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Stable angina and chronic coronary syndrome
In chronic coronary syndrome two tracks run together: preventing events (aspirin, statin, risk-factor control) and relieving symptoms (a beta-blocker or a calcium-channel blocker) — and revascularisation prolongs life only in defined anatomical situations.
Why it matters in the exam
Questions cover diagnosis (when to use CCTA and when a functional test, and what makes an exercise test positive), first- and second-line anti-anginal drugs, LDL targets, and who benefits from PCI or bypass surgery. Vasospastic angina (pain at rest, at night, with transient ST elevation), microvascular angina, silent ischaemia in diabetes, and drugs that must not be combined — nitrates with PDE5 inhibitors — also appear.
A central point is that in a stable patient angiography mainly improves symptoms and does not replace preventive drug treatment. Case questions often present a patient with typical exertional pain and ask for the next test, or a patient with normal coronaries and continuing pain, in whom a microvascular or vasospastic cause should be considered.
Key points
- Two tracks: prevention (aspirin, statin, risk factors) and symptom relief (beta-blocker or calcium blocker).
- CCTA at low-to-intermediate likelihood; functional imaging at higher likelihood.
- LDL target below 55 mg/dL and at least a 50% reduction from baseline.
- Revascularisation prolongs life in left main disease, three-vessel disease with reduced EF and proximal LAD disease.
- Vasospastic angina: pain at rest, transient ST elevation, treated with a calcium-channel blocker.
Summary table
| Item | What to do | Details | Exam note |
|---|---|---|---|
| Diagnosis | CCTA at low-to-intermediate likelihood; functional imaging at higher likelihood | Stress echo, SPECT, stress MRI | Positive exercise test: horizontal or down-sloping ST depression of 1 mm or more |
| Symptom relief - first line | Beta-blocker or calcium-channel blocker | Sublingual nitrate for attacks | With a fast heart rate a beta-blocker is preferred |
| Symptom relief - second line | Long-acting nitrate, ranolazine, ivabradine, nicorandil, trimetazidine | Chosen by heart rate, blood pressure and LV function | No nitrates with sildenafil or tadalafil |
| Prevention | Aspirin 75–100 mg, high-intensity statin, blood pressure and glucose control, stop smoking | LDL target below 55 mg/dL and at least a 50% reduction | Clopidogrel if aspirin is not tolerated |
| Life-prolonging revascularisation | Left main stenosis above 50%, three-vessel disease with reduced EF, proximal LAD | Usually bypass surgery | In other stable patients PCI improves symptoms only |
| Vasospastic angina | Pain at rest and at night, transient ST elevation | Calcium-channel blocker and nitrates | Avoid non-selective beta-blockers |
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Sources
- ESC Guidelines for the management of chronic coronary syndromes, 2024 — Diagnosis, anti-ischaemic therapy and revascularisation
- ESC/EAS Guidelines for the management of dyslipidaemias, 2019 — LDL-cholesterol targets for very-high-risk patients
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Ischemic Heart Disease
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.