Article Text

Chronic ischaemic heart disease
Angina: contemporary diagnosis and management
  1. Thomas Joseph Ford1,2,3,
  2. Colin Berry1
  1. 1 BHF Cardiovascular Research Centre, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, UK
  2. 2 Department of Cardiology, Gosford Hospital, Gosford, New South Wales, Australia
  3. 3 Faculty of Health and Medicine, The University of Newcastle, Newcastle, NSW, Australia
  1. Correspondence to Dr Thomas Joseph Ford, BHF Cardiovascular Research Centre, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow G128QQ, UK;{at}

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Learning objectives

  • Around one half of angina patients have no obstructive coronary disease; many of these patients have microvascular and/or vasospastic angina.

  • Tests of coronary artery function empower clinicians to make a correct diagnosis (rule-in/rule-out), complementing coronary angiography.

  • Physician and patient education, lifestyle, medications and revascularisation are key aspects of management.


Ischaemic heart disease (IHD) remains the leading global cause of death and lost life years in adults, notably in younger (<55 years) women.1 Angina pectoris (derived from the Latin verb ‘angere’ to strangle) is chest discomfort of cardiac origin. It is a common clinical manifestation of IHD with an estimated prevalence of 3%–4% in UK adults. There are over 250 000 invasive coronary angiograms performed each year with over 20 000 new cases of angina. The healthcare resource utilisation is appreciable with over 110 000 inpatient episodes each year leading to substantial associated morbidity.2 In 1809, Allen Burns (Lecturer in Anatomy, University of Glasgow) developed the thesis that myocardial ischaemia (supply:demand mismatch) could explain angina, this being first identified by William Heberden in 1768. Subsequent to Heberden’s report, coronary artery disease (CAD) was implicated in pathology and clinical case studies undertaken by John Hunter, John Fothergill, Edward Jenner and Caleb Hiller Parry.3 Typically, angina involves a relative deficiency of myocardial oxygen supply (ie, ischaemia) and typically occurs after activity or physiological stress (box 1).

Box 1

Definition of angina (NICE guidelines)32

Typical angina: (requires all three)

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

  • Precipitated by physical exertion.

  • Relieved by rest or sublingual glyceryl trinitrate within about 5 min

    • Presence of two of the features is defined as atypical angina.

    • Presence of one or none of the features is defined as non-anginal chest pain.

    • Stable angina may be excluded if pain is non-anginal provided clinical suspicion is not raised based …

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