How can a General Practitioner (GP) manage Chronic Coronary Syndrome (CCS) properly?

From the Guidelines

General Practitioners can effectively manage Chronic Coronary Syndrome through a comprehensive approach focusing on symptom control, risk factor modification, and preventing adverse cardiovascular events, as recommended by the 2023 chronic coronary disease guideline-at-a-glance 1. The cornerstone of management includes prescribing antianginal medications such as short-acting nitrates (e.g., sublingual nitroglycerin 0.4mg PRN for acute angina), beta-blockers (e.g., metoprolol 25-100mg twice daily), calcium channel blockers (e.g., amlodipine 5-10mg daily), and long-acting nitrates (e.g., isosorbide mononitrate 30-60mg daily) 1. For secondary prevention, all CCS patients should receive antiplatelet therapy (aspirin 75-100mg daily), high-intensity statins (atorvastatin 40-80mg or rosuvastatin 20-40mg daily), and ACE inhibitors (e.g., ramipril 2.5-10mg daily) or ARBs for those with left ventricular dysfunction or diabetes 1. Some key points to consider in management include:

• Risk factor management is essential, including blood pressure control (target <130/80 mmHg), diabetes management (HbA1c <7%), smoking cessation, weight management, and regular physical activity (30 minutes moderate exercise 5 times weekly) 1.
• GPs should schedule regular follow-ups every 3-6 months to assess symptom control, medication adherence, and side effects, with annual ECGs and periodic stress tests or imaging as indicated 1.
• Patient education about lifestyle modifications, medication adherence, and recognizing warning symptoms requiring urgent care is crucial 1.
• Implementation of healthy lifestyle behaviours decreases the risk of subsequent cardiovascular events and mortality, and is additional to appropriate secondary prevention therapy 1.
• Cognitive behavioural 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 behaviour change 1. This comprehensive approach addresses the underlying pathophysiology of atherosclerosis while reducing myocardial oxygen demand and improving coronary perfusion. It is also important to note that the selection of the initial non-invasive diagnostic test is based on the PTP, the test’s performance in ruling-in or ruling-out obstructive CAD, patient characteristics, local expertise, and the availability of the test 1. Additionally, assessment of risk serves to identify CCS patients at high event risk who are projected to derive prognostic benefit from revascularization, and patients at high event risk should undergo invasive investigation for consideration of revascularization, even if they have mild or no symptoms 1.

From the Research

Managing Chronic Coronary Syndrome (CCS) as a General Practitioner (GP)

To manage CCS properly, a GP should consider the following key aspects:

• Lifestyle Modifications: Encouraging patients to adopt healthy lifestyle habits is crucial. This includes:
  • Smoking cessation: Studies have shown that quitting smoking can significantly reduce the risk of recurrent coronary heart disease (CHD) and mortality 2, 3.
  • Physical activity: Regular physical activity, such as exercising at least 4 times a week, can help reduce the risk of recurrent CHD and mortality 2.
  • Mediterranean diet: Adhering to a Mediterranean diet has been associated with reduced risk of recurrent CHD and mortality 2.
  • Weight management: Maintaining a healthy weight is essential, and waist circumference should be monitored 2, 3.
• Risk Factor Management: GPs should focus on managing risk factors, including:
  • Hypertension: Optimizing treatment for hypertension is vital to reduce cardiovascular risk 4, 5.
  • Hyperlipidemia: Statin therapy is recommended unless contraindicated, and other non-statin drugs may be considered in certain cases 4.
  • Diabetes mellitus: Aggressive treatment of diabetes is necessary to reduce cardiovascular risk 4, 5.
• Medications and Therapies: GPs should consider the following medications and therapies:
  • Antiplatelet therapy: Aspirin is the mainstay of antiplatelet therapy, with clopidogrel as an alternative 4.
  • Antianginal medications: Beta blockers, calcium channel blockers, nitrates, and ranolazine may be used to manage angina symptoms 4, 5.
  • Coronary revascularization: Percutaneous coronary intervention or coronary artery bypass grafting may be considered for select patients 4, 5.
• Patient Education and Communication: Effective communication and patient education are critical for successful CCS management. GPs should:
  • Provide clear information about risk factors and lifestyle changes: Patients who recollect physician information about risk factors are more likely to make lifestyle changes 6.
  • Set realistic goals and monitor progress: Regular follow-up and monitoring can help patients stay on track with their treatment plans 3, 6.
  • Tailor information to individual patient needs: Considering patient characteristics, such as age, obesity, and comorbidities, can improve patient-doctor communication and treatment outcomes 6.