What is angina?

Typical angina is:

• A compressive, diffuse, retrosternal pain.
• Sometimes radiating to the neck, to the left and/or right shoulder and/or arm.
• Emerging with exertion (in stable angina) or at rest (in acute coronary syndrome).
• Often accompanied by vagal symptoms (sweating, nausea, malaise) and/or dyspnea, malaise.
• Improving with sublingual nitrates.

Angor is not always caused by coronary artery stenosis. Sometimes it can also be a presentation of cardiac decompensation (with increased intracardiac pressures), pronounced LV hypertrophy (for example hypertrophic cardiomyopathy), acute right heart failure (for example acute pulmonary embolism ), etc. However, this distinction cannot be made without further investigations.

Based on clinical history, distinction must be made with atypical thoracic pain that is not of cardiac origin, but of musculoskeletal, pleural or pulmonary origin.
Arguments for atypical thoracic pain include:

• Sharp, stabbing
• Pain that is more localized at one point, sometimes spread over different points.
• Local pressure pain at p
• Pain that is localized more laterally (the more the pain is on the lateral side of the thorax, less likely it is of cardiac origin).
• Pain that worsens in certain positions or with certain movements.
• Pain that worsens with breathing.

Various clinical presentations

• Stable angina :
  • Angina that occurs with certain exertions, quickly improving at
  • Cause: significant coronary artery stenosis.
  • Resting ECG can be normal.
• Acute coronary syndromes :
  • Prolonged angina at rest, new onset of severe angina, angina increasing in frequency/duration, onset at lower threshold or angina after a recent episode of myocardial infarction.
  • Distinction (according to ECG and troponin) :
    • Unstable angina (normal troponin).
    • Myocardial infarction (increased troponin).
      • STEMI : ST-elevation myocardial infarction.
      • Non-STEMI : myocardial infarction without ST elevation.

• • Resting ECG usually abnormal in a certain area (at least 2 leads) :
    • STEMI : ST elevation.
    • Unstable angina or non-STEMI : ST depression, negative T waves; but the ECG may also be normal.
  • Cause :
    • STEMI : occlusion of a coronary artery.
    • Unstable angina or non-STEMI : impending occlusion of a coronary artery.

What to do?

• Good history to distinguish between angina and atypical thoracic pain.
• Clinical exam.
• ECG: signs of ischemia (STEMI or non-STEMI)?
• Blood sample to check troponin and D-dimers (if angina is suspected in the hours or days beforehand).

• -> In case of angina only during exertion (stable angina) : new consultation should be scheduled at short notice.
• -> In case of angina at rest (suspicion of an acute coronary syndrome), ischemia on ECG and/or increased troponin : urgent referral, usually to the emergency department.

If the diagnosis of STEMI or non-STEMI is already made on the ECG, the patient should be admitted immediately to the emergency department for urgent treatment, without taking blood samples or waiting for the results. The blood sample will then be taken in the hospital.

Investigations

• Noninvasive exams :
  • ECG
  • Blood sample: troponin
  • Cycling test
  • CT coronarography
  • Myocardial scintigraphy
• Invasive : coronarography

Therapy

Treatment according to the most recent guidelines.

Revascularization: restoring blood supply to the myocardium.

Options :

• PCI (percutaneous coronary intervention) with balloon dilatation of the coronary stenosis with or without implantation of a stent.
• CABG (coronary bypass surgery) to create a new blood supply to the end branches of the narrowed coronary artery.

Revascularization is indicated in the following situations :

• Acute coronary syndrome (unstable angina or myocardial infarction (STEMI and non-STEMI)).
• Symptoms of cardiac ischemia: angina, dynamic abnormal ECG, ...

However, revascularization with PCI has shown no improvement in the prognosis in patients with heart failure and HFrEF in studies (REVIVED-BCIS2 trial, NEJM 2022) if there are no complaints of angina, even if the myocardium is viable (as shown on cardiac MRI or myocardial scintigraphy (PET)). Optimal drug therapy is crucial in these patients. The policy for these patients must be decided by the heart team (cardiologists, interventional cardiologists, cardiac surgeons). If revascularization is chosen, there are more arguments for choosing CABG than PCI (STICH and STICHES trials).