Guidelines: Management of Stable Angina Pectoris

European Heart Journal (1997) 18, 394413
Guidelines
Management of stable angina pectoris
Recommendations of the Task Force of the European Society of Cardiology
Introduction
Stable angina pectoris is a common and disabling disorder. In recent years, its pathophysiology has been
clarified and there have been major advances in its
diagnosis and management. There is, however, no
consensus as to the optimal strategy of investigation
and treatment. Furthermore, its therapy has not been
subjected to the same scrutiny by large randomized trials
as has, for example, that of myocardial infarction
and unstable angina. Thus, although much has been
achieved in comparing the symptomatic benefit of different modalities of treatment, there is a relative paucity
of information about their prognostic effects.
The Task Force has therefore obtained opinions
from a wide variety of experts and has tried to achieve
agreement on the best contemporary approaches to the
care of stable angina pectoris, bearing in mind not only
the efficacy and safety of treatments, but also the
availability of resources and the cost.
Definition and pathophysiology

Heberden[1] introduced the term angina pectoris in
1772 to characterize a syndrome in which there was a
sense of strangling and anxiety in the chest, especially
associated with exercise. He did not recognise its cardiac
origin but, within a few years, others[2] had demonstrated coronary artery disease at the necropsy of
patients who had experienced the symptoms. It is now
usual to confine the term to cases in whom the syndrome
can be attributed to myocardial ischaemia, although
essentially similar symptoms can be caused by disorders
of the oesophagus, lungs or chest wall. In this Task
Force report, the term is used for chest discomfort due
to myocardial ischaemia associated with coronary artery
disease, although it is recognised that there are other
important causes of angina, such as aortic stenosis
and hypertrophic cardiomyopathy that must not be
overlooked.
Anginal symptoms are regarded as stable if they
have been occurring over several weeks without major
Key Words: Stable angina, drug therapy, percutaneous coronary
angioplasty, coronary bypass surgery
Request for reprints to: European Heart Journal, W. B. Saunders,
2428 Oval Road, London NW1 7DX, U.K.
0195-668X/97/030394+20 $18.00/0
deterioration. They typically occur in conditions associated with increased myocardial oxygen consumption.
Even in stable angina, however, symptoms may vary
considerably from time to time, depending upon such
factors as ambient temperature and emotional stress.
Angina is said to be unstable if pre-existing
angina worsens abruptly for no apparent reason or when
new angina develops at a relatively low work load or at
rest. This form of angina is often associated with fissuring or rupture of an atherosclerotic plaque and subsequent intracoronary thrombus formation. Increases in
coronary artery tone or spasm are important factors
in some cases.
Many patients presenting with anginal symptoms do not fulfil the above definitions. For example,
new symptoms may have developed in recent weeks
but have not progressed. Pathologically, they may
have features of both stable and unstable angina, and
the prognosis is intermediate between these two better
defined syndromes.
Angina is variant or of the Prinzmetal type if it
develops spontaneously with ST elevation on the electrocardiogram. This is usually ascribed to an increase in
coronary tone or spasm, and may then be termed
vasospastic.
The term Syndrome X is applied to a syndrome
in which angina pectoris is accompanied by objective
evidence of myocardial ischaemia (such as ST depression
on the electrocardiogram) in the absence of apparent
coronary atherosclerosis or other organic disease of the
epicardial coronary arteries. Small vessel disease may,
however, be present.
Angina pectoris occurs when there is an imbalance between myocardial perfusion and the demands of
the myocardium. The pathological substrate for this is
almost invariably atheromatous narrowing of the coronary arteries. It is usually considered that a coronary
artery must be narrowed by at least 5070% in luminal
diameter before coronary blood flow is inadequate to
meet the metabolic demands of the heart with exercise or
stress. However, the importance of a stenosis depends
not only on the reduction in luminal diameter but, also
on the length and number of stenoses. In addition, the
luminal diameter of stenoses, particularly eccentric
stenoses, are not fixed and may alter with changes in
coronary tone due to local smooth muscle constriction
or dilatation. This may occur as a response to the release
? 1997 The European Society of Cardiology
Guidelines on management of stable angina pectoris
of various hormones and neurogenic stimuli. Very occasionally, spasm of the coronary arteries can occur in the
presence of apparently normal coronary arteries, but
even in these circumstances minor plaques or damage to
the endothelium are frequently present.
Although the initiating stimulus causing an episode of angina may be an increase in myocardial oxygen
demand or decrease in coronary blood flow due to
vasoconstriction at the site of an atheromatous narrowing, the subsequent sequence of events invariably lead to
segmental dysfunction and/or left ventricular dilatation
causing a fall in coronary blood flow. Also the shortened
diastolic filling time due to the tachycardia that develops
and various hormonal perturbations may lead to coronary vasoconstriction. At the same time, the increases
in heart rate and blood pressure that usually follow the
development of myocardial ischaemia lead to a further
increase in myocardial oxygen demand. Finally, not only
may coronary tone alter but the heart can also adapt
its metabolic demands. Chronic or recurrent episodes
of ischaemia may lead to an adaptive process in myocardial metabolism that can result in hibernating myocardium, defined as chronic but reversible ischaemic left
ventricular dysfunction.
Patients with coronary artery disease are at risk
of developing plaque fissuring or rupture. Once plaque
rupture occurs, this is usually followed by platelet aggregation at the same site, which may lead to (further)
impairment of coronary blood flow or even thrombotic
coronary occlusion. Furthermore, activated platelets at
the site of plaque rupture may release a series of vascular
active substances which will lead to increased vasomotor
tone or even spasm. The clinical syndrome associated
with these events may be labelled either unstable angina
or evolving myocardial infarction.
Epidemiology
The diagnosis of angina pectoris has, until relatively
recently, depended largely upon obtaining a characteristic history. Reliable estimates of incidence and prevalence based upon such evidence have been difficult to
obtain. The cardiovascular questionnaire developed by
Rose and Blackburn[3] has been widely used in studies
on the prevalence of angina pectoris in populations. A
positive response to this questionnaire, however, overestimates the prevalence of angina pectoris in comparison with a history taken by a physician, with particularly
high proportions of false positives in younger women,
as shown in a population-based study carried out in
Finland[4]. Similar or even higher proportions of false
positives have been reported from other studies[5,6].
Population-based studies using various data collection
methods in countries with high or relatively high coronary heart disease rates have shown that among
middle-aged people angina is more than twice as common in men as it is in women[4,710]. In both sexes the
prevalence of angina increases sharply with age: in men
from 25% in the age group 4554 years to 1120% in
395
the age group 6574 years, and in women from 051%

to 1014%, respectively. After the age of 75 years the
prevalence is almost similar in men and women. On the
basis of these studies it may be estimated that in
countries with high or relatively high coronary heart
disease rates the total prevalent number of persons with
angina may be as high as 30 00040 000 per 1 million
total population. In more than one half of patients
with angina the severity of symptoms seriously limits
their everyday activities, often leading to premature
retirement in patients of working age[4,11].
Population-based information on the incidence
of angina pectoris is mainly based on prospective epidemiological studies with repeated re-examinations of
study cohorts. During a 10-year follow-up of the Seven
Countries Studies cohorts, the average annual incidence
of angina pectoris as the only manifestation of coronary
heart disease was in men aged 4059 years 01% in
Japan, Greece and Croatia, 0204% in Italy, Serbia,
Netherlands and U.S.A., and 0611% in Finland[12].
These incidence rates showed a significant positive
correlation with coronary heart disease mortality rates
in the study cohorts. In the 20-year follow-up of the
Framingham Study cohort, the annual incidence of
uncomplicated angina pectoris among men was 03% in
the age group 4554 years, 08% in the age group 5564
years and 06% in the age group 6574 years[13]. Among
women the corresponding age-specific incidence rates
were 02%, 06% and 06%. Angina pectoris was the
presenting manifestation less frequently in men than in
women (37% vs 65%), but due to generally higher
incidence rate of clinically manifest coronary heart disease in men there was a gap in the incidence of angina
between the sexes below the age of 65 years[12].
Half of those having their first myocardial infarction had angina following it, whereas only one fifth of
those having their first infarction had preceding angina[14]. In the 5-year follow-up of the Israel Ischaemic
Heart Disease Study cohort of men over 40 years of age,
the average annual incidence of uncomplicated angina
pectoris was 07%[15]. A study based on the experience of
a general practitioner in London over 25 years[16] produced annual incidence rates close to those observed in
the Framingham and Israel studies. This was 05% in
persons above the age of 40 years, was higher in men
than in women and increased with age; the gap between
men and women diminished with advancing age.
Coronary heart disease mortality has been
declining in a many industrialized, socio-economically
well established countries in Europe and elsewhere. This
decline has been most marked in younger middle-aged
groups and it appears to be, in part, explained by a real
decline in the incidence of the disease and in part by an
improvement in the prognosis of those who get it. These
favourable trends are, however, accompanied with a
shift of the main burden of clinically manifest coronary
heart disease, particulary its milder manifestations, towards older age groups[17], and in countries showing
such trends the prevalence of angina pectoris can be
predicted to increase in the older age groups. This has
Eur Heart J, Vol. 18, March 1997
396
recently been documented by morbidity statistics for

England and Wales collected by the Royal College of
General Practitioners in 19811982 and 19911992[10].
During the 10-year period the prevalence of angina
pectoris increased in the age group 6574 years by 63%
in men and by 69% in women and in the age group 75
years and over by 79% in men and 92% in women.
Natural history and prognosis

