Mostly coronary artery disease affects people in middle age or in later years, but sadly we do see younger patients with angina and heart attack.

Furring up of the coronary arteries, or technically, atherosclerosis or atheroma, is the cause of the majority of cases.

The symptom of angina is felt as pain in the chest, neck, arms, back or jaw or even teeth, or in some people, breathlessness.

Stable angina is when discomfort is reasonably predictable – a patient can walk so far, then has to stop, slow down or rest, and the pain or breathlessness goes away either with rest or after the use of a spray or tablet under the tongue, often called GTN.

Patients with stable angina may benefit from drug treatment, angioplasty and stenting, or even coronary artery bypass grafting.

When angina pains come on with less and less exercise, we call this crescendo angina, and it suggests a more urgent problem. Angina coming on at rest suggests unstable angina, a form of ‘acute coronary syndrome’. Patients with acute coronary syndrome (ACS) are best managed by urgent admission to hospital, and may require powerful blood thinning treatments, and in most cases, a coronary angiogram to visualise the problem in the coronary arteries and allow angioplasty and stent treatment.

Some patients admitted with ACS are having a heart attack. The ECG helps the emergency team decide whether a particular patient needs immediate, or primary angioplasty, or whether initial care in the admissions ward or coronary care unit is needed, with the coronary angiogram happening after a day or so during which time drug treatment stabilises the patient.

These decisions often depend whether the ECG shows a particular pattern of abnormality known as ST elevation, which is the sign of the most dramatic sort of heart attack, where most commonly, one of the coronary arteries has become abruptly and totally blocked. Primary or immediate coronary angioplasty is now the standard treatment in this situation, whereas historically thrombolysis or clot buster drugs had been extensively used.