The diagnostic process of stable angina

Since Heberden's first description, stable angina has represented a challenge for the clinicians. Even the most recent guidelines seem ineffective to correctly identify patients who should be sent to cath labs. Still too many patients who undergo coronary angiography are found not to have significant lesions; moreover, its extensive use as the first diagnostic test leads to revascularizations with uncertain appropriateness and prognostic significance. These considerations underline the importance of noninvasive testing before sending patients to invasive coronary angiography. However, it is still debatable whether it is better to pursue anatomic evaluation of the coronary tree with the use of computed tomography or assessment of myocardial ischemia, a controversy which has not been resolved by recent trials comparing the two diagnostic modalities. A combined approach using both functional and anatomic testing may lead to a more careful risk stratification before invasive coronary angiography. The aim of this article is to discuss the most recent evidence in this field, and its application in clinical practice.