Chronic stable angina is compatible with a relatively
good prognosis in the majority of patients. Several
studies have shown that mortality on average is approximately 23% per annum and a further 23% each year
will sustain a non-fatal myocardial infarction[1820].
There are, however, subgroups at higher risk: patients
with significant impairment of left ventricular function,
especially if heart failure has occurred. Another small
subgroup with a poor outlook are those with malignant
coronary anatomy: patients with left main stem stenosis
or very proximal left anterior descending stenoses[21]. It
is important as part of management to identify patients
at high risk so that appropriate therapy is targeted to
improve prognosis.
Nowadays, the natural history of stable angina
is affected by the complex and dynamic results of
anti-ischaemic, anti-thrombotic, anti-hypertensive and
lipid lowering therapy, as well as by revascularization
procedures which lead to a new managed history.
Intensive risk factor modification may radically change
the outcome of the disease. Reduction of lipid levels by
diet, statins and other drugs, or ileal bypass have been
shown to reduce coronary events and the need for
revascularization. In stable angina pectoris patients,
coronary atherosclerotic disease can progress subclinically, but usually does so slowly. Angiographically complex and smooth stenoses progress at different rates
within the same coronary tree, the former changing
more rapidly than the latter. Long-term progression of
disease may be slow and linear or episodic and rapid, or
a combination of both[22]. In patients with stable angina
who had been advised to undergo coronary angioplasty
in whom the coronary angiogram was repeated 73
months apart, a similar proportion of target and nontarget lesions progressed rapidly (9% and 8% respectively), both contributing to the appearance of new
symptoms[23]. These observations indicate that in
patients with stable angina, coronary stenoses exist that
may progress rapidly and that plaque events, rather than
slow linear progression, can take place at the site of
stenosis. These findings also indicate that progression of
disease leading to clinical symptoms or outcome may
not necessarily be related to the severity of the stenosis.
In many patients, smaller plaques are present in
addition to those causing severe stenosis. The likelihood
of instability or rupture of one of the many smaller
plaques exceeds the risk of instability of the few areas
with a marked stenosis[24]. The most severe stenosis in a
vessel is not necessarily the one most likely to lead to
infarction.
In the evaluation of patients with chronic stable

angina it is important to identify those patients at
increased risk whose outcome may be improved by
revascularization. Information on long-term prognosis
of patients with stable angina can be derived from the
follow-up results of the large control groups of randomized trials aimed at evaluating the effectiveness of
revascularization[2527]. In general, the outcome is worse
(and the revascularizationrelated improvement greater)
in patients with worse left ventricular function, a greater
number of diseased vessels, more proximal locations
of coronary stenosis, greater severity of lesions, more
severe angina, more easily provoked angina or ischaemia, and greater age.
Ischaemic episodes in patients with angina pectoris are often silent. Ambulatory silent ischaemia has
been reported to predict adverse coronary events in
some studies but not in others[28,29] and there is conflicting evidence that the suppression of silent ischaemia in
stable angina pectoris improves cardiac outcome[30]. The
significance and treatment of silent ischaemia in this
context appears to be different from that of unstable and
post-infarction angina where it has been clearly shown
that recurrent ischaemia predicts an adverse outcome[31].
Diagnosis and assessment

Symptoms and signs
A carefully taken history is essential in the diagnosis and
management of angina pectoris. In the majority of cases,
it is possible to make a confident diagnosis on the basis
of the history alone, although physical examination and
objective tests are necessary to determine its cause and
assess its severity.
The classic symptom has four cardinal features:
location; relationship to exercise; character, and duration. Most patients can describe the first two characteristics without difficulty, but are less precise about the
latter two.
Location. Typically the discomfort is located in the
retrosternal region, and may radiate to both sides of
the chest and the arms (more commonly the left) as far
as the wrist, and to the neck and jaw. Less often, it may
radiate to the back. Quite frequently, the pain starts in
one of the other areas and only later spreads to the
central chest; sometimes it does not involve the sternal
region at all.
Relationship to exercise. In most cases, angina is provoked by increased myocardial oxygen consumption
during exercise (or other stress) and is quickly relieved
by rest. Some patients experience angina at rest; this
suggests either changes in coronary artery tone, arrhythmias, or unstable angina. However, emotion, a potent
provoking factor, may be responsible.
Character. Although angina is often described as a pain,
patients may deny this but acknowledge a discomfort
which may be a feeling of pressure or a strangling sensation. The intensity of the symptoms varies greatly, from
a slight localised discomfort to the most severe pain.
Duration. Anginal pain provoked by physical exercise is
usually spontaneously relieved within 13 min after
discontinuation of exercise, but may last up to 10 min or
even longer after very strenuous exercise. Anginal pain
provoked by emotion may be relieved more slowly than
that provoked by physical exercise. Anginal episodes
in patients with syndrome X are frequently longer and
less consistent in their relation to exercise than those in
patients with atherosclerotic coronary artery stenosis.
The chest discomfort may be accompanied by or
even overshadowed by such symptoms as breathlessness,
fatigue and faintness.
Classification of angina
The Canadian Cardiovascular Society[32] has provided a
grading classification of angina:
Class I
Ordinary physical activity does not cause

angina such as walking or climbing stairs.
Angina with strenuous or rapid or prolonged
exertion at work or recreation.
Class II Slight limitation of ordinary activity
walking or climbing stairs rapidly, walking
uphill, walking or stair climbing after meals,
in cold, or in wind, or when under emotional
stress, or only during the few hours after
awakening. Walking more than two blocks*
on the level and climbing more than one flight
of stairs at a normal pace and in normal
conditions.
Class III Marked limitation of ordinary physical
activity walking one or two blocks on
the level and climbing one flight of stairs in
normal conditions and at normal pace.
Class IV Inability to carry on any physical activity
without discomfort anginal syndrome may
be present at rest.
The Canadian classification has proved popular
and is widely used, but alternative, and prognostically superior, instruments are available such as the
Specific Activity Scale and the Duke Activity Status
Index[33-35].
In clinical practice it is important to describe
accurately the factors associated with angina pectoris in
each individual patient. This should include specific
activities associated with angina, walking distance,
frequency and duration of episodes.
Differential diagnosis of the symptoms. If all four cardinal features are present, or even only the first two if they
are quite typical, the diagnosis of chronic stable angina
is virtually assured. Often, however, the picture is not
*Equivalent to 100200 m.
397
so clear-cut and other diagnoses must be considered.

Chief amongst these are oesophageal reflux and spasm,
peptic ulcer, gallstones, musculo-skeletal disorders and
non-specific chest pains, often associated with anxiety
states.
Physical signs. There are no physical signs which are
specific for angina, but those characteristic of an underlying cause (such as aortic stenosis) may be present. The
patient often looks pale, distressed and sweaty during an
attack. Third or fourth heart sounds may be heard as
well as a murmur of (temporary) mitral incompetence.
Evaluation for concomitant disorders. Co-existent metabolic and clinical disorders are common. A full lipid
profile should be obtained, and the appropriate clinical
and laboratory examinations should be undertaken with
respect to anaemia, hypertension, diabetes and thyroid
function.
ALGORITHM FOR THE DIAGNOSIS OF

ANGINA PECTORIS, THE CHOICE OF
INVESTIGATIONS
While history often suffices to establish the diagnosis of
angina pectoris, additional investigations are usually
needed to confirm the diagnosis, to assess prognosis and
to select the most appropriate therapy. Different strategies may be followed depending on the patients previous history and the severity (frequency and intensity)
of their symptoms. In patients with new symptoms,
in whom the diagnosis of coronary artery disease has
not yet been established, the approach will differ in comparison with patients with known coronary artery disease, after previous coronary angiography or coronary
intervention or after previous myocardial infarction.
Three diagnostic strategies can be distinguished:
(1) It may be adequate to rely solely on the patients
history, supplemented by physical examination
and a resting electrocardiogram. This approach often suffices in elderly patients with mild symptoms
responding promptly to medical therapy and in
patients in whom coronary interventions are not
considered a therapeutic option.
(2) Another approach is based on a functional assessment of the presence or absence and extent of
myocardial ischaemia, which may include exercise
testing with electrocardiography, exercise (or other
stress) myocardial perfusion imaging (thallium or
one of the technetium-99 m labelled perfusion
tracers), stress-echocardiography and, possibly, exercise radionuclide angiography. In patients with
significant functional abnormalities, this may be
followed by coronary angiography to assess whether
coronary intervention is indicated and which intervention would be most appropriate. The indications
for coronary angiography are discussed in more
detail below.
398
Table 1(a)
Pretest likelihood of coronary artery disease in symptomatic patients according to age and sex
Typical angina
Age
(years)
3039
4049
5059
6069
Non-anginal
chest pain
Atypical angina
Male
Female
Male
Female
Male
Female
697&32
873&10
920&06
943&04
258&66
552&65
794&24
901&10
218&24
461&18
589&15
671&13
42&13
133&29
324&30
544&24
52&08
141&13
215&17
281&19
08&03
28&07
84&12
186&19
Table 1(b) Coronary artery disease post-test likelihood (%) based on age, sex, symptom classification and
exercise-induced electrocardiographic ST-segment depression
Age
(years)
ST depression
(mV)
Typical angina
Atypical angina
Non-anginal
chest pain
Asymptomatic
Male
Female
Male
Female
Male
Female
Male
Female
3039
000004
005009
010014
015019
020024
>025
25
68
83
91
96
99
7
24
42
59
79
93
6
21
38
55
76
92
1
4
9
15
33
63
1
5
10
19
39
68
<1
1
2
3
8
24
<1
2
4
7
18
43
<1
4
<1
1
3
11
4049
000004
005009
010014
015019
020024
>025
61
86
94
97
99
>99
22
53
72
84
93
98
16
44
64
78
91
97
3
12
25
39
63
86
4
13
26
41
65
87
1
3
6
11
24
53
1
5
11
20
39
69
<1
1
2
4
10
28
5059
000004
005009
010014
015019
020024
>025
73
91
96
98
99
>99
47
78
89
94
98
99
25
57
75
86
94
98
10
31
50
67
84
95
6
20
37
53
75
91
2
8
16
28
50
78
2
9
19
31
54
81
1
3
7
12
27
56
6069
000004
005009
010014
015019
020024
>025
79
94
97
99
99
>99
69
90
95
98
99
99
32
65
81
89
96
99
21
52
72
83
93
98
8
26
45
62
81
94
5
17
33
49
72
90
3
11
23
37
61
85
2
7
15
25
47
76
(3) A further option is to proceed immediately from

