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Stable angina — ABIM Board MCQ

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ModerateCardiovascularStable anginaABIM Board

A 71-year-old woman has exertional substernal chest pressure that resolves with rest. Despite adherence to maximally tolerated guideline-directed therapy, including a beta blocker, amlodipine, a long-acting nitrate, aspirin, a high-intensity statin, and risk-factor modification, she continues to have angina several times weekly that limits routine walking. Stress imaging shows moderate reversible ischemia. Coronary angiography demonstrates significant stenoses in the left anterior descending and right coronary arteries that are amenable to revascularization, without left main stenosis. Left ventricular ejection fraction is 55%. Which of the following is the most appropriate next management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Perform coronary revascularization to improve angina and functional status

Explanation lettering: B = shown as A · C = shown as B · A = shown as C · E = shown as D · D = shown as E

A is correct. She has chronic coronary disease with lifestyle-limiting angina despite multiple maximally tolerated antianginal classes and significant stenoses amenable to intervention. The 2023 AHA/ACC guideline recommends revascularization in this setting to improve symptoms and functional status. With preserved LVEF and no left main disease, the principal tested indication is symptom relief rather than a definite survival benefit; PCI versus CABG should be selected according to coronary anatomy and shared Heart Team decision-making. Continuing the same regimen would leave disabling symptoms untreated. Enhanced external counterpulsation is reserved for refractory angina when no other treatment options remain. Adding clopidogrel without acute coronary syndrome or PCI does not improve outcomes and increases bleeding exposure. An ICD is not indicated with an LVEF of 55% and no ventricular arrhythmia.

Reference: Virani SS, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease, Revascularization—Goals of Revascularization, 2023. https://www.heart.org/-/media/PHD-Files-2/Science-News/2/2023/2023_chronic_coronary_disease_guideline_slide_set.pdf