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  • Stable ischemic heart disease (SIHD) is caused by atherosclerotic plaque buildup in the coronary arteries.

  • 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. Medication therapy management (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. β-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.


Chronic stable angina (CSA) describes a syndrome in which the cardiac demand for oxygen exceeds the available supply in patients with stable ischemic heart disease (SIHD). Over time, atherosclerotic plaques build up in the coronary arteries. The plaques narrow the diameter of the arteries that supply blood to the heart. When oxygen demand increases (for example, 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 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 reviews 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 also more likely to present with atypical symptoms such as nausea, vomiting, or sharp chest pain.2

TABLE 18-1Typical Anginal Symptoms

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

TABLE 18-2Differential Diagnosis of Episodic ...

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