history, physical examination and ECG to coronary
angiography. This approach may be indicated particularly in patients with typical and severe symptoms, including unstable angina, patients with early
post infarction angina, and in patients with early
recurrence of symptoms after previous coronary
intervention[36].
In clinical practice, the second approach is followed most frequently. In patients with frequent or
severe stable angina, functional assessment is often
useful prior to or in addition to angiography. It should
be appreciated that symptoms resembling angina do
not necessarily have a causal relation to any coronary

artery narrowings present. Thus, additional functional
assessment may be needed in patients with less typical
symptoms and moderately severe coronary artery
narrowings. Furthermore, such an assessment may help
to establish the functional significance of abnormalities
observed in the coronary angiogram[37]. For example, in
a patient with both complete obstruction of one coronary vessel (and possibly previous myocardial infarction) and a moderately severe stenosis in another vessel,
perfusion scintigraphy may help to decide whether
symptoms are likely to be alleviated by percutaneous
intervention (PTCA) of the moderately severe lesion
only, or by surgical intervention of both vessels.
Table 2
399
Functional tests of coronary artery disease

Exercise ECG
Detection of CAD
Sensitivity
Specificity
Greatest sensitivity
Stress echocardiography
5080%
8095%
Multi-vessel disease
6590%
9095%
Single vessel disease
6590%
9095%
Single and multi-vessel disease
No influence
Difficult interpretation
80% LAD
60% RCA
Unhampered
Unhampered
To provide additional data in

some patients, particularly
location of myocardial ishcaemia
First choice in patients unable to

exercise. Limited value in patients
with poor echo quality
Location of CAD
Use in patients with
abnormal ST at rest
Recommended use
Thallium scintigraphy
First choice in most patients
CAD=coronary artery disease; LAD=left anterior descending; RCA=right coronary artery.
FUNCTIONAL ASSESSMENT, A
MULTI-STAGED APPROACH TO
ESTIMATE THE PROBABILITY OF
CORONARY ARTERY DISEASE
In patients without previous diagnosis of coronary
artery disease, a stepwise approach can be followed to
assess the probability of significant coronary artery
disease based on a combined analysis of factors such
as age, gender and the type of chest pain, as well as
presence and degree of ST segment changes during
exercise (Tables 1 (a) and (b)). The probability of the
presence of significant coronary artery disease can be
refined by analysis of the presence and degree of ST
segment changes during exercise[38,39]. From the Table
it is apparent that an exercise test will not be very
useful to verify the diagnosis of coronary artery disease
in a 64-year-old man with typical angina. Even in the
absence of ECG changes during the test, the likelihood
of coronary artery disease will still be 79%, while it
would rise to 99% if 02 mV ST segment depression
were to occur. Yet the test may help to determine the
functional impairment of that patient (exercise tolerance), to measure the blood pressure response (as an
indicator of left ventricular function) and to estimate
prognosis. Similarly, the diagnostic value of exercise
electrocardiography is low in asymptomatic men and
women.
The greatest diagnostic value is obtained in
patients with an intermediate pre-test likelihood, for
example between 20% and 80%. A further refinement
is a multivariate analysis of stress test results[40,41], in
which the probability is estimated based on a combination of heart rate at peak exercise, ST segment depression, the presence or absence of angina during the test,
workload achieved and ST segment slope. Such estimation of the likelihood of coronary artery disease provides more insight into the actual situation of a patient
than an arbitrary classification of normal or abnormal.
In patients with a low probability of coronary
artery disease (for example, <20%) and an adequate
exercise tolerance, usually no further investigations will
be necessary, even though the presence of coronary

artery disease can not be excluded. In patients with a
high post test likelihood (for example >80%) the diagnosis of coronary artery disease has been established. If
the symptomatology is moderately severe or severe, and
not adequately controlled by medical therapy, coronary
angiography is indicated to determine whether coronary
intervention is warranted.
In patients with an intermediate post test likelihood (between 20 and 80%) after a stress test, a second
non invasive test will be helpful to distinguish between
subgroups of patients with a higher or lower post test
probability. Depending on facilities and experience in a
given environment, either myocardial perfusion scintigraphy or stress echocardiography may be chosen as a
second test (Table 2).
In principle, subsequent tests to improve diagnostic certainty should be requested only if the results
would impact on patient management, including prescription of preventive measures. Often, no further tests
are required in patients with mild symptoms and a
normal exercise tolerance, even if the diagnosis remains
somewhat uncertain. In contrast, additional stress test or
angiography is warranted in patients with more severe
or frequent symptoms, particularly if these occur at low
workload in the absence of electrocardiographic signs
of myocardial ischaemia. Additional stress tests with
perfusion scintigraphy or echocardiography are often
useful in:
(1) Patients with typical anginal symptoms and nondiagnostic exercise ECG (ECG changes at rest
because of left ventricular hypertrophy, preexcitation or bundle branch block) or difficulty in
performing exercise due to non-cardiac limitations,
or a normal exercise ECG with (moderately) severe
symptoms.
(2) Subjects with atypical angina or absence of symptoms with a positive exercise ECG (with the
exception of very abnormal changes).
(3) Special subgroups with typical angina and a positive
exercise ECG where false-positive stress tests are
common, for example in younger women[42].
400
It should be appreciated that the diagnostic

approach to patients with chest pain of possible cardiac
origin has changed since the introduction of effective
measures for prevention of progression of coronary
artery disease. In addition to an advice to stop smoking
and treatment of hypertension and diabetes, patients
with known coronary artery disease may now require
treatment with lipid lowering drugs, particularly cholesterol synthesis inhibitors (statins). It has been shown
unequivocally that these drugs reduce the rate of progression of coronary disease[43,44] and reduce the incidence of coronary events.[4547]. Since these drugs are
costly, these should be prescribed for (secondary) prevention only in patients with documented coronary
disease. Thus, it has become important to establish or
rule out this diagnosis even in patients with mild symptoms in whom coronary intervention would not be
considered.
Non-invasive investigations
Resting electrocardiogram (ECG)
All patients with the suspicion of angina pectoris
based upon symptoms should have a resting 12-lead
electrocardiogram (ECG) recorded. This will not identify with certainty whether patients have coronary artery
disease or not; a normal resting ECG is not uncommon
even in patients with very severe angina. However, the
resting ECG may show signs of coronary artery disease
such as previous myocardial infarction or an abnormal
repolarisation pattern. In addition, the ECG may show
other abnormalities such as left ventricular hypertrophy,
bundle branch block, pre-excitation, arrhythmias or
conduction defects. Such information may be helpful in
defining the mechanisms responsible for chest pain or in
identifying patient subgroups with a higher risk of death
or myocardial infarction.
ECG stress testing

For patients with stable angina pectoris, the first investigation after clinical assessment and a resting ECG is
likely to be an exercise ECG. The exercise test should be
carried out only after careful clinical evaluation of
symptoms and a physical examination including resting
ECG. ECG changes during exercise are associated with
the presence of coronary artery disease with a sensitivity
of around 70% and a specificity of approximately 90%.
The results of the ECG stress testing should be interpreted by trained clinicians[48,49]. In population studies
with a low prevalence of ischaemic heart disease the
proportion of false positive tests will be high. Furthermore, false positive exercise recordings are common in
women with a low prevalence of disease. ECG changes
during exercise suggesting myocardial ischaemia in the
absence of coronary artery disease are also seen in
patients with such conditions as syndrome X, digitalis

