What is the management of Chronic Coronary Syndrome (CCS)?

Management of Chronic Coronary Syndrome

The management of Chronic Coronary Syndrome (CCS) requires a comprehensive approach focusing on lifestyle modifications, pharmacological therapy, and revascularization when appropriate, with the primary goal of reducing mortality and improving quality of life through risk factor modification and symptom control.

Diagnosis and Risk Assessment

1. Initial Evaluation:

   • Assess clinical likelihood of obstructive CAD
   • Perform functional testing (stress imaging preferred) or anatomical testing (CCTA) based on pre-test likelihood 1
   • High-risk features requiring invasive coronary angiography (ICA):
     • Severe angina unresponsive to medical therapy
     • High-risk findings on non-invasive testing
     • Left ventricular dysfunction (LVEF ≤35%)

2. Risk Stratification:

   • High-risk indicators on non-invasive testing 1:
     • Exercise ECG: Duke Treadmill Score < −10
     • Stress imaging: ≥10% ischemic myocardium (SPECT/PET) or ≥3 segments with stress-induced dysfunction (echo)
     • CCTA: Left main disease ≥50%, three-vessel disease ≥70%, or proximal LAD disease ≥70% with FFR-CT ≤0.8

Pharmacological Management

1. Anti-anginal Therapy

• First-line therapy 1:

  • Beta-blockers and/or calcium channel blockers (CCBs) for symptom control
  • Short-acting nitrates for immediate relief of angina

• Second-line therapy (if symptoms persist):

  • Long-acting nitrates
  • Ranolazine, nicorandil, or trimetazidine (based on comorbidities and tolerability)

• Special considerations:

  • Ivabradine may be considered for patients with LVEF <40% but is not recommended for patients with LVEF >40% 1
  • Avoid nitrates in patients with hypertrophic cardiomyopathy or concurrent phosphodiesterase inhibitor use 1

2. Antithrombotic Therapy

• For patients without indication for oral anticoagulation 1:

  • Aspirin 75-100 mg daily lifelong in patients with established CAD
  • Clopidogrel 75 mg daily is a safe and effective alternative to aspirin
  • After PCI: DAPT (aspirin + clopidogrel) for up to 6 months
  • Consider shorter DAPT duration (1-3 months) in patients with high bleeding risk

• For patients with indication for oral anticoagulation 1:

  • Prefer DOAC over VKA when eligible
  • After PCI: Triple therapy (OAC + aspirin + clopidogrel) initially, then early cessation of aspirin (≤1 week) followed by OAC + clopidogrel

3. Lipid-lowering Therapy

• Target LDL-C <1.4 mmol/L (55 mg/dL) and ≥50% reduction from baseline 1
• Stepwise approach:
  1. High-intensity statin at maximum tolerated dose
  2. Add ezetimibe if target not achieved
  3. Add bempedoic acid if target still not achieved or statin intolerant 1
  4. Consider PCSK9 inhibitor for very high-risk patients not at goal

4. Additional Pharmacotherapy

• ACE inhibitors or ARBs: Recommended for patients with hypertension, diabetes, or heart failure 1
• SGLT2 inhibitors: Recommended for patients with T2DM and CCS to reduce CV events 1
• GLP-1 receptor agonists: Recommended for patients with T2DM and CCS 1
• Semaglutide: Consider for CCS patients without diabetes but with overweight/obesity (BMI >27 kg/m²) 1
• Low-dose colchicine (0.5 mg daily): Consider to reduce MI, stroke, and revascularization 1

Revascularization

Revascularization is recommended in the following scenarios 1:

1. To improve prognosis:

   • Left main stem stenosis (functionally significant)
   • Three-vessel disease (functionally significant)
   • Single or two-vessel disease involving proximal LAD (functionally significant)
   • Multivessel CAD with LVEF ≤35% (CABG preferred)

2. To improve symptoms:

   • Persistent angina despite guideline-directed medical therapy
   • Functionally significant coronary stenosis

3. Decision-making:

   • Heart Team discussion recommended for complex cases
   • Consider patient preferences, comorbidities, and procedural risks
   • Use SYNTAX score to assess anatomical complexity
   • Use intracoronary pressure measurements (FFR/iFR) to guide lesion selection

Lifestyle Modifications

• Physical activity: 150-300 minutes/week of moderate-intensity or 75-150 minutes/week of vigorous-intensity aerobic activity 1
• Smoking cessation: Essential for all patients
• Diet: Mediterranean-style diet rich in vegetables, fruits, whole grains, and fish
• Weight management: Target BMI 20-25 kg/m²
• Stress management: Consider psychological interventions

Follow-up and Monitoring

• Regular clinical assessment for symptom control and medication adherence
• Periodic risk factor assessment and optimization
• Consider non-invasive testing for patients with worsening symptoms
• Reassess CAD status in patients with deteriorating LV function

Special Considerations

Heart Failure with CCS

• In patients with LVEF ≤35% and suspected CAD, ICA is recommended to assess potential for revascularization 1
• CABG is recommended over medical therapy alone in surgically eligible patients with multivessel CAD and LVEF ≤35% 1
• Optimize heart failure medications including beta-blockers, ACE inhibitors/ARBs, MRAs, and SGLT2 inhibitors 2

Common Pitfalls to Avoid

• Underutilization of guideline-directed medical therapy before considering revascularization
• Failure to assess functional significance of coronary stenoses before intervention
• Premature discontinuation of DAPT after PCI
• Inadequate risk factor modification and lifestyle counseling
• Not considering microvascular dysfunction or vasospasm in patients with angina but non-obstructive CAD

By following this comprehensive approach to CCS management, clinicians can effectively reduce cardiovascular morbidity and mortality while improving patients' quality of life.