29394453
[15]Long L, Anderson L, He J, et al. Exercise-based cardiac rehabilitation for stable angina: systematic review and meta-analysis Open Heart, 2019.PMID 31245012