Clinical Notes : Cardiovascular Disease

161. Angina 

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  • Unstable angina 

    • is an acute coronary syndrome that is defined by the absence of biochemical evidence of myocardial damage. (1)​

    • It is characterised by specific clinical findings of

      • prolonged (>20 minutes)

      • angina at rest

      • new onset of severe angina

      • angina that is increasing in frequency, longer in duration, or lower in threshold

      • angina that occurs after a recent episode of myocardial infarction

  • Stable angina : (2)

    • Pain occurs only in context of

      • exertion or emotional stress

      • not worsening over time

      • relieved by nitrates or rest

    • ECG may be normal in the absence of pain but may show ST depression during episodes of angina or on stress testing.

Typical characteristics of angina


  • SIGN (3)

    • type of discomfort

      • often described as tight, constricting, dull, or heavy

    • location

      • often retrosternal or left side of chest and can radiate to left arm, neck, jaw, and back

    • relation to exertion

      • angina is often brought on with exertion or emotional stress and eased with rest

    • duration

      • typically the symptoms last up to several minutes after exertion or emotional stress has stopped

    • other factors

      • angina may be precipitated by cold weather or after a large meal.

NICE (4)

  • three features of angina pain can help determine a diagnosis:

    • constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms

    • pain precipitated by physical exertion

    • pain relieved by rest or glyceryl trinitrate (GTN) within about 5 minutes.

  • The number of features present labels the angina

    • presence of all three features represents typical angina

    • two features signifies atypical angina

    • one or none of the three features are present, the pain is defined as non-anginal.



  • A 12-lead ECG is an essential part of the assessment 

    • pathological Q waves

    • left bundle branch block

    • ST-segment and T wave abnormalities (such as flattening or inversion).

  • The likelihood of a diagnosis of angina increases with the number of cardiovascular risk factors in individual patients : (5)

    • smoking

    • hypertension

    • diabetes

    • previous history of coronary artery disease (CAD) or other vascular disease

    • family history of CAD

    • hyperlipidaemia

    • chronic kidney disease.

  • A diagnosis of angina is less likely if the chest pain is : (4)

    • continuous and/or very prolonged

    • unrelated to activity

    • brought on by breathing in

    • associated with symptoms such as dizziness, palpitations, tingling, or difficulty swallowing


Differential diagnosis of chest pain

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  • Unstable angina

    • oxygen

      • to maintain oxygen saturation >90%

    • glyceryl trinitrate

      • 0.3 to 0.6 mg (tablets) sublingually every 5 minutes when required, maximum 3 doses in 15 minutes

      • or 400-800 micrograms (1-2 sprays) sublingually every 3-5 minutes when required, maximum 3 doses in 15 minutes

    • morphine sulfate

      • 2-5 mg intravenously every 5-30 minutes when required

    • refer all to A+E for

      • investigation and monitoring

      • beta blocker

      • antiplatelet therapy

      • advanced interventions as required

  • Stable angina management may include :

    • lifestyle education

    • antiplatelet therapy

    • anti-anginal therapy

    • statin or other lipid-lowering therapy

    • antihypertensive therapy

    • blood sugar control

    • revascularisation

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1. ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

Roffi M, Patrono C, Collet JP, et al.

European Society of Cardiology (ESC).

Eur Heart J. 2016 Jan 14;37(3):267-315.


2, Ubnstable angina

BMJ Best Practice

Last reviewed: March 2019

Last updated: September  2018


3. Management of stable angina.

Scottish Intercollegiate Guidelines Network.

SIGN 151. Edinburgh



4. Chest pain of recent onset: assessment and diagnosis.

Clinical Guideline CG95. NICE

Published date: March 2010

Last updated: November 2016


5. Stable angina: how does the SIGN guideline compare with NICE?

Begg A

Guidelines in Practice

October 2018


Acute coronary syndrome

Scottish Intercollegiate Guidelines Network.

SIGN 148

April 2016


AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes

American College of Cardiology; American Heart Association

April 2016


Australian clinical guidelines for the management of acute coronary syndromes 2016

National Heart Foundation of Australia; Cardiac Society of Australia and New Zealand



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