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  • Angina results when the heart's demand for oxygen exceeds the available supply.

  • Stable angina is reproducible and relieved by rest or nitroglycerin. An increase in angina frequency, severity, or duration

  • characterizes it as unstable. A patient with unstable angina should be referred for medical evaluation.

  • Acute angina attacks that do not resolve with rest may require the use of nitroglycerin. MTM providers should counsel on proper use of nitroglycerin, including when to call 911.

  • Management of chronic stable angina aims to reduce the frequency of angina attacks. Beta blockers, calcium channel blockers, and long-acting nitrates are common treatments.

  • MTM providers should stress the importance of adherence to medications for chronic stable angina and counsel on appropriate use of medications to maximize the therapeutic effect, eg, the importance of a nitrate-free interval for patients on long-acting nitrates.


The term chronic stable angina describes a syndrome in which the cardiac demand for oxygen exceeds the available supply. Over time, atherosclerotic plaques build up in the coronary arteries. These plaques narrow the diameter of the arteries that supply blood to the heart. When oxygen demand increases (eg, during exercise or stress) the healthy heart compensates by increasing blood flow and consequently increasing oxygen supply. This compensatory increase in blood flow is not always achieved in patients with chronic stable angina.1,2 When myocardial oxygen demand exceeds the supply from the coronary arteries, the patient may feel chest pain, pressure, or tightness (angina). Pain may radiate to the jaw, shoulder, back, or arm. Table 18-1 shows typical angina symptoms. It is important to note that not all patients will present with these classic symptoms; in fact, some patients may have no symptoms at all. This is called silent ischemia.1 Women are more likely to present with atypical symptoms such as nausea, vomiting, or sharp chest pain.2

Table 18-1.Typical Angina Symptoms3

Noncardiac chest pain or discomfort can mimic angina pain (Table 18-2).1,2 Careful questioning can help determine whether a patient's chest pain may stem from a noncardiac cause. However, the MTM provider should err on the side of caution and refer patients to their healthcare providers or the emergency department if they report worsening symptoms.

Table 18-2.Differential Diagnosis of Episodic Chest Pain Resembling Angina Pectoris

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