Coronary Artery Disease / Stable Angina
Diagnose and manage stable CAD — medical therapy, anti-anginals, risk-factor control, and when to refer.
Learning Objectives
- 1.Recognize and diagnose stable ischemic heart disease.
- 2.Apply guideline-directed medical therapy for stable CAD.
- 3.Know when to refer for revascularization.
Overview
Stable CAD is chronic, exertional ischemia from fixed coronary disease. The cornerstone is optimal medical therapy and risk-factor control; revascularization is reserved for refractory symptoms or high-risk anatomy.
Why this matters
Most stable CAD is managed medically. Distinguishing stable angina from an acute coronary syndrome — and optimizing therapy — is the daily job.
Presentation & diagnosis
- •Typical angina: exertional substernal pressure relieved by rest/nitroglycerin.
- •Diagnose with functional stress testing or coronary CTA in stable patients; angiography for high-risk or refractory cases.
- •Always separate stable angina from ACS (rest/crescendo pain → acute pathway).
Medical therapy (two goals: prevent events + relieve symptoms)
- •Event prevention: antiplatelet (aspirin), high-intensity statin, ACE-i/ARB if indicated, aggressive risk-factor control.
- •Anti-anginal: beta-blocker first-line; add or substitute a calcium channel blocker and/or long-acting nitrate; ranolazine as add-on.
- •Sublingual nitroglycerin for acute episodes (and PDE5-inhibitor caution).
- •Lifestyle: smoking cessation, activity, diet, weight, diabetes/BP/lipid control.
When to refer for revascularization
- •Refractory/limiting symptoms despite optimal medical therapy.
- •High-risk findings (e.g., significant left main or multivessel disease, large ischemic burden).
- •Revascularization decisions (PCI vs CABG) are the cardiologist’s/heart-team’s domain — refer.
Red flags / escalation
- •Rest pain, crescendo angina, or pain at lower thresholds → unstable angina/ACS — escalate to the acute pathway.
Escalate
Stable angina that becomes rest/crescendo pain is now ACS — escalate emergently, don’t adjust outpatient anti-anginals.
Common beginner mistakes
- •Missing the transition from stable to unstable angina.
- •Under-treating risk factors (statin/BP/diabetes) while focusing only on symptoms.
- •Combining nitrates with PDE5 inhibitors.
- •Referring for revascularization before optimizing medical therapy (outside high-risk anatomy).
Nurse / MA workflow connection
- •Nurses triage worsening/rest angina urgently; MAs capture symptom changes and EKGs.
Mini cases
Stable CAD patient, well controlled, now reports chest pressure at rest and with minimal exertion over 2 days.
What changed?
Show answer
Progression to unstable angina (ACS spectrum). Escalate to the acute pathway (EKG, troponin, physician) — this is no longer an outpatient anti-anginal titration.
Stable exertional angina, controlled on a beta-blocker but still limited; risk factors at goal.
Next step?
Show answer
Optimize anti-anginal therapy (add a CCB and/or long-acting nitrate, consider ranolazine). If symptoms remain limiting despite optimal medical therapy, refer for revascularization evaluation.