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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Predictable chest pressure with exertion or emotional stress, relieved by rest or SL nitroglycerin within 1-5 minutes
- Diagnosis: stress testing — exercise ECG if can exercise + interpretable ECG; stress imaging (nuclear or echo) if unable to exercise or baseline ECG abnormality
- Anti-anginal therapy: beta-blocker first-line, add long-acting nitrate or CCB (amlodipine or diltiazem) if needed
- All patients: aspirin 81 mg, high-intensity statin, BP control <130/80, lifestyle modification
- ISCHEMIA trial: revascularization (PCI/CABG) did NOT reduce MI or death vs optimal medical therapy in stable CAD with moderate-severe ischemia
Overview
Stable angina (chronic coronary disease) is characterized by predictable, reproducible chest discomfort triggered by exertion, emotional stress, or other demand-increasing states, caused by fixed atherosclerotic narrowing that limits coronary blood flow during increased myocardial oxygen demand. Unlike ACS, the plaque is stable without acute rupture. The 2023 ACC/AHA Chronic Coronary Disease Guideline emphasizes optimal medical therapy (OMT) as the cornerstone, with revascularization reserved for refractory symptoms or high-risk anatomy.
Epidemiology
Approximately 10 million Americans have stable angina. CAD is the leading cause of death in the US. Risk factors mirror those for atherosclerosis: age, male sex, smoking, hypertension, diabetes, hyperlipidemia, family history, obesity, and sedentary lifestyle. The annual rate of MI or death in medically treated stable angina is ~1-3%.
Clinical Features
Symptoms
Substernal pressure, tightness, or heaviness — NOT typically sharp or pleuritic
Provoked by exertion, emotional stress, cold exposure, or heavy meals
Relieved by rest within 1-5 minutes or by SL nitroglycerin
Duration typically 2-10 minutes (>20 min suggests ACS)
May radiate to left arm, jaw, neck, back, or epigastrium
Anginal equivalents: exertional dyspnea, fatigue (more common in women, elderly, diabetics)
Signs
Often entirely normal examination between episodes
S4 gallop during episode (ischemic diastolic dysfunction)
Transient MR murmur during ischemia (papillary muscle dysfunction)
Signs of atherosclerotic disease elsewhere: carotid bruits, diminished pedal pulses
Investigations
First-line
Resting ECGOften normal between episodes. May show old Q waves, ST-T changes, LVH. Normal resting ECG does not exclude CAD
Stress testing (choosing modality)Can exercise + interpretable baseline ECG: exercise treadmill ECG (Bruce protocol). Cannot exercise: pharmacologic stress (adenosine, regadenoson, or dobutamine) with imaging. Baseline ECG uninterpretable (LBBB, LVH with strain, paced rhythm, digoxin, WPW): stress imaging (nuclear MPI or stress echo). Exercise is preferred over pharmacologic when possible (provides functional capacity data)
Basic labsLipid panel, HbA1c/fasting glucose, BMP (eGFR), CBC, TSH
Second-line
CT coronary angiography (CCTA)High NPV for ruling out significant CAD in low-intermediate risk patients. Class I recommendation as alternative to stress testing per 2023 CCD guideline
Coronary artery calcium (CAC) scoreRisk stratification in asymptomatic patients. CAC = 0 has excellent NPV for obstructive CAD. Not useful in symptomatic patients — get stress test or CCTA instead
Specialist
Invasive coronary angiographyIf non-invasive testing suggests high-risk features, symptoms refractory to OMT, or revascularization is being considered. Also if stress test shows high-risk findings (large area of ischemia, hypotension with exercise, ST depression >=2 mm)
1
Optimal medical therapy (all patients)
- Aspirin 81 mg daily (or clopidogrel if aspirin-intolerant)
- High-intensity statin: atorvastatin 40-80 mg or rosuvastatin 20-40 mg
- BP control to <130/80: ACEi/ARB preferred if diabetes, CKD, or HFrEF
- Diabetes management: SGLT2i or GLP-1 RA preferred (CV benefit)
- Smoking cessation, weight management, exercise 150 min/week, DASH diet
2
Anti-anginal therapy
- First-line: beta-blocker (metoprolol, atenolol) — reduces HR, BP, and myocardial oxygen demand
- Alternative first-line: DHP CCB (amlodipine) or non-DHP CCB (diltiazem) if beta-blocker contraindicated or not tolerated
- Add-on: long-acting nitrate (isosorbide mononitrate) — must have 10-12 h nitrate-free interval to prevent tolerance
- Ranolazine: add-on for refractory angina (late sodium channel inhibitor, does not affect HR or BP)
- SL nitroglycerin PRN for acute episodes
3
Revascularization
- ISCHEMIA trial: in stable CAD with moderate-severe ischemia, revascularization + OMT did NOT reduce death or MI vs OMT alone over 3.2 years
- Indications for revascularization: refractory symptoms despite maximal OMT, high-risk anatomy (left main >=50%, proximal LAD, 3-vessel disease with reduced LVEF)
- CABG preferred over PCI for: left main disease, 3-vessel disease (especially with diabetes — FREEDOM trial), reduced LVEF
- PCI preferred for: 1-2 vessel disease without left main or proximal LAD involvement, high surgical risk
Complications
- Progression to ACS: Plaque rupture can convert stable to unstable disease
- Heart failure: Chronic ischemia leads to hibernating myocardium and LV dysfunction
- Arrhythmias: Ischemia is a substrate for VT/VF
- Reduced quality of life: Activity limitation from angina
USMLE Step 2 CK Exam Tips
- 1ISCHEMIA trial is high-yield: revascularization does NOT reduce death/MI in stable CAD vs medical therapy — optimize meds first
- 2Stress test choice: can exercise + normal ECG = exercise treadmill. Cannot exercise = pharmacologic + imaging. Abnormal baseline ECG = stress imaging
- 3LBBB, LVH with strain, paced rhythm, or digoxin use = baseline ECG is uninterpretable for ischemia — must add imaging to stress test
- 4Nitrate tolerance: must have a 10-12h nitrate-free interval daily (usually overnight)
- 5Beta-blocker + non-DHP CCB (diltiazem/verapamil) together = risk of severe bradycardia/heart block. Use with caution. BB + amlodipine is safer
- 6CABG > PCI for left main, 3-vessel disease, and diabetic patients with multivessel disease (FREEDOM trial)
- 7If a patient on OMT still has angina, add a second anti-anginal (CCB or nitrate) before jumping to catheterization
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