About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Stable angina = predictable chest tightness/pressure on exertion or stress, relieved by rest or GTN within 5 minutes
- Diagnosis: clinical assessment → CTCA (first-line investigation for suspected stable angina per NICE)
- First-line anti-anginal: beta-blocker (bisoprolol) OR CCB (amlodipine/diltiazem); GTN spray for acute relief
- Secondary prevention: aspirin 75 mg OD + atorvastatin 80 mg + ACEi (if diabetic) + optimal BP control
- Revascularisation (PCI or CABG) if symptoms not controlled on optimal medical therapy or high-risk anatomy (left main stem disease)
Overview
Stable angina is a clinical syndrome of predictable, reproducible chest discomfort caused by myocardial ischaemia due to fixed atherosclerotic coronary artery stenosis. Unlike acute coronary syndromes, stable angina does not involve plaque rupture or acute thrombus formation. Symptoms are provoked by exertion, emotional stress, cold exposure, or heavy meals, and are reliably relieved by rest or sublingual GTN. NICE CG126 guides management, and NICE CG95 (updated) covers investigation of recent-onset chest pain including the role of CT coronary angiography.
Epidemiology
The Health Survey for England reports that approximately 8% of men and 3% of women aged 55 and over have or have had angina. It is the most common initial presentation of coronary heart disease. Risk factors mirror those for atherosclerosis: smoking, hypertension, hypercholesterolaemia, diabetes, family history of premature CHD, obesity, and male sex. Incidence increases with age. The Canadian Cardiovascular Society (CCS) classification grades severity from I (angina only with strenuous exertion) to IV (angina at rest).
Clinical Features
Symptoms
Central chest tightness, heaviness, or pressure (not sharp or pleuritic)
Provoked by exertion, emotional stress, cold weather, or heavy meals
Radiation to left arm, neck, jaw, or back
Relieved by rest within 5 minutes or by sublingual GTN
Duration typically 2–10 minutes
Associated dyspnoea on exertion
Angina at rest, new-onset, or crescendo pattern (suggests ACS — escalate urgently)
Signs
Examination is often entirely normal between episodes
Xanthelasma or corneal arcus (hyperlipidaemia markers)
Hypertension
Signs of peripheral arterial disease (absent pulses, bruits)
Aortic stenosis murmur (may cause angina independently)
Investigations
First-line
12-lead ECGMay be normal at rest. May show ST depression or T-wave changes during pain. Previous MI changes (Q waves). LVH
BloodsFBC, U&Es, TFTs, HbA1c, lipid profile, LFTs (pre-statin baseline)
Second-line
CT coronary angiography (CTCA)First-line investigation for stable chest pain of suspected cardiac origin (NICE CG95). Anatomical assessment of coronary arteries
Functional imagingIf CTCA inconclusive or not feasible: stress echocardiography, myocardial perfusion scintigraphy (MPS), or stress cardiac MRI
Specialist
Invasive coronary angiographyIf non-invasive tests suggest significant disease and revascularisation is being considered
Fractional flow reserve (FFR)Assess haemodynamic significance of borderline stenoses during angiography
Management
NICE CG126 (Stable angina), 2011/20161
Acute symptom relief
- GTN sublingual spray or tablet — use at onset of symptoms or prophylactically before known trigger
- Advise: sit down, spray under tongue, wait 5 min, repeat once if needed, call 999 if pain persists after 2 doses
2
First-line anti-anginal therapy
- Beta-blocker (bisoprolol, atenolol) OR calcium channel blocker (amlodipine, diltiazem)
- Choice based on comorbidities, contraindications, and patient preference
- If one not tolerated or ineffective, switch to the other or combine (beta-blocker + dihydropyridine CCB)
- Do NOT combine beta-blocker with verapamil/diltiazem (risk of heart block)
3
Second-line add-on (if still symptomatic)
- Long-acting nitrate (isosorbide mononitrate — use asymmetric dosing to prevent tolerance)
- Ivabradine, nicorandil, or ranolazine may be considered as third-line agents
4
Secondary prevention (all patients)
- Aspirin 75 mg OD (lifelong)
- Atorvastatin 80 mg OD (high-dose statin)
- ACEi if diabetic; offer to others per CVD risk
- Optimal BP control per NICE NG136
- Lifestyle: smoking cessation, healthy diet, regular exercise, weight management
- Refer for cardiac rehabilitation
5
Revascularisation
- PCI — percutaneous coronary intervention for single/double vessel disease
- CABG — for left main stem disease, triple vessel disease (especially if diabetic or reduced LVEF)
- Decision via multidisciplinary Heart Team
Complications
- Acute coronary syndrome: Plaque rupture converting stable to unstable disease
- Myocardial infarction: If complete thrombotic occlusion
- Heart failure: Chronic ischaemia → ischaemic cardiomyopathy
- Arrhythmias: Ischaemia-related VT/VF or conduction disease
- Reduced quality of life: Activity limitation, anxiety, depression
UKMLA Exam Tips
- 1CTCA is the first-line investigation for new stable chest pain — not exercise ECG (which is no longer first-line per NICE)
- 2GTN should relieve stable angina within 5 minutes — if it does not, suspect ACS
- 3Do NOT combine a beta-blocker with verapamil or diltiazem — but beta-blocker + amlodipine is safe
- 4Asymmetric nitrate dosing prevents tolerance — e.g. ISMN 8am and 2pm (not 8am and 8pm)
- 5If stable angina + diabetes → add ACEi even if normotensive
- 6Three-vessel or left main stem disease → CABG offers survival benefit over PCI
practicetest your knowledge on stable anginaApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — cardiovascular and beyond.
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