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Diagnosis and Management of Stable AnginaA Review

Educational Objective
To understand the clinical management of patients with stable coronary artery disease.
1 Credit CME

Importance  Nearly 10 million US adults experience stable angina, which occurs when myocardial oxygen supply does not meet demand, resulting in myocardial ischemia. Stable angina is associated with an average annual risk of 3% to 4% for myocardial infarction or death. Diagnostic tests and medical therapies for stable angina have evolved over the last decade with a better understanding of the optimal use of coronary revascularization.

Observations  Coronary computed tomographic angiography is a first-line diagnostic test in the evaluation of patients with stable angina due to higher sensitivity and comparable specificity compared with imaging-based stress testing. Moreover, coronary computed tomographic angiography allows detection of nonobstructive atherosclerosis that would not be identified with other noninvasive imaging modalities, improving risk assessment and potentially triggering more appropriate allocation of preventive therapies. Novel therapies treating lipids (proprotein convertase subtilisin/kexin type 9 inhibitors, ezetimibe, and icosapent ethyl) and type 2 diabetes (sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists) have improved cardiovascular outcomes in patients with stable ischemic heart disease when added to usual care. Randomized clinical trials showed no improvement in the rates of mortality or myocardial infarction with revascularization (largely by percutaneous coronary intervention) compared with optimal medical therapy alone, even in the setting of moderate to severe ischemia. In contrast, revascularization provides a meaningful benefit on angina and quality of life compared with antianginal therapies. Measures of the effect of angina on a patient’s quality of life should be integrated into the clinic encounter to assist with the decision to proceed with revascularization.

Conclusions and Relevance  For patients with stable angina, emphasis should be placed on optimizing lifestyle factors and preventive medications such as lipid-lowering and antiplatelet agents to reduce the risk for cardiovascular events and death. Antianginal medications, such as β-blockers, nitrates, or calcium channel blockers, should be initiated to improve angina symptoms. Revascularization with percutaneous coronary intervention should be reserved for patients in whom angina symptoms negatively influence quality of life, generally after a trial of antianginal medical therapy. Shared decision-making with an informed patient is important for effective treatment of stable angina.

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Article Information

Corresponding Author: James A. de Lemos, MD, Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5909 Harry Hines Blvd, Dallas, TX 76390 (james.delemos@utsouthwestern.edu).

Accepted for Publication: February 1, 2021.

Author Contributions: Drs Joshi and de Lemos had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Both authors.

Drafting of the manuscript: Joshi.

Critical revision of the manuscript for important intellectual content: Both authors.

Administrative, technical, or material support: Joshi.

Supervision: de Lemos.

Conflict of Interest Disclosures: Dr Joshi reported receiving grant support from the American Heart Association, NASA, Novartis, Novo Nordisk, Sanofi, GlaxoSmithKline, AstraZeneca, and Pfizer; receiving personal fees from Bayer and Regeneron; and having an equity interest in G3 Therapeutics. Dr de Lemos reported receiving grant support from the National Institutes of Health, the American Heart Association, the National Space Biomedical Research Institute, Roche Diagnostics, and Abbott Diagnostics; receiving personal income from Novo Nordisk, Amgen, Regeneron, Eli Lilly, Abbott Diagnostics, Siemens Healthcare Diagnostics and Ortho Clinical Diagnostics for serving on data monitoring committees, steering committees, or end point committees; and receiving consulting income from Janssen and Quidel Inc.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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