Study note
MedicineCardiology

CCS angina grading and clinical assessment of stable angina

THE CONTEXT
The Canadian Cardiovascular Society (CCS) angina score grades activity limitation. Assessment also includes examination for associated disease and selection of investigations according to whether coronary artery disease is already known.

CCS angina classes

FeatureDetails
Class I
angina occurs only during strenuous or prolonged physical activity.
Class II
there is slight limitation, with angina only during vigorous physical activity.
Class III
there is moderate limitation, with symptoms during everyday activities.
Class IV
there is severe limitation, with inability to perform any activity without angina or with angina at rest.

Physical examination

•
Physical examination is frequently unremarkable, but a careful search should be made for an ejection systolic murmur, particularly from aortic stenosis or hypertrophic obstructive cardiomyopathy.
•
Assess for hypertension and diabetes mellitus as important risk factors, and for cardiomegaly or a gallop rhythm as features of left ventricular dysfunction.
•
Look for other manifestations of arterial disease, including carotid bruits and peripheral arterial disease.
•
Anaemia and thyrotoxicosis are unrelated conditions that may exacerbate angina and should be sought.

Investigation context

•
The illustrated investigation and treatment scheme for stable angina on effort is best adopted in patients with possible angina who have no previously known coronary artery disease.
•
For patients with known coronary artery disease, further stress imaging is recommended rather than computed tomography coronary angiography. Options include echocardiography, radionuclide perfusion and magnetic resonance perfusion.
•
The example CT coronary angiogram demonstrates three-vessel coronary artery disease with soft lipid-rich plaque and extensive calcified coronary atheroma.
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