Stable coronary syndromes

Angina pectoris is usually considered a consequence of flow-limiting epicardial coronary artery disease (CAD), which impairs myocardial blood flow and results in myocardial ischaemia (i.e. ischaemic heart disease, IHD). In clinical practice, the diagnostic management of patients with angina centres on the detection of obstructive epicardial CAD, and the treatment involves optimal medical therapy and consideration of myocardial revascularisation using percutaneous coronary intervention or coronary artery bypass grafting. This clinical paradigm fails to account for the considerable proportion of patients with angina in whom obstructive epicardial disease is excluded (i.e. angina and nonobstructive coronary artery disease, ANOCA). This common scenario presents a diagnostic conundrum. Stable coronary syndrome (SCS) is a term which subtends a clinically relevant classification that fully encompasses the different diseases of the epicardial and microvascular coronary circulation. In this chapter, we describe the causes of angina based on the underlying coronary vascular pathophysiology and discuss the diagnostic and therapeutic approaches to patients with angina secondary to disorders of coronary vascular dysfunction