CARDIOVASCULAR DISEASE AND STROKE (P PERRONE-FILARDI AND S. AGEWALL, SECTION EDITORS) Stable Angina Pectoris Marco Valgimigli & Simone Biscaglia Published online: 18 May 2014 # Springer Science+Business Media New York 2014 Abstract The stable coronary artery disease (SCAD) popu- lation is a heterogeneous group of patients both for clinical presentations and for different underlying mechanisms. The recent European Society of Cardiology guidelines extensively review SCAD from its definition to patients’ diagnostic and therapeutic management. In this review, we deal with five topics that, in our opinion, represent the most intriguing, novel and/or clinically relevant aspects of this complex coronary condition. Firstly, we deal with a peculiar SCAD population: patients with angina and ‘normal’ coronary arteries. Secondly, we reinforce the clinical importance of a diagnostic approach based on the pretest probability of disease. Thirdly, we review and critically discuss the novel pharmacological therapies for SCAD patients. Finally, we analyse the results of the most recent clinical trials comparing revascularization versus opti- mal medical therapy in SCAD patients and review the cur- rently recommended use of intracoronary functional evalua- tion of stenosis. Keywords Stable coronary artery disease . Microvascular angina . Vasospasticangina . Pretest probability of the disease . Optical medical therapy . Fractional flow reserve Introduction The recent European Society of Cardiology (ESC) guidelines [1••] provide a comprehensive and updated overview of contemporary management in patients with known or suspected stable coronary artery disease (SCAD). The SCAD population is extremely heterogeneous, including: 1. Patients symptomatic for stable angina pectoris or angina equivalent (e.g. dyspnoea) 2. Patients with a history of obstructive or non-obstructive coronary artery disease (CAD), who have become asymp- tomatic with treatment and need regular follow-up 3. Patients reporting symptoms for the first time, but already in a chronic stable condition (e.g. symptoms presents for several months) Therefore, different phases of CAD are included in SCAD, with the exception of acute coronary syndromes (ACS). Narrowings of 50 % or more in the left main coronary artery and 70 % or more in one or several of the major coronary arteries have traditionally represented the pathophysiological mechanism underlying SCAD, causing exercise- and stress- related chest symptoms. Actually, SCAD is more complex than this. In fact, the wide spectrum of SCAD clinical presentations is due to dif- ferent underlying mechanisms: 1. Plaque-related obstruction of epicardial arteries 2. Focal or diffuse spasm of normal or plaque-diseased arteries 3. Microvascular dysfunction 4. Left ventricular dysfunction caused by prior acute myocar- dial necrosis and/or hibernation (ischaemic cardiomyopathy) For all these reasons, it is difficult to assess the real prev- alence and incidence of SCAD, because its definition differs among different studies. The prognosis of SCAD patients can be derived from clinical trials of anti-anginal and preventive This article is part of the Topical Collection on Cardiovascular Disease and Stroke M. Valgimigli (*) Thoraxcenter, BA 587, Erasmus MC, Rotterdam, The Netherlands e-mail: m.valgimigli@erasmusmc.nl S. Biscaglia Cardiology Department, University of Ferrara, Ferrara, Italy Curr Atheroscler Rep (2014) 16:422 DOI 10.1007/s11883-014-0422-4