What is the management approach for chronic coronary syndromes?

Management of Chronic Coronary Syndromes

The management of chronic coronary syndromes requires a comprehensive approach including lifestyle modifications, pharmacological therapy for symptom relief and event prevention, and selective revascularization based on risk stratification and symptom severity. 1

Diagnostic Assessment and Risk Stratification

• Initial evaluation should include assessment of clinical likelihood of obstructive coronary artery disease (CAD), symptom characteristics, and risk factor profile 1
• Risk stratification is recommended based on clinical assessment and diagnostic test results, with high-risk patients requiring more intensive management 1
• In patients with deteriorating symptoms or high-risk features, stress imaging is recommended for risk stratification 1
• Invasive coronary angiography with functional assessment (FFR/iFR) is recommended for patients with high-risk features or symptoms refractory to medical therapy 1

Lifestyle Modifications

• Multidisciplinary behavioral approaches to achieve healthy lifestyle changes are recommended alongside pharmacological management 1, 2
• Exercise-based cardiac rehabilitation is recommended to improve cardiovascular risk profile and reduce mortality 1, 3
• Aerobic physical activity of 150-300 minutes per week of moderate intensity or 75-150 minutes per week of vigorous intensity is recommended 1
• Mobile health interventions (text messages, apps, wearable devices) are recommended to improve adherence to lifestyle changes and medical therapy 1, 2

Pharmacological Management for Symptom Relief

• Short-acting nitrates are recommended for immediate relief of angina symptoms 1, 3
• Beta-blockers and/or calcium channel blockers (CCBs) are recommended as first-line treatment to control heart rate and symptoms 1, 3
• Selection of antianginal drugs should be tailored based on patient characteristics, comorbidities, concomitant medications, and underlying pathophysiology 1
• Nitrates are contraindicated in patients with hypertrophic cardiomyopathy or when co-administered with phosphodiesterase inhibitors 1, 3

Pharmacological Management for Event Prevention

Antithrombotic Therapy

• Aspirin 75-100 mg daily is recommended lifelong in patients with prior myocardial infarction (MI) or revascularization 1
• Clopidogrel 75 mg daily is recommended as a safe and effective alternative to aspirin monotherapy 1
• In patients who undergo percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended for up to 6 months 1
• In patients at high bleeding risk but not at high ischemic risk, DAPT can be discontinued 1-3 months after PCI 1
• In patients requiring oral anticoagulation, a direct oral anticoagulant alone is preferred unless contraindicated 1

Lipid-Lowering Therapy

• Statins are recommended for all patients with chronic coronary syndromes 1, 2
• If LDL-C goals are not achieved with maximum tolerated statin dose, combination with ezetimibe is recommended 2
• For very high-risk patients not achieving goals on statin and ezetimibe, adding a PCSK9 inhibitor is recommended 2

Other Preventive Medications

• ACE inhibitors (or ARBs) are recommended in patients with heart failure, diabetes, or hypertension 1, 2
• Annual influenza vaccination is recommended, especially in elderly patients 2, 3

Management of Special Populations

• In older individuals, diagnostic and revascularization decisions should be based on symptoms, extent of ischemia, frailty, life expectancy, comorbidities, and patient preferences 1
• Similar guideline-directed cardiovascular preventive therapy is recommended in women and men 1
• Systemic post-menopausal hormone therapy is not recommended in women with chronic coronary syndromes due to lack of cardiovascular benefit and increased risk of thromboembolic complications 1
• In patients with HIV, attention to interaction between antiretroviral treatment and statins is recommended 1

Revascularization

• Invasive coronary angiography with functional assessment is recommended for patients with symptoms refractory to medical treatment or at high risk of adverse events 1, 4
• Recent evidence does not demonstrate conclusive benefit of routine revascularization combined with optimal medical therapy versus optimal medical therapy alone in reducing major clinical outcomes 4, 5
• For patients with symptoms or quality of life that is acceptable on medical therapy, a conservative approach with selective use of revascularization is a justifiable evidence-based strategy 4

Follow-up and Monitoring

• Periodic visits (e.g., annual) to a healthcare professional are recommended to evaluate risk factor control and assess changes in disease status 1
• Reassessment of CAD status is recommended in patients with deteriorating left ventricular function 1
• Simplifying medication regimens (e.g., using fixed-dose combinations) is recommended to increase patient adherence 1
• Timely review of response to medical therapies (2-4 weeks after initiation) is recommended 2

Common Pitfalls and Considerations

• Avoid classifying chest pain as non-cardiac without thorough evaluation including objective exclusion of myocardial ischemia 1
• Avoid combining ivabradine with non-dihydropyridine calcium channel blockers or other strong CYP3A4 inhibitors 1
• Consider bleeding risk assessment using validated tools before initiating antithrombotic therapy 1
• Recognize that the severity of symptoms does not always correlate with the severity of obstructive CAD, particularly in women 1
• Avoid using the term "stable" coronary artery disease, as the disease is never truly stable but rather a dynamic process requiring ongoing management 6, 7