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Evaluation and Management of Patients with Chest Pain Due to Heart Disease

CardioSmart Contributors

By Richard Ferraro, MD; Roger S. Blumenthal, MD; Martha Gulati, MD; and Garima Sharma, MD

Cardiovascular disease, or disease of the heart and blood vessels, remains the most common cause of death in the United States. Coronary heart disease is the most frequent type of cardiovascular disease and leads to the most complications for patients. Therefore, the treatment of coronary heart disease is a significant issue for patients and medical providers alike. Important considerations in heart disease evaluation and management were reviewed in a recent article in the Journal of the American College of Cardiology.

Angina, or chest pain due to heart disease, is a common complaint of patients coming to primary care and cardiology offices. It is the most common symptom of coronary heart disease. How to best manage these symptoms, however, has been the topic of debate among medical practitioners.

There are two major ways to treat the symptoms of angina. The first way is through medications, which work to improve blood flow to the heart and therefore relieve chest pain symptoms. The second way is to do so with procedures, either by directly opening up the vessels of the heart and placing a stent, a procedure called percutaneous coronary intervention, or PCI, or through a surgery that attempts to create bypass channels for blood to flow to the heart muscle, a surgery called coronary artery bypass grafting, or CABG.

In this article, the authors discuss the most appropriate times for patients and providers to consider each of these treatment options. After examining data from several large research trials, the authors conclude that stable chest pain due to angina is best managed first with medications and lifestyle improvements, which improve symptoms and stabilize existing heart disease. Due to the risks and costs involved, generally only if chest pain with exertion remains significant and bothersome to patients after medication management should providers pursue procedures to manage the disease.

A question that patients might have is even if my chest pain improves with medications, is there still a risk of having a heart attack or other event? What is the best way to prevent them?  These are certainly a risk in anyone with heart disease. Fortunately, the same medication regimen for preventing the symptoms of heart disease also does the most to prevent future events.

The recent data suggest that optimal medical treatment does just as good a job at preventing events such as a heart attack as more invasive procedures or surgery. Medical treatment also comes at a much-reduced cost, lowering the financial burden on patients and the health care system. So while the risk of events will never be zero, the goal of medical treatment is to both improve patients’ symptoms and protect them from future events to the best degree possible.

Richard Ferraro, MD, is a resident physician in the Department of Medicine at Johns Hopkins Hospital. Roger S. Blumenthal, MD, FACC, is Director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Martha Gulati, MD, FACC, is the Editor-in-Chief of CardioSmart. Garima Sharma, MD, FACC, is an Assistant Professor at the Johns Hopkins University Ciccarone Center for the Prevention of Cardiovascular Disease.

Read the journal article: “Evaluation and Management of Patients With Stable Angina: Beyond the Ischemia Paradigm,” Journal of the American College of Cardiology, Aug. 30, 2020. 

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