treatment and electrolyte abnormalities.
In order to improve the specificity and sensitivity
of exercise ECG to identify coronary artery disease the
test procedure should be standardized with the use of
nomograms predicting the exercise response taking into
account age, gender and body size. The test may be
conducted in patients taking anti-ischaemic drugs. A
normal test in such patients does not rule out significant coronary disease. Thus, a second test, with less or
no medication, may be indicated, depending on the
clinical question to be answered[48].
The evaluation of the exercise test demands
assessment of the pretest and post-test likelihood of
coronary disease in the particular patient under investigation (Table 1 (a) and (b)). The ECG should be
continuously recorded with a print-out of signal averaged recordings at preselected intervals, mostly at each
minute during exercise, and 4 to 10 minutes of recovery after exercise. An exercise test is commonly
regarded as positive if there is horizontal or downsloping ST-segment depression 01 mV in any lead. Such a
dichotomous approach (i.e. positive or negative) is to
be deplored. It is misleading because in assessing the
significance of the test, one should take into account not
only the ECG changes but also the work load, heart rate
increase and blood pressure response, and the clinical
context. ST changes related to heart rate have been
suggested to be more reliable, describing the slope of ST
segment changes over time[40,50]. Either the Bruce protocol or one of its modifications on a treadmill or a bicycle
ergometer can be employed. The bicycle work load is
described in terms of Watts (W). Increments are of 20 W
per 1 minute stage starting from 20 to 50 W, but
increments may be reduced to 10 W per stage in patients
with heart failure or severe angina[48]. A standard protocol should be employed, since this may be used for
future reference in the same patient. In addition to the
diagnostic value of the exercise ECG, the stress test has
an important role in demonstrating silent ischaemia and
in predicting the prognosis of patients with chronic
stable angina pectoris and following the progress of the
disease or the effect of treatment.
The reason for stopping the test and the symptoms at that time, including their severity, should always
be recorded. Time to the onset of ECG changes and/or
symptoms, the overall exercise time, the blood pressure
and heart rate response, and the post-exercise recovery
pace of ECG changes should be assessed. The exercise
stress test is terminated at the discretion of the physician
for one of the following reasons:
(1) Symptom limitation, e.g. pain, fatigue, dyspnoea;
for repeated exercise tests. The use of Borg scale is
recommended to allow comparisons[51].
(2) Combination of symptoms such as pain with significant ST-changes.
(3) Safety reasons such as marked ST-segment changes
(particularly ST-segment elevation), arrhythmias, or
a sustained fall in systolic blood pressure.
Ambulatory monitoring
The sensitivity and specificity of the ST segment changes
for the diagnosis of coronary artery disease are lower
than for the exercise test, but may reveal evidence of
myocardial ischaemia that is not provoked by exercise[52,53]. Ambulatory electrocardiographic (Holter)
monitoring rarely adds important clinical information
for assessment of the diagnosis of chronic stable angina
pectoris over and above that provided by an exercise
test. Evaluation of repolarisation changes by ambulatory monitorning requires the use of equipment with
an adequate frequency response, according to the guidelines for electrocardiography. Two-lead or three-lead
recordings are used most frequently and should include
a bipolar V5 chest lead. Recording of twelve-leads by
ambulatory monitoring may have advantages.
Echocardiography at rest
Two-dimensional echocardiography is useful to estimate the size of the heart chambers and regional and
global left ventricular function. In addition, M Mode
echocardiography offers accurate and reproducible
measurements of cardiac chamber dimension and wall
thickness, although the geometry in patients with coronary artery disease is often complex due to myocardial
infarction, remodelling and aneurysms. Measurements
of left ventricular performance during systole and diastole may include ejection fraction, ejection time intervals, and systolic and diastolic volumes, wall stress,
stroke volume, cardiac output and the diastolic Doppler
flow pattern. Echocardiography is also useful to rule out
the possibility of other disorders such as valvular heart
disease or hypertrophic cardiomyopathy as a cause of
symptoms[54].
Stress echocardiography
Stress echocardiography has been developed as an alternative to classical exercise testing with electrocardiography, and as an additional investigation to establish
the presence or location of myocardial ischaemia during
stress.
At least 10 to 20% of patients referred for
evaluation of chest pain are unable to perform an
adequate diagnostic ECG exercise test. In these patients
dobutamine stress echocardiography represents an
alternative exercise independent stress modality. Yet it
should be appreciated that 5% of patients have an
inadequate echo window and 10% of the patients referred for a dobutamine stress test have a non-diagnostic
result (submaximal negative test).
The methodology and interpretation of stress
echocardiography has been described in several excellent reviews[55,56]. In short, the heart is stressed
by infusion of dobutamine or similar substances.
Dobutamine is administered intravenously starting
401
at 10 g . kg "1 . min "1 for 3 min, increasing by

10 g . kg "1 . min "1 every 3 min to a maximum of
40 g . kg "1 . min "1, which is continued for 6 min. In
patients not achieving 85% of their age-predicted maximal heart rate, who have no symptoms or signs of
ischaemia, atropine is given at the lower stage (025 mg
injections to a maximum of 10 mg) while dobutamine is
continued. Throughout the test the ECG is monitored,
and full 12 lead ECG recordings are made every minute.
The two-dimensional echocardiogram is continuously
monitored on a quad screen display for side by side
examination of rest and stress images, and recorded by
video, or on digital equipment. Normal myocardium
shows an increase of movement and thickening during
stress, while ischaemia is recognized by reduced regional
wall thickening and transient regional wall motion
abnormalities.
It should be appreciated that proper interpretation of changes in wall motion on a stress
echocardiogram requires considerable, experience and
expertise. Optimal recording equipment and computer
display (quad screen) is essential. In experienced hands
this method can become an excellent tool to clarify
regional wall motion abnormalities due to coronary
disease.
Myocardial perfusion scintigraphy

Myocardial perfusion scintigraphy is usually performed
in association with a symptom limited exercise test on
either a bicycle ergometer or a treadmill. It offers a
somewhat more sensitive and specific prediction of the
presence of coronary artery disease than exercise electrocardiography and allows detection of the location of
myocardial ischaemia during exercise. Isotopes used
most frequently are thallium 201 and technetium-99 m
labelled perfusion tracers. The isotope is injected at peak
exercise, preferably at the time when a patient experiences symptoms compatible with myocardial ischaemia.
Images are made immediately (thallium) or shortly after
exercise and repeated a few hours later, or the next day
after a new injection of the tracer. In patients who are
unable to exercise adequately, infusion with dobutamine
or similar agents may be used to stress the heart. A third
approach is the use of vasodilators (dipyridamole or
adenosine) to enhance perfusion in areas supplied by
normal coronary arteries.
Myocardial ischaemia, or underperfused areas
after vasodilatation, can be recognized as an area with
diminished isotope uptake during exercise in comparison with the uptake at rest. Interpretation of the test can
be facilitated by semi-quantitative analysis and tomographic display (SPECT=single photon emission computer tomography). Sensitivity and specificity for
perfusion scintigraphy are similar to those obtained with
stress echocardiography. Increased uptake of thallium
201 in the lung field identifies patients with extensive
coronary artery disease[5760].
402
Radionuclide angiography during exercise

Radionuclide angiography using technetium labelled red
blood cells can be used to assess left ventricular function
(global ejection fraction and regional wall motion) at
rest and during exercise. For these studies exercise is
conducted in the supine position with stepwise increments in work load with a 3 to 5 min step duration.
Images are collected over 1 to 2 min on each exercise
stage. Healthy subjects will show a normal ejection
fraction at rest which increases on exercise, while
patients with coronary disease (or other types of left
ventricular dysfunction) often exhibit no increase or a
decrease of global ejection fraction as well as development of regional wall motion abnormalities during
exercise[57,58].
Coronary angiography
Coronary angiography has a pivotal position in the
management of patients with chronic stable angina
pectoris. It is currently the most reliable tool to ascertain
the anatomical severity of coronary artery disease. However, necropsy and ultrasound studies[61] have clearly
demonstrated that the extent of plaque mass is grossly
underestimated by this technique. It carries a small risk
of mortality (<01%)[62] and often needs to be supplemented by functional tests.
Indications. Taking into account the development of new
techniques of myocardial revascularization and the low
risk of complications of coronary angiography, it should
be considered in the following conditions:
(1) Severe stable angina (Class 3 of the Canadian Cardiovascular Society Classification (CCS)), particularly if the symptoms are inadequately responding to
medical treatment;
(2) Chronic stable angina (Class 1 to 2) if there is
a history of myocardial infarction or evidence of
myocardial ischaemia at a low work load;
(3) Chronic stable angina in patients with bundle
branch block if readily-induced ischaemia is demonstrated by myocardial perfusion scintigraphy;
(4) Patients with stable angina who are being considered for major vascular surgery (repair of
aortic aneurysm, femoral bypass, or carotid artery
surgery);
(5) Patients with serious ventricular arrhythmias;
(6) Patients previously treated by myocardial revascularization (PTCA or CABG) who develop recurrence of moderate or severe angina pectoris;
(7) When it is essential to establish the diagnosis for
clinical or occupational reasons.
The performance and interpretation of coronary
angiography must be irreproachable. A complete examination includes left ventricular cineangiography performed in the right arterior oblique projection together
with a ventriculogram in the left oblique projection. This

