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Cardiology

Coronary Atherosclerosis and Stable Angina

Progressive lipid-driven arterial wall inflammation forming plaques that narrow coronary lumina and predispose to acute coronary syndromes.

Last reviewed 12 May 2026 - MedicoMedics editorial team

Coronary atherosclerotic plaque narrowing artery lumen

Pathophysiology

LDL enters intima, is oxidised, and taken up by macrophages forming foam cells. Chronic inflammation, smooth muscle migration and fibrous cap formation create atheromatous plaques. Plaque rupture exposes thrombogenic core, triggering platelet activation and coronary thrombosis.

Sources: AHA/ACC 2023 Chronic Coronary Disease Guideline (Circulation 2023;148:e9); ESC 2024 Guidelines on CCS (Eur Heart J 2024;45:3415); AHA/ACC/Multisociety Cholesterol Guideline 2018 (Circulation 2019;139:e1082)

Clinical presentation

Stable angina: exertional retrosternal pressure relieved within minutes by rest or nitrates, reproducible on similar exertion. Modified risk factors: smoking, hypertension, diabetes, dyslipidaemia, obesity; non-modifiable: age, male sex, family history.

Sources: AHA/ACC 2023 Chronic Coronary Disease Guideline (Circulation 2023;148:e9); ESC 2024 Guidelines on CCS (Eur Heart J 2024;45:3415); AHA/ACC/Multisociety Cholesterol Guideline 2018 (Circulation 2019;139:e1082)

Diagnosis

12-lead ECG (may be normal at rest). Functional testing: exercise ECG, stress echo, or nuclear MPI. Anatomical: coronary CT angiography for low-intermediate probability; invasive angiography with FFR/iFR when revascularisation likely.

Sources: AHA/ACC 2023 Chronic Coronary Disease Guideline (Circulation 2023;148:e9); ESC 2024 Guidelines on CCS (Eur Heart J 2024;45:3415); AHA/ACC/Multisociety Cholesterol Guideline 2018 (Circulation 2019;139:e1082)

Medical therapy

All patients: high-intensity statin, low-dose aspirin (secondary prevention), risk-factor optimisation. Anti-anginal: beta-blocker or calcium-channel blocker first-line; long-acting nitrate, ranolazine, ivabradine as add-ons. GLP-1/SGLT2 agents for diabetics.

Sources: AHA/ACC 2023 Chronic Coronary Disease Guideline (Circulation 2023;148:e9); ESC 2024 Guidelines on CCS (Eur Heart J 2024;45:3415); AHA/ACC/Multisociety Cholesterol Guideline 2018 (Circulation 2019;139:e1082)

Revascularisation

PCI for symptom relief and prognostic benefit in left main, three-vessel disease with high SYNTAX, or refractory symptoms. CABG preferred for complex three-vessel disease and diabetes with multivessel disease.

Sources: AHA/ACC 2023 Chronic Coronary Disease Guideline (Circulation 2023;148:e9); ESC 2024 Guidelines on CCS (Eur Heart J 2024;45:3415); AHA/ACC/Multisociety Cholesterol Guideline 2018 (Circulation 2019;139:e1082)

Sample USMLE-style MCQs

Try 10 questions on this topic. Practice hundreds more free with a trial.

Question 1

Which lipid parameter best predicts atherosclerotic risk?

Question 2

Which secondary prevention drug reduces mortality most in stable CAD?

Question 3

A 60-year-old with prior MI has LDL 95 on atorvastatin 40. Best next step?

Question 4

Which agent inhibits ATP citrate lyase and lowers LDL ~20%?

Question 5

A patient with chronic stable angina has FFR 0.65 in LAD. Best action?

Question 6

CABG is preferred over PCI in which patient?

Question 7

Which imaging best assesses coronary anatomy non-invasively?

Question 8

First-line antiplatelet after PCI with DES?

Question 9

Which anti-anginal is contraindicated in severe aortic stenosis?

Related topics:aortic stenosis

Question 10

Which lipid target is Class I for very-high-risk ASCVD?

References

Primary guidelines and peer-reviewed sources used for this entry. Reviewed 12 May 2026 by MedicoMedics editorial team.

  1. AHA/ACC 2023 Chronic Coronary Disease Guideline (Circulation 2023;148:e9)
  2. ESC 2024 Guidelines on CCS (Eur Heart J 2024;45:3415)
  3. AHA/ACC/Multisociety Cholesterol Guideline 2018 (Circulation 2019;139:e1082)

Frequently asked

What defines high-intensity statin?

Atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily - typically produces >=50% LDL reduction.

When is CABG preferred over PCI?

Diabetes with multivessel disease, complex three-vessel disease (high SYNTAX score), or left main disease with unfavourable anatomy.

Which anti-anginal reduces heart rate without inotropic effect?

Ivabradine - selective If current inhibitor in the sinus node.

What does an FFR <0.80 indicate?

Physiologically significant coronary stenosis - benefits from revascularisation.

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