What is the recommended diagnostic approach for investigating stable angina?
Stable angina investigation begins with clinical assessment and pre-test probability estimation. Non-invasive functional testing (stress ECG, stress imaging) or anatomical testing (coronary CT angiography) is selected based on patient characteristics and local expertise. Invasive coronary angiography is reserved for high-risk findings or when non-invasive testing is inconclusive.
Pre-Test Probability Assessment
Clinical likelihood of coronary artery disease guides test selection. Factors include age, sex, symptom characteristics, and cardiovascular risk factors. Intermediate pre-test probability patients benefit most from diagnostic testing, while very low probability may not require further investigation and very high probability may proceed directly to invasive assessment.
Non-Invasive Testing Options
Exercise ECG is appropriate for patients who can exercise with interpretable baseline ECG. Stress imaging (echocardiography, nuclear perfusion, CMR) provides functional and anatomical information. Coronary CT angiography offers excellent negative predictive value for ruling out significant CAD, particularly useful in lower-intermediate probability patients.
Risk Stratification
Testing aims to identify patients at higher risk who may benefit from revascularization. High-risk features include significant left main or proximal LAD disease, reduced ejection fraction, large area of ischemia, or multivessel disease. Medical therapy optimization is first-line for most stable angina patients regardless of test results.
Points of Disagreement
Debate continues regarding optimal first-line test: functional testing versus anatomical CT angiography for intermediate-risk patients.
Multi-Guideline Agreement: High (89%)
Consensus Models: Gemini 3, Gemini 3 Pro, Sonnet 4.5, GPT 5.2
External Auditors: Grok 4, Opus 4.5
Last reconciled: December 31, 2025 | Version: 1.0