Angina pectoris. Clinical strategies in diagnosis

Angina pectoris is a clinical diagnosis with various forms and manifestations. In many cases, the diagnosis can be made without expensive supplementary cardiovascular tests. In a given patient, the likelihood of significant coronary artery disease can be assessed clinically from such variables as age, sex, type of symptoms, and risk factors. Because of cost considerations and limited resources, additional cardiovascular testing (treadmill exercise testing, radionuclide procedures, echocardiography, and coronary angiography) cannot be done in every case, and the physician must carefully decide if and when to order each of these tests as well as judge their cost-effectiveness. Cardiovascular tests should be ordered on a 'need-to-know' basis and with a specific, answerable question in mind. The physician needs to consider not only the expected probability of disease in the patient to be studied but also the reliability and performance characteristics of each test.