Debabrata Mukherjee, MD, FACC
The following are key points to remember from the 2019 European
Society of Cardiology (ESC) guidelines for the diagnosis and management
of chronic coronary syndromes (CCS):
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1. Coronary artery disease (CAD) can
have long, stable periods, but can also become unstable at any time,
typically due to an acute atherothrombotic event caused by plaque
rupture or erosion. The disease is chronic, most often progressive, and
hence serious, even in clinically apparently silent periods.
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2. The dynamic nature of the CAD
process results in various clinical presentations, which can be
conveniently categorized as either acute coronary syndromes (ACS) or
chronic coronary syndromes (CCS). These guidelines have been revised to
focus on CCS instead of stable CAD.
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3. This change emphasizes the fact
that the clinical presentations of CAD can be categorized as either ACS
or CCS. CAD is a dynamic process of atherosclerotic plaque accumulation
and functional alterations of coronary circulation that can be modified
by lifestyle, pharmacological therapies, and revascularization, which
result in disease stabilization or regression.
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4. In the current guidelines on CCS,
six clinical scenarios most frequently encountered in patients are
identified: (i) patients with suspected CAD and “stable” anginal
symptoms, and/or dyspnea; (ii) patients with new onset of heart failure
(HF) or left ventricular (LV) dysfunction and suspected CAD; (iii)
asymptomatic and symptomatic patients with stabilized symptoms <1 year after an ACS or patients with recent revascularization; (iv) asymptomatic and symptomatic patients >1 year after initial diagnosis
or revascularization; (v) patients with angina and suspected
vasospastic or microvascular disease; (vi) asymptomatic subjects in whom
CAD is detected at screening.
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5. The pretest probability of CAD
based on age, gender, and nature of symptoms have undergone major
revisions. In addition, these guidelines introduced a new phrase
“Clinical likelihood of CAD” that utilizes also various risk factors of
CAD as pretest probability modifiers. The application of various
diagnostic tests in different patient groups to rule-in or rule-out CAD
have been updated.
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6. The general approach for the
initial diagnostic management of patients with angina and suspected
obstructive CAD includes six steps. The first step is to assess the
symptoms and signs, to identify patients with possible unstable angina
or other forms of ACS (step 1). In patients without unstable angina or
other ACS, the next step is to evaluate the patient’s general condition
and quality of life (step 2). Comorbidities that could potentially
influence therapeutic decisions are assessed and other potential causes
of the symptoms are considered. Step 3 includes basic testing and
assessment of LV function. Thereafter, the clinical likelihood of
obstructive CAD is estimated (step 4) and, on this basis, diagnostic
testing is offered to selected patients to establish the diagnosis of
CAD (step 5). Once a diagnosis of obstructive CAD has been confirmed,
the patient’s event risk will be determined (step 6), as it has a major
impact on the subsequent therapeutic decisions.
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7. Careful evaluation of patient
history, including the characterization of anginal symptoms, and
evaluation of risk factors and manifestations of cardiovascular disease,
as well as proper physical examination and basic testing, are crucial
for the diagnosis and management of CCS.
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8. Unless obstructive CAD can be
excluded based on clinical evaluation alone, either noninvasive
functional imaging or anatomical imaging using coronary computed
tomography angiography may be used as the initial test to rule-out or
establish the diagnosis of CCS. Selection of the initial noninvasive
diagnostic test is based on the pretest probability, the test’s
performance in ruling-in or ruling-out obstructive CAD, patient
characteristics, local expertise, and the availability of the test.
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9. For revascularization decisions,
both anatomy and functional evaluation are to be considered. Either
noninvasive or invasive functional evaluation is required for the
assessment of myocardial ischemia associated with angiographic stenosis,
unless very high grade (>90% diameter stenosis). Assessment of risk
serves to identify CCS patients at high event risk who are projected to
derive prognostic benefit from revascularization. Risk stratification
includes the assessment of LV function. In general, patients at high
event risk should undergo invasive investigation for consideration of
revascularization, even if they have mild or no symptoms.
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10. Implementation of healthy
lifestyle behaviors decreases the risk of subsequent CV events and
mortality, and is additional to appropriate secondary prevention
therapy. Clinicians should advise on and encourage necessary lifestyle
changes in every clinical encounter. Cognitive behavioral interventions
such as supporting patients to set realistic goals, self-monitor, plan
how to implement changes and deal with difficult situations, set
environmental cues, and engage social support are effective
interventions for behavior change. Multidisciplinary teams can provide
patients with support to make healthy lifestyle changes, and address
challenging aspects of behavior and risk.
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11. Anti-ischemic treatment must be
adapted to the individual patient based on comorbidities,
co-administered therapies, expected tolerance and adherence, and patient
preferences. The choice of anti-ischemic drugs to treat CCS should be
adapted to the patient’s heart rate, blood pressure, and LV function.
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12. Beta-blockers and/or calcium
channel blockers remain the first-line drugs in patients with CCS.
Beta-blockers are recommended in patients with LV dysfunction or HF with
reduced ejection fraction. Long-acting nitrates provoke tolerance with
loss of efficacy. This requires prescription of a daily nitrate-free or
nitrate-low interval of approximately 10–14 hours.
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13. Antithrombotic therapy is a key
part of secondary prevention in patients with CCS and warrants careful
consideration. Patients with a previous myocardial infarction, who are
at high risk of ischemic events and low risk of fatal bleeding, should
be considered for long-term dual antiplatelet therapy with aspirin and
either a P2Y12 inhibitor or very low-dose rivaroxaban, unless they have
an indication for an oral anticoagulation such as atrial fibrillation.
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14. Statins are recommended in all
patients with CCS. Angiotensin-converting enzyme inhibitors (or
angiotensin-receptor blockers) are recommended in the presence of HF,
diabetes, or hypertension and should be considered in high-risk
patients. Proton pump inhibitors are recommended in patients receiving
aspirin or combination antithrombotic therapy who are at high risk of
gastrointestinal bleeding.
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15. Efforts should be made to explain
to patients the importance of evidence-based prescriptions to increase
adherence to treatment, and repeated therapeutic education is essential
in every clinical encounter. Patients with a long-standing diagnosis of
CCS should undergo periodic visits to assess potential changes in risk
status, adherence to treatment targets, and the development of
comorbidities. Repeat stress imaging or invasive coronary angiography
with functional testing is recommended in the presence of worsening
symptoms and/or increased risk status.