permits assessment of left ventricular function including
wall motion abnormalities. The left coronary artery is
usually examined in five projections, to ensure optimal
assessment of each specific coronary segment, and the
right coronary artery in at least two projections. Recording of overlapping segments must be avoided and
specific, steeply angulated caudal left and right anterior
oblique projection must frequently be used. Interpretation of the arteriogram includes description of the
morphology and severity of coronary lesions, together
with the presence of collateral vessels.
Most angiographers tend to overestimate the
degree of stenosis prior to intervention, and underestimate the residual narrowing after treatment[63,64].
Quantitative coronary angiography greatly improves the
accurate assessment of coronary stenoses. In clinical
practice, assessment and, even more, the treatment of a
5075% stenosis must be complemented by evaluation of
its physiological importance with the usual markers of
ischaemia. In a diffusely narrowed and/or small vessel,
it is preferable not to use the percentage of stenosis
but to use the absolute value (mm) of the minimal
lumen diameter (MLD). In general, an MLD<1 mm in
a proximal vessel indicates a flow-limiting stenosis,
regardless of the percentage diameter stenosis.
In conclusion, coronary angiography has
evolved into a routine examination. It provides a considerable body of information for establishing the diagnosis and assessing the prognosis of coronary artery
disease. Nevertheless, the decision to perform this examination must be based on the clinical and physiological findings derived from a careful review of the history
and evidence of myocardial ischaemia.
In selected patients, objective intravascular ultrasound may provide additional information regarding the
status of plaques and the presence or absence of intracoronary thrombosis. The measurement of fractional
flow reserve[65] is a promising new technique for assessment of the functional significance of stenoses. These
methods are still under investigation.
TREATMENT
Aims of treatment
To improve prognosis by preventing myocardial
infarction and death
In order to achieve this end, attempts must be made
to induce regression or halt progression of coronary
atherosclerosis, and to prevent complications, especially
thrombosis. Lifestyle changes and drugs play a vital role
in this, but the myocardium may also be protected if its
perfusion is enhanced by interventional techniques.
To minimize or abolish symptoms
Lifestyle changes, drugs, and interventional techniques
all play a part.
General management
Patients and their close associates should be informed of
the nature of angina pectoris, and the implications of the
diagnosis and the treatments that may be recommended.
The patient can be reassured that, in most cases, angina
improves with proper management. Risk factors, especially smoking habit and lipid levels, should be assessed
in all cases. Particular attention must be paid to elements
of the lifestyle that could have contributed to the
condition and which may influence prognosis. The recommendations of the European Task Force[66] on Prevention of Coronary Heart Disease in Clinical Practice
should be followed.
Smoking. Cigarette smoking should be strongly discouraged, as there is abundant evidence that it is the
most important reversible risk factor in the genesis of
coronary disease in many patients[67,68]. Cessation of
smoking greatly impoves both symptoms and prognosis.
Patients often require special help in abandoning their
addiction, and transdermal nicotine has proved effective
and safe in helping patients with coronary artery disease
to quit smoking.
Diet. Patients should be encouraged to adopt a
Mediterranean diet, with vegetables, fruit, fish and
poultry being the mainstays. The intensity of change
needed in the diet depends upon the total (LDL) plasma
cholesterol level and other lipid abnormalities[69]. Those
who are overweight should be put on a weight reducing
diet. Alcohol in moderation may be beneficial[70], but
excessive consumption is harmful, especially in patients
with hypertension or heart failure.
Hypertension, diabetes and other disorders. Concomitant
disorders should be managed appropriately. Particular
attention should be given to control of elevated blood
pressure and diabetes mellitus. Both increase the risk
of progression of coronary disease, particularly when
ill-controlled. Also anaemia, if present, should be
corrected.
Physical activity. Physical activity within the patients
limitations should be encouraged, as it may increase
exercise tolerance[71], and reduce symptoms and has
favourable effects on weight, blood lipids, blood pressure, glucose tolerance and insulin sensitivity. Advice on
exercise must take into account the individualss overall
fitness and the severity of symptoms. An exercise test
can act as a guide to the level at which an exercise
programme can be initiated. Detailed recommendations
on exercise prescription, and on recreational and vocational activities are provided by the ESC Working
Group on Cardiac Rehabilitation[72].
Psychological factors. While the role of stress in the
genesis of coronary artery disease is controversial, there
is no doubt that psychological factors are important in
provoking attacks of angina. Furthermore, the diagnosis
403
of angina often leads to excessive anxiety. Reasonable

reassurance is essential, and patients may benefit from
relaxation techniques and other methods of stress control. Appropriate programmes may reduce the need for
drugs and surgery[73].
Car driving. In most countries, patients with stable
angina are permitted to drive except for commercial
public transport or heavy vehicles. Stressful driving
conditons should be avoided.
Sexual intercourse. Sexual intercourse may trigger
angina. Common sense will dictate that this should
not be too physically nor emotionally demanding.
Nitroglycerin prior to intercourse may be helpful.
Employment. An assessment should always be made of
the physical and psychological factors involved in an
affected subjects work (including housework). Patients
should, if possible, be encouraged to continue in
their occupation, with appropriate modifications, if
necessary.
Pharmacological treatment of patients with

chronic stable angina
Pharmacological treatment of angina encompasses
both the prevention of the complications of coronary
atherosclerosis and the relief of symptoms.
The prevention of myocardial infarction and death
In recent years, it has become clear that drugs that
modify lipids or decrease the risk of thrombosis substantially improve prognosis with regard to the incidence of
both myocardial infarction and death. Nitrates and
calcium antagonists have not been shown to be effective
in this respect, but large trials have established that, at
least in the post-infarction patient, betablockers reduce
mortality and reinfarction.
Lipid-lowering drugs. All patients with angina pectoris
should have a lipid profile. The Scandinavian Simvastatin
Survival Study[45] showed that a statin, given to patients
with angina pectoris and a total cholesterol level between 55 and 80 mmol . l "1 (212 and 308 mg . dl "1),
substantially reduces the risk of myocardial infarction,
death, and the need for coronary bypass surgery. Supportive evidence from other trials suggests benefit at
even lower lipid levels[46,47]. Previous concerns about the
risks of lipid-lowering have now been allayed. Indications for drug therapy depend upon the overall risk of
the patient[66,74]. If diet fails to reduce the cholesterol
level, lipid-lowering drugs should be prescribed with the
aim of reducing the total cholesterol level to below
50 mmol . l "1 (192 mg . dl "1) and LDL cholesterol below 26 mmol . l "1 (100 mg . dl "1). The choice of lipidlowering regimen will depend upon the lipid-profile.
Aspirin. An overview of trials of antiplatelet agents
in 3000 patients with stable angina showed a 33%
404
reduction in vascular events[75,76]. It is recommended

that aspirin is administered routinely in a dosage of
75160 mg daily in the absence of contra-indications.
Hormone replacement therapy (HRT). Epidemiological
evidence strongly suggests a beneficial effect of HRT in
patients without manifest coronary disease. Although
there is little information on the benefits and safety of
HRT in anginal patients, there is no reason not to use
these drugs where indicated in patients with coronary
artery disease.
Anti-oxidants. The theoretical benefits of anti-oxidant
therapy have not yet been confirmed in adequate trials.
Further studies are needed before this therapy can be
recommended for angina patients.
Drugs for symptom relief
Three main classes of drugs are used to control symptoms in chronic stable angina:nitrates, beta-blockers and
calcium antagonists[77]. Given in appropriate regimens,
all these agents can be effective in this context, but there
is a considerable and, to a large extent, unpredictable
variation in response and adverse effects. The aim of
anti-anginal treatment is to reduce the myocardial oxygen requirements or to increase myocardial perfusion.
Often, it may be possible to achieve both aims.
Nitrates. Sublingual nitrates work rapidly, i.e. within
minutes, and the effect lasts for about 3045 min.
Profound relief of symptoms is the result of venodilatation, afterload reduction and coronary dilatation.
Many nitrate delivery systems have been developed for
chronic prophylactic use. It has become clear, however,
that patients can develop at least partial tolerance to
this therapy. The use of nitrate-free interval between
dosing is an effective means of overcoming the development of tolerance, although in some cases a rebound
of symptoms may occur at this time. This can be
obviated by the concomitant use of another class of
anti-anginal agent. Nitrates did not influence morbidity
or mortality in the 46 weeks after myocardial infarction in the ISIS-4[78] and GISSI-3[79] trials. There have
been no long-term trials of nitrates in patients with
chronic stable angina.
The main adverse effect of nitrates is headache,
which may be troublesome but tends to diminish with
continued use. Other side-effects include flushing and
syncope. Nitrates are particularly indicated for the
prompt relief or prevention of angina and are also of
value long-term in patients with heart failure or with
contra-indications to beta-blockers. They are often (but
not always) effective in patients with vasospastic angina
and in syndrome X.
-blockers. -blockers act mainly by blocking the
1 receptor. Non-selective -blockers also block the 2
receptor but even selective -blockers have some effect
upon this receptor, especially at higher dosages. Blockade of the 1 receptor slows the heart rate and reduces
myocardial contractility; both these effects reduce

myocardial oxygen demand and thereby the severity
of ischaemia. All -blockers when given in adequate
dosages help to prevent anginal attacks.
Selective -blockers are generally to be preferred
in patients suffering from asthma, peripheral vascular
disease and insulin-dependent diabetes, although they
are not entirely safe in these contexts. Some more
recently developed agents cause peripheral vasodilatation and may be more useful in cases of peripheral
vascular disease. Major adverse effects include severe
bradycardia, hypotension, brochospasm and, rarely,
heart failure, but these are uncommon if patients are
appropriately selected. More subtle side-effects, which
may go unrecognised unless sought, include fatigue,
lassitude, nightmares, and cold extremities.
The effect of -blockers on the prognosis of
stable angina has not been specifically studied in a large
trial. A history of angina has, however, been present in
about one-third of the patients recruited into postinfarction studies of these agents. The Beta-Blocker
Pooling Project[80] reported a highly significant reduction in mortality in this sub-group, and it seems reasonable to assume that -blockers have the potential to
prevent death, especially sudden death, and the development of myocardial infarction even when there has been
no prior infarction.
-blockers are indicated for most patients with
more than the mildest angina, in the absence of contraindications. They are particularly indicated in the postinfarction patient.
Calcium antagonists. Calcium antagonists cause coronary and peripheral vasodilation. Furthermore, smooth
muscle relaxation and reduction of afterload together
with the negative inotropic effects of some of the agents
will reduce myocardial oxygen consumption. While
various formulations of the two prototype papaverinelike and benzothiazepine-like calcium antagonists
verapamil and diltiazem are widely available, most
current development involves analogues of the
nifedipine-like dihydropyridine class. The calcium antagonists are a structurally heterogeneous group of compounds with important differences in pharmacological
action.
Verapamil slows conduction through the atrioventricular node and has important negative inotropic
effects as well as causing smooth muscle relaxation
which leads to an increase in coronary blood flow and a
reduction in afterload. The dihydropyridines, such as
nifedipine and amlodipine, also cause smooth muscle
relaxation but have no effect on cardiac pacemaker
tissue which may result in a reflex increase in the heart
rate. In common with other calcium antagonists, these
drugs have negative inotropic effects, which are, however, less marked than those of verapamil. The effect of
diltiazem is similar to those of verapamil though it has a
less potent effect of left ventricular function.
The calcium antagonists in general should be
used with caution in patients in heart failure or with
poor left ventricular function, although some long acting

