What is the initial management for patients with chronic coronary syndrome?

Initial Management of Chronic Coronary Syndrome

The initial management for patients with chronic coronary syndrome should include beta-blockers and/or calcium channel blockers for symptom control, along with short-acting nitrates for immediate relief of angina, combined with comprehensive risk factor modification and antithrombotic therapy tailored to the patient's risk profile. 1

Diagnostic Assessment and Risk Stratification

• Initial evaluation should include assessment of cardiovascular risk factors, detailed medical history, and symptom characteristics to determine the likelihood of obstructive coronary artery disease 1, 2
• A resting 12-lead ECG is mandatory for all patients with suspected chronic coronary syndrome, particularly during or immediately after episodes suggestive of myocardial ischemia 1, 3
• Basic blood tests are recommended for all patients, including lipid profile, complete blood count, renal function assessment, and glycemic status 1, 3
• Resting transthoracic echocardiography is recommended to assess left ventricular function, identify regional wall motion abnormalities, and exclude non-coronary cardiac disease 1, 2
• Risk stratification should be based on clinical assessment and the results of initial diagnostic tests to guide treatment intensity 1, 2

Lifestyle Modifications

• Multidisciplinary behavioral approaches to help patients achieve healthy lifestyles alongside pharmacological management are strongly recommended 1, 2
• A structured exercise-based cardiac rehabilitation program is recommended to improve cardiovascular risk profile and reduce mortality 1, 2
• Aerobic physical activity of 150-300 minutes per week of moderate intensity or 75-150 minutes per week of vigorous intensity is recommended, along with reduction in sedentary time 1, 2
• Mobile health interventions (text messages, apps, wearable devices) can improve adherence to lifestyle changes and medical therapy 2

Pharmacological Management for Symptom Control

• Short-acting nitrates are recommended for immediate relief of angina symptoms 1, 2
• Initial treatment with beta-blockers and/or calcium channel blockers is recommended to control heart rate and symptoms for most patients 1, 2
• Selection of antianginal drugs should be tailored based on patient characteristics, comorbidities, concomitant medications, and underlying pathophysiology of angina 1, 2
• Metoprolol is an effective antianginal agent, with dosages ranging from 100-400 mg daily in controlled clinical trials 4
• Avoid nitrates in patients with hypertrophic cardiomyopathy or when co-administered with phosphodiesterase inhibitors 1
• Ivabradine is not recommended as add-on therapy in patients with chronic coronary syndrome, LVEF >40%, and no clinical heart failure 1

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, 2
• Clopidogrel 75 mg daily is recommended as a safe and effective alternative to aspirin monotherapy 1, 2
• In patients without prior MI or revascularization but with evidence of significant obstructive CAD, aspirin 75-100 mg daily is recommended lifelong 1
• Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for up to 6 months is recommended in patients who undergo percutaneous coronary intervention (PCI) 1, 2

Lipid-Lowering Therapy

• Statins are recommended for all patients with chronic coronary syndrome 5, 2
• If LDL-C goals are not achieved with maximum tolerated statin dose, combination with ezetimibe is recommended 5, 2
• For very high-risk patients not achieving goals on statin and ezetimibe, adding a PCSK9 inhibitor is recommended 5, 2

Revascularization Considerations

• Invasive coronary angiography with functional assessment (FFR/iFR) is recommended for patients with symptoms refractory to medical treatment or at high risk of adverse events 1, 2
• In individuals at high risk of adverse events (regardless of symptoms), invasive coronary angiography complemented by invasive functional measures is recommended to refine risk stratification and improve outcomes through revascularization 1
• Recent evidence suggests that patients selected for revascularization with PCI may experience better outcomes compared to medical therapy alone, particularly for reducing myocardial infarction and urgent revascularization 6

Follow-up and Monitoring

• Timely review of response to medical therapies (2-4 weeks after initiation) is recommended 2
• Periodic visits (e.g., annual) to a healthcare professional are recommended to evaluate risk factor control and assess changes in disease status 2
• Annual influenza vaccination is recommended, especially for elderly patients 2

Common Pitfalls to Avoid

• Assuming chest pain is always cardiac in origin - many patients with coronary disease present with atypical symptoms 3
• Failing to recognize that women and men may present with different symptom patterns of coronary disease 3
• Combining ivabradine with non-dihydropyridine calcium channel blockers or other strong CYP3A4 inhibitors 1
• Underestimating the importance of lifestyle modifications alongside pharmacological therapy 2, 7