Retrosternal pain on the stairs that passes after two minutes of rest is not "a diagnosis of atherosclerosis". It is typical angina, one of the ways in which coronary atherosclerosis becomes clinical. ESC 2024 describes chronic coronary syndromes (CCS) as a spectrum of clinical presentations associated with structural and/or functional changes in the coronary arteries and/or the microcirculation.
The spectrum of CCS according to the ESC 2024 central illustration:
- exertional angina or an equivalent with obstructive CAD;
- the stabilised phase after ACS, PCI or CABG;
- angina or an equivalent without obstructive CAD (ANOCA/INOCA — angina/ischaemia with non-obstructive coronary arteries: symptoms or ischaemia in the absence of obstructive stenosis of the large coronary arteries);
- an asymptomatic course with an abnormal anatomical or functional test;
- LV dysfunction or heart failure of ischaemic origin.
Angina is transient myocardial ischaemia, clinically usually a squeezing/pressing pain or discomfort behind the sternum, provoked by exertion or emotion, lasting minutes, relieved by rest or nitroglycerin. ESC 2024 recommends collecting the characteristics of the symptom (onset, duration, type, location, triggers, what relieves it, time of day) — class I C. Symptoms such as pain triggered by emotion, dyspnoea or dizziness on exertion, pain in the arms, jaw, neck, upper back, and fatigue should be considered possible angina equivalents (IIa B). Women with "angina" are on average older, have a greater burden of risk factors, more often dyspnoea and fatigue, and more often microvascular angina — these are stratified observations that ESC 2024 cites so that an "atypical" complaint is not dismissed.
What coronary atherosclerosis is complicated by — a list the course requires you to name.
- Stable angina (as a manifestation of CCS).
- Acute coronary syndrome: unstable angina, non-ST-elevation myocardial infarction, ST-elevation myocardial infarction — morphologically usually a complicated plaque with thrombosis.
- Sudden cardiac death.
- Ischaemic cardiomyopathy / chronic HF of ischaemic origin.
- Arrhythmias.
- Diffuse small-focal (atherosclerotic) cardiosclerosis and large-focal post-infarction scar as morphological end-points.
The ESC 2024 diagnostic framework has four steps: general clinical assessment; further evaluation with estimation of the clinical likelihood of obstructive CAD using a risk-factor-weighted model (class I B); confirmation of the diagnosis (CT angiography or functional tests — depending on the likelihood); initial therapy. With a very low pre-test likelihood (≤5%), deferral of further tests may be considered (IIa B). With a low pre-test likelihood (5–15%), the calcium score may be considered for reclassification (IIa B). This is the clinician's algorithm, not the pathologist's.
High risk of adverse events, in which ESC 2024 recommends invasive coronary angiography (including in asymptomatic people), includes, among other things: Duke Treadmill Score < −10; an ischaemic area ≥10% of the LV myocardium on stress SPECT/PET; ≥3 of 16 segments with stress-induced abnormality on stress echocardiography; on CT angiography — left main ≥50%, three-vessel disease ≥70%, two-vessel disease ≥70% including the proximal LAD, or proximal LAD ≥70% and FFR-CT (fractional flow reserve derived from CT angiography — a computed estimate of the haemodynamic significance of a stenosis) ≤0.8.
The boundary of the lesson. The course does not teach how to differentiate all causes of chest pain and does not replace the ACS protocol. ANOCA/INOCA are part of CCS, but their specialised diagnosis (coronary flow reserve, acetylcholine test) is the level of a specialised centre, not a student's first skill.
The link to morphology. Stable angina more often corresponds to a haemodynamically significant fibrous plaque or diffuse atherosclerosis; ACS to a complicated lesion; diffuse small-focal cardiosclerosis to the sum of small ischaemic losses against a background of chronic stenosis.