dihydropyridines, such as amlodipine, may be safer in
this context.
Unlike -blockers, calcium antagonists have not
been shown to reduce mortality after myocardial infarction, although there is some evidence that verapamil
and diltiazem may reduce the risk of reinfarction[81,82].
Concerns have been expressed about the safety of calcium antagonists, particularly the short-acting preparations[83]. Calcium antagonists should be considered if
beta-blockers are contra-indicated or ineffective. They
are specifically indicated for vasospastic angina.
Other agents. Molsidomine belongs to a newly discovered class of sydnonimines, which resemble nitroglycerin
in their mode of action. Molsidomine appears to act
more slowly than nitrates, but its effect lasts longer.
Nicorandil, a potassium channel activator, also possesses nitrate-like activity. It relaxes vascular smooth
muscle; and does not appear to cause tolerance with
chronic dosing. Metabolic agents, such as trimetazidine,
may also be useful.
Combination treatment. Many but by no means all
studies have demonstrated additional beneficial antianginal effects when a beta-blocker is used in combination with a calcium antagonist or a long-acting nitrate
preparation. Care needs, to be taken however, with the
combination of a -blocker and verapamil or diltiazem,
especially if there is evidence of conduction disturbance
or left ventricular dysfunction. Furthermore, calcium
antagonists may be combined with long-acting nitrates.
The effects of combining drugs may be due to an
additional reduction in the rate-pressure product both at
rest and on exercise, but the IMAGE study[84] suggests
that the benefit of adding a new agent may be due to the
recruitment of new reponders than to combination per
se. In addition, synergy between two classes of drug may
abolish the potentially detrimental effects of each. There
is little evidence to support the current vogue of using
triple therapy. Indeed as Tolins et al.[85] have emphasized, maximal therapy is not necessarily optimal
therapy.
Choice of anti-anginal agent. All patients should be
offered short-acting nitrates either sublingually or by
spray. These drugs may be used not only to treat an
acute episode but are particuarly valuable taken prophylactically when an attack is anticipated, for example
prior to exercise.
Choice of first line treatment for prophylaxis
depends on the underlying predominant pathophysiological process, left ventricular function, and associated
conditions. Patients with very clear-cut effort-related
angina should be offered a beta-blocker as should those
with a prior myocardial infarction. Diltiazem and verapamil are also useful in such circumstances though they
should be avoided in the presence of significant left
ventricular dysfunction. Nitrates are of value where
there is left ventricular dysfunction; -blockers and some
405
vascular selective long-acting dihydropiridines can also

be given cautiously in such circumstances. Patients with
asthma and peripheral vascular disease may be best
treated with a long acting nitrate or a calcium antagonist, although selective -blockers may be given with
caution. As mentioned above, various combinations of
-blockers, nitrates and calcium antagonists have been
shown to be useful where a single agent is ineffective, but
it is probably best to evaluate an alternative single drug
before starting combination treatment.
Percutaneous transluminal coronary

angioplasty
Percutaneous transluminal coronary angioplasty
(PTCA) is widely used in the treatment of stable angina
pectoris. Introduced in 1977 by Grntzig, the number of
procedures has increased exponentially and angioplasty
has surpassed the frequency of coronary bypass graft
surgery (CABG). This dramatic increase is largely the
result of major changes in the technique, the materials,
and lesion selection criteria. The introduction of better
imaging systems has also contributed to the great
improvements in results that have been seen. In the
majority of cases, the procedure is achieved with a
balloon tracking over a guide wire. Alternative methods
may be preferred for particular types of lesions. Large
bulky, eccentric lesions are good indications for directional atherectomy. Ablation with a Rotablator is most
effective in the treatment of hard, fibrocalcific lesions,
ostial lesions, and diffuse disease. Earlier enthusiasm for
laser therapy has declined because of the frequent need
for adjunctive balloon angioplasty and a high rate of
restenosis. By contrast, stents are used more and more
frequently in coronary interventional cardiology. Better
deployment and new management after stent implantation have increased the safety of coronary stenting and
led to a low risk of subacute thrombosis and vascular
complications[86]. Stents have markedly decreased the
need for emergency CABG, the rate of post procedure
myocardial infarction, and restenosis.
Success and risks. In stable angina pectoris, a procedural
success in anatomically suitable patients is achieved in
95% of cases[87]. The mortality rate is less than 02% in
patients with single vessel disease and 05% in case of
multivessel disease. The need for emergency bypass
surgery is currently less than 1% since the advent of
stents. The rate of myocardial infarction, as recognised
by developments of new Q waves, is now less than 1%.
These results can be achieved within a short
period of hospitalisation. Furthermore, the use of small
(6 F) catheters allow simple lesions to be treated on a
day case basis. The return to work is rapid.
Restenosis. Restenosis remains a major concern. It
occurs in 35 to 40% of cases with angiographic control.
In some cases, restenosis is detected by the recurrence of
symptoms but it can be completely silent and detected
406
only by systematic angiography. Non-invasive tests are

not very predictive (predictive value 50% if positive) but
have a good negative predictive value (93%).
There are two principal mechanisms of restenosis: chronic recoil of the artery (remodelling)[88] and
neo-intimal proliferation (healing process). In more than
50 randomised multicentre trials, drugs have failed to
prevent neo-intimal proliferation perhaps because they
attacked only one (relatively limited) of the mechanisms.
Recently, trials with c73E3 Gp IIb/IIIa receptor blockade have indicated a reduction in death and myocardial
infarction after PTCA[89]. The remodelling process can
be prevented by stent implantation which significantly
decreases the rate of restenosis in patients with stable
angina and vessels with diameters between 26 and
34 mm. The combination of stent implantation and a
drug locally or generally delivered could lead in the near
future to a marked reduction in the rate of restenosis.
When the patient experiences recurrence of chest pain
and significant restenosis, a repeat PTCA with or without stent implantation can be performed. The risk of this
reintervention is low and the success rate high.
Comparisons of PTCA and drug treatment. There is, as
yet, no convincing evidence that PTCA is superior to
medical treatment with regard to the risk of myocardial
infarction or death in patients with chronic stable
angina. The decision whether to undertake PTCA in
such patients depends, therefore, on the anticipated
benefit to be obtained in respect of angina. Few comparative trials have been undertaken to address this
issue. In the ACME trial[90,91], a randomized study
comparing PTCA vs medical therapy in single LAD
disease, PTCA decreased the incidence of symptomatic
ischaemia and was associated with more normal treadmill exercise tests. However, 48% of the medically
treated patients were rendered free of angina compared
with 64% of the PTCA group, and PTCA was associated
with a higher frequency of complications and greater
expense.
Coronary bypass graft surgery

Coronary bypass graft surgery has been recognised as a
very effective method of myocardial revascularisation
for more than 25 years. Coronary artery surgery is now
a reproducible and technically precise procedure. Patient
survival and freedom from events are dependent to an
important degree on attention to technical details. The
coronary bypass operation is usually performed with
cardiopulmonary bypass using the pump oxygenator,
although less invasive techniques are being increasingly
employed. A number of methods of minimising perioperative ischaemia and numerous strategies for
myocardial management are in use.
Conduits for coronary bypass graft surgery. Several
autogenous conduits are available. The long saphenous
vein is still widely used, but if possible, arterial grafts are
preferred because their long-term patency is superior to

that of saphenous vein graft. The left internal mammary
artery is incorporated in almost all bypass procedures of
the left coronary artery. The right internal mammary
artery, may also be used. Other conduits, such as the
right gastro-epiploic artery and inferior epigastric artery
may also be considered. Endarterectomy is most often
reserved for vessels with distal disease not satisfactory
for distal grafts. This method is most commonly applied
to the right coronary artery at and beyond the crux.
It has been shown that endarterectomy is associated
with a higher perioperative mortality and myocardial
infarction whilst a lower long-term graft patency is
frequently observed.
Risks and complications. The in-hospital major complications largely depend on the extent of vessel disease,
left ventricular function and associated diseases (renal or
respiratory insufficiency). The in-hospital mortality rate
is 1% in single vessel disease and increases up to 4 to 5%
in multivessel disease with poor left ventricular function.
Perioperative myocardial infarction characterized by the
occurrence of new Q waves may be observed in 4 to 5%
of cases[92].
Patency of the conduits. The patency rate of saphenous
vein grafts is quite variable but 10 to 20% of grafts are
occluded within one week of surgery from thrombosis.
By 3 to 5 years after operation, 6070% of vein grafts
have evidence of atherosclerotic narrowing[93]. This new
disease is characterized by very soft, friable material
which is very prone to embolize to the distal part of the
vessels. By contrast, 90% of the internal mammary
artery grafts anastomosed to the left anterior coronary
artery are patent 10 years after operation[94]. The risk of
re-operation is high, the 5 to 11% mortality rate depending mainly on the LV function.
Comparison of CABG with medical therapy. Yusuf
et al.[95] have undertaken a systematic review of the
outcomes of 2649 patients randomly assigned to receive
CABG or medical management for coronary artery
disease in seven individual trials conducted between
1972 and 1984. This meta-analysis demonstrated that
CABG reduced mortality in patients with left main
disease and others at relatively high risk, such as those
with three vessel disease associated with impaired left
ventricular function.
Comparison of PTCA vs CABG. Five major randomised
trials have compared these two forms of intervention,
mainly in patients with multiple vessel disease. Three
were conducted in Europe (RITA[96], GABI[97] and
CABRI[98] and two in U.S.A. (EAST[99] and BARI[100].
Only one (RITA)[96] compared the results of PTCA and
CABG in patients with single vessel disease.
The results of these trials are uniform and consistent: both methods of myocardial revascularization
were associated with a similar risk of death and nonfatal myocardial infarction, although the trials were
Stable angina
Evidence of
myocardial
ischaemia
Poor LV
function
(EF < 30%)
Left main
coronary
stenosis
Associated
severe
co-morbid
conditions
(renal, pulm.)
Normal
or mild
impairment
of
LV function
Left main 3 VD
2 VD
1 VD
coronary
+
stenosis Prox. LAD
stenosis
Protected?
2 Sten. 1 Sten.
PTCA
1 occlus.
with/without
No
Yes
LV assistance
(CPS)
CABG PTCA CABG
CABG
CABG PTCA PTCA PTCA
+
or
or
LV assistance
PTCA
CABG
Figure 1
Single
remaining
vessel
Factors in the choice of intervention.
underpowered to detect small differences between both

