Chest pain of cardiac (heart) origin can be depicted in a variety of ways, one of those is stable angina. Around 2 million people suffer from angina in UK and 20 percent of total deaths are caused by coronary artery disease. Hence recognition of cause of chest pain and further classifying the pain of cardiac origin according to underlying pathology is very essential in order to make correct timely intervention and save precious lives.

1. Underlying Mechanism:

Atheromatous plaque hinders the coronary blood supply. As a result coronary arteries cannot meet the demand of the functioning heart due to reduced supply resulting in cardiac ischemia and hence chest pain and shortness of breath.

2. Symptoms:

It usually presents as central chest tightness or pain, which can even radiate to jaw and left upper limb. It can also present as shortness of breath on exertion, which is more common among women.

3. Signs:

Physical examination is usually unremarkable however one should always watch out for aortic stenosis, anemia, elevated blood pressure and feeble/absent peripheral pulses.

4. Decision Making About Investigations:

If angina is unlikely as inferred from history and examination then unnecessary investigations should be avoided and only risk factors should be addressed. However if firm reassurance is required then myocardial perfusion imaging can be performed.

On the other hand if history and examination reveal that angina is likely then exercise ECG should be performed and those patients who are unable to exercise or have heart block can undergo myocardial perfusion imaging. If these investigations reveal ischemia then one should proceed to coronary angiography. If there are no ischemic changes even on exercise ECG or myocardial perfusion imaging then patients should be stratified as high risk and low risk based on history, physical examination and risk factor exposure. High risk patients should also undergo coronary angiography while low risk patients should get reassurance and medication. Low risk patients should undergo coronary angiography only if symptoms are not controlled.