In addition, ASA should be a standard part of each regimen. The details of these therapies and the evidence for their use are described in Chapter 4. Some patients who present with symptoms suggestive of unstable angina and are initially categorized as having low likelihood of CAD will continue to report symptoms suggestive of angina despite an antianginal regimen that appears appropriate. The medical provider should first review all diagnoses and management decisions and, if appropriate, obtain or repeat other noninvasive exercise or pharmacologic stress tests. Fear of heart disease or other psychological problems commonly underlies complaints of cardiovascular symptoms which are out of proportion to objective evidence of ischemia.
Some patients benefit from more complete and frequent counseling and reassurance.
This group of patients will often respond to cardiac rehabilitation in a structured environment with supervised exercise. A trial of simple measures is reasonable in this group of patients, but failure to respond may necessitate the decision to perform a cardiac catheterization with the intention of confirming the absence of coronary artery disease. If this is to be undertaken, patients must be informed of the reason for the procedure when they provide informed consent. Some patients find sufficient reassurance with angiographic documentation of normal coronary arteries that their symptoms gradually dissipate. Patients who continue to have symptoms they consider to be angina despite normal coronary angiograms may have small-vessel or vasospastic coronary artery disease requiring further evaluation that is not covered by this guideline.