methods or differences among specific patient subgroups. CABG involved a longer hospitalization and
convalescence but thereafter, patients had less angina
and required fewer anti-anginal drugs. PTCA is a
simpler method, without thoracotomy, general anaesthesia, or exposure to nosocomial infection, but, subsequently, patients, particularly women, were more likely
to complain of angina, take anti-anginal drugs and
undergo further revascularization procedures. In the
BARI trial, treated diabetics (insulin or oral therapy)
had a significantly lower 5-year mortality rate with
CABG than with PTCA (19% versus 35% P<002). In
contrast, the mortality rate in diabetics not on drug
treatment was 9% for both therapies. Over 2 years, the
cost of a treatment policy commencing with PTCA is
around 80% of a policy based on CABG. In evaluating
these studies, it has to be borne in mind that all are
relatively short term, and that in the long-term further
interventions are likely to be necessary in both groups as
native vessel coronary disease progresses. The high risk
of repeat CABG may then become an important issue,
while angioplasty should be considered as a repeatable
low risk procedure.
The choice of treatment in stable angina

pectoris
In selecting a treatment programme for patients with
stable angina pectoris, the physician must constantly
bear in mind the two aims of treatment to improve
prognosis and to relieve symptoms. This strategy is
based on four pieces of information: a careful history,
the response to some form of stress testing, ventricular
function, and the extent of coronary artery disease.
Other factors have obviously to be taken into consideration, such as age, gender, and comorbid conditions
(pulmonary or renal disease, for example).
General
patients,
vention,
improve
management. It must be stressed that all

whether or not they are candidates for intershould adopt those lifestyle changes that
prognosis such as stopping smoking and a
407
lipid-modifying diet. Aspirin should be given as a

routine in the absence of contra-indications, and lipidmodifying drugs should be added if cholesterol remains
high in spite of a diet.
Medical treatment vs intervention. When first seen and
regularly thereafter, the physician should consider
whether the patient is at high risk of death. If so, and
if investigations show that the prognosis would be
improved by surgery, this should be undertaken, irrespective of the severity of the symptoms. Otherwise,
medical treatment should be initiated. If symptoms are
not adequately controlled after some weeks of what is
considered to be optimal medical management, the
indications for PTCA and CABG should be reviewed.
Choice of intervention (Fig. 1). In deciding whether
PTCA or CABG should be selected, the following
considerations should be taken into account:
High risk patients with significantly impaired LV function. CABG is recommended in patients with poor LV
function (EF <30%) and left main coronary artery
disease. If the left main artery has been surgically
bypassed, PTCA of that artery (with or without the
help of LV assistance) may be performed. The high
risk of acute and chronic recoil leading to restenosis
necessitates stent implantation in this case. CABG is
also recommended for a single remaining vessel. CABG
is indicated for abnormal LV function and triple
vessel disease, particularly when the proximal LAD is
involved.
Associated severe co-morbid conditions. In some cases,
such as severe renal failure or pulmonary insufficiency,
CABG may be contraindicated. PTCA, with or without the help of a left ventricular assistance device
(cardiopulmonary support), can be used.
Patients with normal or mild impairment of LV function.
Patients with left main narrowing should be treated by
surgery. Triple vessel disease including proximal LAD
stenosis could be considered for CABG in most of the
cases but, depending on the characteristics of the lesions
and if complete myocardial revascularization is possible,
PTCA could be performed. Patients with double vessel
disease may be treated by coronary angioplasty, even in
cases with a totally occluded vessel : Subgroup analysis
of CABRI showed that in this particular group of
patients, there was no difference in terms of survival or
non-fatal MI between the two techniques of myocardial
revascularization. Patients with single vessel disease
should be treated with angioplasty rather than with
CABG.
Special subgroups
Women
There is a growing awareness of coronary artery disease
in women[101,102]. Especially in younger women where
408
coronary artery disease is assumed to be less likely,

chronic stable angina pectoris may be underdiagnosed.
Symptoms of chest pain in women are often atypical and
therefore dismissed, particularly if the woman is young.
Furthermore, because the prevalence of coronary artery
disease in younger women is low, the exercise test is
more likely to be falsely positive. This explains the more
frequent prevalence of chest pain with normal coronary
arteries in women (five times that of men) and therefore
the better prognosis for women with angina who have
been evaluated without angiography as a baseline[103].
The diagnostic value of exercise stress testing is lower in
women[104], primarily because of the lower prevalence of
coronary artery disease. Women who can exercise to
stage III of the Bruce protocol or who have ST-segment
normalisation within 4 min postexercise are unlikely to
have coronary artery disease[105]. Microvascular disease
(syndrome X) may provoke chest pain in women due to
myocardial ischaemia despite angiographically normal
arteries[106]. Women are less likely to be referred for
coronary angiography than men and women referred for
chest pain who subsequently underwent coronary angiography are found to have normal coronary arteries
more often than men[107]. Due to the high frequency of
false positive exercise ECG tests, myocardial perfusion
scintigraphy or stress echocardiography should more
often be considered. Women with typical angina symptoms on effort with positive exercise ECG or myocardial perfusion defects should have access to coronary
angiography.
There is no justification for treating men and
women differently after coronary artery disease is diagnosed. Women have a higher morbidity and mortality
when suffering myocardial infarction than men after
taking into account known adverse factors and correcting for age. There are suggestions that treatment of
myocardial infarction is less vigorous in women than in
men and that survival chances are reduced in women
discharged after myocardial infarction because they do
not have the same therapeutic interventions as men[108].
There is a need to improve detection and treatment of
coronary artery disease in women; when diagnosed
they have the same benefits from medical therapy and
revascularization.
The elderly
After the age of 75 years there is an equal prevalence of
coronary artery disease in men and women[109]. The
disease is more likely to be diffuse and severe; left main
coronary artery stenosis and triple vessel disease are
more prevalent in older patients, as is depressed left
ventricular function[110]. Coexistent illness or a sedentary
lifestyle may limit the usefulness of exertional chest pain
as a diagnostic finding and exercise testing is less often of
diagnostic value for technical reasons. Due to the diffuse
distribution of coronary artery disease, there is a higher
likelihood of non-specific ECG changes during the
stress test[48]. In general, elderly patients with anginal
symptoms should be evaluated and managed in the same

way as younger ones. With increasing age, however,
many patients are willing to accept a less well proven
diagnosis of chronic stable angina pectoris and to start
treatment for evaluation of its efficacy. This means that
not all elderly patients need be referred for exercise stress
testing, especially when noncardiac factors might limit
the test.
Changes in drug bioavailability, elimination and
sensitivity mean that dose modification is essential when
prescribing cardiovascular drugs to elderly patients[111].
Further issues which should be taken into account when
prescribing for the elderly include risk of drug interactions, polypharmacy and compliance problems.
Although evidence suggests that doctors may be reluctant to treat angina aggressively in very old patients, the
usual antianginal medications are as efficacious in this
patient population as in the young. On the other hand,
elderly patients have a higher incidence of contraindications, complications and therapy withdrawals. Considering symptoms as well as prognosis, elderly patients
have the same benefit from medical therapy, angioplasty
and bypass surgery as younger patients[112,113,114].
Syndrome X
A significant proportion of patients undergoing diagnostic coronary angiography for chest pain show normal or
near normal coronary arteries. It has been reported that
6 to 30% of the patients fall into this category[115,116].
The term syndrome X is often used if patients with
normal angiograms have angina-like chest pain and a
positive exercise stress test[115]. Angina with a normal
coronary angiogram is clearly a heterogeneous condition
and a noncardiac cause, e.g. oesophageal disease is
probably common[117]. In subsets of patients, myocardial ischaemia can clearly be provoked and a reduced
coronary vasodilator reserve has been demonstrated in
these patients. There are observations suggesting that
patients with syndrome X may have an endothelial
dysfunction[118].
Patients with angina pectoris and normal coronary arteries have a good prognosis regarding mortality[119]. This is important information for the patient
who often has severe chest pain, functional limitation
and psychological distress. Patients with syndrome X are
considered to respond poorly to conventional pharmacological treatment. Sublingual nitrates are reported to
relieve chest pain in only about 50% of the patients[115].
Conventional anti-ischaemic treatments have less consistent benefits. Since there is a female predominance in
angina with normal coronary arteries and the symptoms
commonly start after menopause, a pathogenetic role of
oestrogen deficiency has been suggested[120]. Hormone
replacement therapy may be useful[121].
Logistics of care
The organisation of medical care varies greatly from one
country to another, and no uniform role can therefore
be assigned to the generalist or specialist respectively. In

those countries in which general practitioners or other
generalists play a major role, it is important to recognise
both their potential contribution and their limitations in
the management of angina. Because of their usually
better knowledge of the patient and his or her personal
circumstances, they are often best placed to assess the
whole individual and to advise on and supervise lifestyle
modifications, as well as compliance with therapy. However, specialist assessment is virtually always necessary
with regard to establishing the diagnosis and assessing
severity and prognosis. Chest pain clinics which can
review patients without delay are of considerable value,
particularly in patients with recent onset or suspected
unstable angina.
Conclusions and recommendations

