What Should You Do If You Experience Chest Pain?
If you have known angina, sit down, rest, and take sublingual nitroglycerin. If pain does not resolve within 5 minutes, take a second dose. If pain persists after a third dose, call 911. If you have new or unexplained chest pain, especially with shortness of breath, sweating, or nausea, call 911 immediately — do not wait.
Distinguishing between stable angina and acute coronary syndrome (ACS) is critical. Stable angina follows a predictable pattern — it occurs with the same level of exertion, lasts 3-5 minutes, and resolves with rest or nitroglycerin. Any change in this pattern — episodes occurring at rest, lasting longer, occurring with less exertion, or not responding to nitroglycerin — should be treated as potential unstable angina and evaluated emergently. The 2021 ACC/AHA Chest Pain Guideline provides a systematic approach to evaluating chest pain syndromes.
In the emergency department, evaluation for acute chest pain follows a rapid protocol including 12-lead ECG within 10 minutes, high-sensitivity troponin testing at presentation and 1-3 hours, and clinical risk assessment using validated tools like the HEART score. The HEART score incorporates History, ECG findings, Age, Risk factors, and Troponin to stratify patients into low, intermediate, and high-risk categories for major adverse cardiac events.
The 2021 ACC/AHA Chest Pain Guideline provides systematic evaluation approach
What Is Angina and What Types Exist?
Angina is chest pain or discomfort caused by myocardial ischemia — insufficient blood flow and oxygen delivery to the heart muscle. Stable angina is predictable exertional chest pain. Unstable angina is new, worsening, or rest angina indicating acute coronary syndrome. Variant (Prinzmetal) angina is caused by coronary artery spasm.
Stable angina pectoris affects approximately 10 million Americans and is the initial manifestation of coronary artery disease in roughly half of patients. It results from fixed atherosclerotic narrowing of one or more coronary arteries that limits blood flow during increased myocardial oxygen demand. The classic presentation is substernal pressure or tightness provoked by exertion, emotional stress, or cold exposure and relieved by rest or nitroglycerin within 1-5 minutes. The Canadian Cardiovascular Society (CCS) grading system classifies angina severity from Class I (angina only with strenuous exertion) to Class IV (inability to carry on any physical activity without angina).
Microvascular angina (formerly cardiac syndrome X) is increasingly recognized as a significant cause of chest pain, particularly in women. It results from dysfunction of small coronary arteries rather than large vessel atherosclerosis, and standard coronary angiography appears normal. The WISE (Women's Ischemia Syndrome Evaluation) study demonstrated that microvascular coronary disease affects up to 50% of women with angina and normal coronary arteries and is associated with adverse cardiovascular outcomes.
The WISE study demonstrated microvascular coronary disease affects up to 50% of women with angina
How Is Angina Diagnosed?
Diagnosis involves clinical history, resting ECG, stress testing (exercise or pharmacologic), coronary CT angiography, and invasive coronary angiography when needed. Stress testing evaluates for inducible ischemia, while imaging defines coronary anatomy and severity of blockages.
The initial evaluation includes a detailed history assessing pain character, triggers, duration, and relief factors, combined with a resting 12-lead ECG which may show ST-segment or T-wave changes suggesting ischemia. Exercise stress testing is the most common first-line test for patients who can exercise and have an interpretable resting ECG. For patients who cannot exercise, pharmacologic stress with regadenoson, dipyridamole, or dobutamine combined with nuclear perfusion imaging or echocardiography provides equivalent diagnostic accuracy.
Coronary CT angiography (CCTA) has emerged as an excellent noninvasive alternative for evaluating stable chest pain. The SCOT-HEART trial demonstrated that CCTA-guided management significantly reduced fatal and nonfatal myocardial infarction compared to standard care. CCTA provides detailed anatomic information about coronary plaque burden and stenosis severity. Invasive coronary angiography remains the gold standard for defining coronary anatomy and is performed when revascularization is being considered or when noninvasive testing is inconclusive.
The SCOT-HEART trial demonstrated CCTA-guided management reduced fatal and nonfatal myocardial infarction
What Medications Treat Angina?
Anti-anginal therapy includes sublingual nitroglycerin for acute episodes, beta-blockers as first-line preventive therapy, calcium channel blockers as alternative or add-on agents, long-acting nitrates for chronic angina, and ranolazine for refractory symptoms. All patients should receive aspirin and statins for secondary prevention.
Beta-blockers (metoprolol, atenolol, bisoprolol) are the cornerstone of chronic angina management. They reduce myocardial oxygen demand by lowering heart rate, blood pressure, and contractility. Calcium channel blockers are equally effective and preferred for variant angina due to their vasodilatory effects. Dihydropyridine CCBs (amlodipine, nifedipine) are used with beta-blockers, while non-dihydropyridine CCBs (diltiazem, verapamil) should generally not be combined with beta-blockers due to risk of bradycardia.
Long-acting nitrates (isosorbide mononitrate, isosorbide dinitrate) provide sustained vasodilation and are effective add-on agents. A nitrate-free interval of 10-14 hours daily is essential to prevent tolerance. Ranolazine (Ranexa) works through a unique mechanism — inhibiting the late sodium current — and is effective for patients with refractory angina on maximal traditional therapy. It does not affect heart rate or blood pressure, making it useful in combination regimens.
