What is chronic coronary syndrome and how is it managed?

From the Guidelines

Chronic coronary syndrome (CCS) is a condition that requires a comprehensive management approach, including lifestyle modifications, medication therapy, and potentially revascularization, to reduce morbidity, mortality, and improve quality of life, as recommended by the most recent guidelines 1.

Definition and Diagnosis

Chronic coronary syndrome is a stable manifestation of coronary artery disease characterized by episodes of reversible myocardial demand/supply mismatch, typically triggered by exercise or stress and associated with chest pain (angina) 1. The diagnosis of CCS involves careful evaluation of patient history, physical examination, and basic testing, as well as non-invasive functional imaging or anatomical imaging using coronary CTA to rule-out or establish the diagnosis of CCS 1.

Management

Management of CCS involves both lifestyle modifications and medication therapy. Patients should adopt a heart-healthy diet low in saturated fats, engage in regular moderate exercise (30 minutes most days), maintain healthy weight, quit smoking, and control comorbidities like diabetes and hypertension 1.

• First-line medications include:
  • Aspirin (75-100mg daily) for antithrombotic protection
  • Statins (such as atorvastatin 20-80mg or rosuvastatin 10-40mg daily) to lower cholesterol
• For symptom control, beta-blockers (metoprolol 25-200mg daily or bisoprolol 2.5-10mg daily) and/or calcium channel blockers (amlodipine 5-10mg daily) are prescribed to reduce heart rate and workload 1.
• Short-acting nitrates like sublingual nitroglycerin (0.4mg as needed) provide immediate relief during angina episodes.
• For patients with persistent symptoms, long-acting nitrates, ranolazine (500-1000mg twice daily), or additional antianginal medications may be added.

Revascularization

In selected cases with significant coronary stenosis, revascularization through percutaneous coronary intervention (stenting) or coronary artery bypass grafting may be necessary to improve prognosis and reduce symptoms 1.

Follow-up

Regular follow-up every 3-6 months is essential to assess symptom control, medication adherence, and potential side effects, as well as to adjust treatment plans as needed 1. This comprehensive approach targets both symptom management and prevention of disease progression by addressing the underlying atherosclerotic process. The most recent guidelines emphasize the importance of a stepwise approach to the initial management of individuals with suspected CCS, including lifestyle and risk factor modification, antianginal medical treatment, and revascularization as needed 1.

From the FDA Drug Label

What is chronic angina? Chronic angina means pain or discomfort in the chest, jaw, shoulder, back, or arm that keeps coming back There are other possible signs and symptoms of angina including shortness of breath. Angina usually comes on when you are active or under stress. Chronic angina is a symptom of a heart problem called coronary heart disease (CHD), also known as coronary artery disease (CAD). When you have CHD, the blood vessels in your heart become stiff and narrow Oxygen-rich blood cannot reach your heart muscle easily. Angina comes on when too little oxygen reaches your heart muscle.

Chronic coronary syndrome, also referred to as chronic angina, is a condition characterized by recurring pain or discomfort in the chest, jaw, shoulder, back, or arm, often triggered by physical activity or stress. It is a symptom of coronary heart disease (CHD) or coronary artery disease (CAD), where the blood vessels in the heart become stiff and narrow, limiting the supply of oxygen-rich blood to the heart muscle.

• Key symptoms include:
  • Pain or discomfort in the chest, jaw, shoulder, back, or arm
  • Shortness of breath
• Management of chronic coronary syndrome typically involves medications such as ranolazine, as well as lifestyle modifications to reduce the frequency and severity of angina episodes 2.

From the Research

Definition and Overview of Chronic Coronary Syndrome

• Chronic coronary syndrome (CCS) refers to a condition where the heart does not receive enough blood and oxygen due to blockages in the coronary arteries, leading to chest pain, shortness of breath, and other symptoms 3.
• CCS is also known as stable coronary artery disease, which is a reversible supply/demand mismatch related to ischemia, a history of myocardial infarction, or the presence of plaque documented by catheterization or computed tomography angiography 3.

Management of Chronic Coronary Syndrome

• Treatment of CCS involves risk factor management, antiplatelet therapy, and antianginal medications 3.
• Lifestyle modifications such as tobacco cessation, exercise, and weight loss are crucial in managing CCS 3.
• Medications such as statins, beta blockers, calcium channel blockers, nitrates, and ranolazine may be prescribed to manage symptoms and prevent further complications 3, 4.
• Coronary revascularization with percutaneous coronary intervention or coronary artery bypass grafting may be recommended for select patients 3, 4.

Comparison with Acute Coronary Syndromes

• Acute coronary syndromes (ACS) are characterized by a sudden reduction in blood supply to the heart, including ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina 5.
• Management of ACS involves immediate electrocardiography, rapid reperfusion with primary percutaneous coronary intervention (PCI), and fibrinolytic therapy 5.
• High-sensitivity troponin measurements are the preferred test to evaluate for NSTEMI, and prompt invasive coronary angiography and percutaneous or surgical revascularization are associated with a reduction in death 5.

Treatment Options

• Aspirin is the mainstay of antiplatelet therapy, while clopidogrel is an alternative 3, 6.
• Beta blockers, calcium channel blockers, nitrates, and ranolazine are used as adjunctive or second-line therapy when beta blockers are ineffective or contraindicated 3, 4.
• Statins and ACE-inhibitors should be initiated in the early course of acute coronary syndrome for plaque stabilization 6.
• Ranolazine is a innovative anti-anginal drug with a great successful in the management of patients with refractory angina 4.