(1) Stable angina pectoris due to coronary atherosclerosis is a common and disabling disorder. While
compatible with longevity, there is a substantial
risk of progression to myocardial infarction, and/or
death. With proper management, the symptoms
can usually be controlled and the prognosis substantially improved. In practice, it seems probable
that there is both widespread underdiagnosis and
overdiagnosis, and that optimal management strategies are often not implemented.
(2) Every patient with suspected stable angina requires
prompt and appropriate cardiological investigation
to ensure that the diagnosis is correct and that the
prognosis is evaluated. As a minimum, each patient
should have a carefully taken history and physical
examination, an assessment of risk factors and a
resting electrocardiogram. Ready access to diagnostic facilities should be available to general practitioners. Cardiology Departments should ensure
that such patients are attended to without delay;
some hospitals now provide a special Chest Pain
clinic for this purpose.
Three diagnostic strategies may be followed depending upon patient characteristics and the severity of
symptoms:
(a) The minimal assessment, as described above,
without additional investigations. This may suffice, particularly in elderly patients with readily controlled symptoms, or in those disabled or seriously ill for other
reasons.
(b) An initial non-invasive strategy which is
appropriate for most patients. This allows an assessment
of the likelihood of and the severity of coronary heart
disease in patients with mild to moderate symptoms e.g.
exercise testing with or without perfusion scintigraphy
or stress echocardiography. In many patients, this may
lead to coronary angiography.
(c) Coronary angiography without prior functional testing. This may be an option for patients with
uncontrolled severe symptoms in whom revascularisation seems indicated urgently.
409
(3) It is essential in interpreting the findings of the

exercise test, that the demographic and clinical features of the individual are taken into account, as
well as the workload achieved and the blood pressure and heart rate responses. While of great value
in many cases, however, this test may provide
equivocal or misleading information in some. Alternative investigations are needed when the diagnosis
remains uncertain or functional assessment is inadequate, especially when there are electrocardiographic features which are difficult or impossible to
interpret. Myocardial perfusion imaging and stress
echocardiography are of particular value in demonstrating the extent and localisation of myocardial
ischaemia. Echocardiography and radionuclide angiography are helpful in evaluating ventricular
function.
(4) The interpretation of chest pain is particularly
difficult in young and middle-aged women. The
classical symptom complex of chronic stable angina, which is a reliable indicator of myocardial
ischaemia in men is not so in younger women. This
problem is compounded by the relatively high
prevalence of syndrome X in women, and by the
frequency of false positive exercise tests.
(5) The general management of the patient is of paramount importance. This must include a strategy
tailored to personal circumstances, an explanation
of the nature of the condition and its treatment,
and attention to lifestyle issues. Aspirin should be
administered unless contra-indicated, and lipidlowering drugs should be considered if dietary
measures fail to reduce total serum cholesterol
below 50 mmol . l "1.
(6) Nitrates, -blockers and calcium antagonists, alone
or in combination, are effective in controlling the
symptoms of angina in most cases. Because there is
considerable variation in the response of patients to
each class of drug, and the side-effects are unpredictable, the choice of agent should be determined
on an individual basis. -blockers are particularly
indicated in those who experience angina after a
myocardial infarction as they reduce the risk of
reinfarction and death. The costs of the various
drug regimens needs to be taken into account.
(7) Coronary angiography should be undertaken when
symptoms are not satisfactorily controlled by medical means, when non-invasive investigations suggest that the prognosis could be improved by
angioplasty or coronary artery bypass surgery, and
when it is considered essential to establish the
diagnosis.
(8) Percutaneous transluminal coronary angioplasty
(PTCA) is an effective treatment for stable angina
pectoris, and is indicated for patients with angina
not satisfactorily controlled by medical treatment
when there are anatomically suitable lesions. Restenosis continues to be a problem, which is diminished but not abolished by stenting. There is, as yet,
no evidence that PTCA reduces the risk of death.
410
(9) Coronary bypass graft surgery is highly effective in

relieving the symptoms of stable angina and reduces the risk of death over the succeeding 10 years
in particular subgroups of patients, such as those
with left main stenosis, and three vessel disease,
escpecially if left ventricular function is impaired.
(10) There is evidence that there are large numbers of
patients in the community who are not being
appropriately assessed and treated. Specifically,
many of those with stable angina have never undergone functional testing to confirm the diagnosis
and determine prognosis. Furthermore, neither
lipid-lowering agents nor aspirin are being as
widely prescribed as they should be.
(11) Because of the wide variations in the quality of care
afforded to sufferers from angina, there is a strong
case for auditing several components of the management of the condition. As is the practice in some
countries, local, regional or national registers of the
outcome of PTCA and surgery should be created
and maintained.
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Appendix
Procedure of the Task Force
The Task Force on the Management of Stable Angina
Pectoris was created by the Committee for Scientific
and Clinical Initiatives of the European Society of
Cardiology in September 1995 and asked to report to
the Congress of the Society in August 1996.
The members of the Task Force were Prof. D. G.
Julian (Chairman) U.K., Prof. M. E. Bertrand (France),
Prof. . Hjalmarson (Sweden), Dr K. Fox (U.K.),
Prof. M. L. Simoons (The Netherlands), Prof. L.
Ceremuzynski (Poland), Prof. A. Maseri (Italy), Prof. T.
Meinertz (Germany), Prof. J. Meyer (Germany), Prof.
K. Pyrl (Finland), Ass. Prof. N. Rehnqvist (Sweden),
Prof. L. Tavazzi (Italy), Prof. P. Toutouzas (Greece),
Prof. T. Treasure (U.K.)
413
A Core Group consisting of D. G. Julian, M. E.

Bertrand, . Hjalmarson, K. Fox and M. L. Simoons
prepared an initial document which was circulated to the
Task Force. The document was then extensively revised
and circulated to the members of the Committee for
Scientific and Clinical Initiatives and to the following
Working Groups:
Cardiac Rehabilitation and Exercise Testing
Drug Therapy in Cardiology
Myocardial Function
Nuclear Cardiology and Magnetic Resonance
Microcirculation
Echocardiography
Coronary Circulation
Epidemiology and Prevention
Thrombosis and Platelets
Pathogenesis of Atherosclerosis
Cardiovascular Surgery
Heart Failure
After further revision, it was submitted for
approval to the Committee for Scientific and Clinical
Initiatives of the Society. It was also sent to Dr F. L.
Ritchie of Seattle and Dr B. Gersch of Washington who
kindly commented on it. The report was finalised for
publication in November 1996.
The Task Force wishes to thank Mrs W. Thieme
for her invaluable assistance.
Financial Support
The Task Force wishes to express its appreciation of
the financial support provided by Astra Hssle AB,
Behringwerke AG, Institut de Recherches Internationales Servier, Knoll AG, Laboratoires Searle,
Merck, Sharp and Dohme, Pfizer Ltd and Synthlabo.
The Task Force report was developed without any
involvement of the pharmaceutical companies that
provided financial support.

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European Heart Journal (1997) 18, 394413

Definition and pathophysiology

Guidelines on management of stable angina pectoris

the age group 6574 years, and in women from 051%

Guidelines on management of stable angina pectoris

recently been documented by morbidity statistics for

Natural history and prognosis

In the evaluation of patients with chronic stable

Diagnosis and assessment

Guidelines on management of stable angina pectoris

Ordinary physical activity does not cause

so clear-cut and other diagnoses must be considered.

ALGORITHM FOR THE DIAGNOSIS OF

Guidelines on management of stable angina pectoris

(3) A further option is to proceed immediately from

not necessarily have a causal relation to any coronary

Guidelines on management of stable angina pectoris

Functional tests of coronary artery disease

To provide additional data in

First choice in patients unable to

First choice in most patients

CAD=coronary artery disease; LAD=left anterior descending; RCA=right coronary artery.

be necessary, even though the presence of coronary

Guidelines on management of stable angina pectoris

It should be appreciated that the diagnostic

ECG stress testing

patients with such conditions as syndrome X, digitalis

Guidelines on management of stable angina pectoris

at 10 g . kg "1 . min "1 for 3 min, increasing by

Myocardial perfusion scintigraphy

Guidelines on management of stable angina pectoris

Radionuclide angiography during exercise

with a ventriculogram in the left oblique projection. This

Guidelines on management of stable angina pectoris

of angina often leads to excessive anxiety. Reasonable

Pharmacological treatment of patients with

Guidelines on management of stable angina pectoris

reduction in vascular events[75,76]. It is recommended

myocardial contractility; both these effects reduce

Guidelines on management of stable angina pectoris

poor left ventricular function, although some long acting

vascular selective long-acting dihydropiridines can also

Percutaneous transluminal coronary

Guidelines on management of stable angina pectoris

only by systematic angiography. Non-invasive tests are

Coronary bypass graft surgery

preferred because their long-term patency is superior to

Guidelines on management of stable angina pectoris

Factors in the choice of intervention.

underpowered to detect small differences between both

The choice of treatment in stable angina

management. It must be stressed that all

lipid-modifying diet. Aspirin should be given as a

Guidelines on management of stable angina pectoris

coronary artery disease is assumed to be less likely,

symptoms should be evaluated and managed in the same

Guidelines on management of stable angina pectoris

be assigned to the generalist or specialist respectively. In