What is the optimal management plan for a patient with chronic coronary syndrome?

Chronic Coronary Syndrome Management Algorithm

Initial Diagnostic Assessment and Risk Stratification

All patients with suspected chronic coronary syndrome require resting echocardiography to quantify left ventricular function, followed by risk stratification using stress imaging or coronary CTA (if local expertise permits), or exercise stress ECG if significant exercise capacity exists and ECG is interpretable. 1, 2

High-Risk Features Requiring Invasive Assessment

Proceed directly to invasive coronary angiography with FFR/iFR guidance if any of the following are present: 1, 2

• Symptoms inadequately responding to medical treatment
• Left main disease ≥50% stenosis on CCTA
• Three-vessel disease with ≥70% stenosis
• Two-vessel disease with ≥70% stenosis including proximal LAD
• Proximal LAD disease ≥70% with FFR-CT ≤0.8
• ≥10% ischemic myocardium on stress imaging
• Deteriorating left ventricular function

Critical pitfall: Never perform invasive angiography solely for risk stratification without functional assessment (FFR/iFR) unless stenosis is >90% diameter. 1, 2

Mandatory Foundation Therapy for All Patients

Antithrombotic Therapy

For patients with prior MI or revascularization, clopidogrel 75 mg daily is now recommended as equally safe and effective as aspirin monotherapy. 1, 2 Aspirin 75-100 mg daily remains an acceptable alternative. 1, 2

For patients without prior MI or revascularization but with documented obstructive CAD, aspirin 75-100 mg daily is recommended. 1

After PCI, dual antiplatelet therapy (aspirin + clopidogrel) is required for 6 months, shortened to 1-3 months only if life-threatening bleeding risk exists. 1, 2

After CABG, aspirin 75-100 mg daily lifelong is mandatory. 1

Lipid-Lowering Therapy

Target LDL-C <1.4 mmol/L (55 mg/dL) with ≥50% reduction from baseline using the following escalation: 1, 2

1. Maximum tolerated statin dose
2. Add ezetimibe if goal not achieved
3. Add bempedoic acid for statin-intolerant patients or if goal still not met 1
4. Add PCSK9 inhibitor for very high-risk patients not achieving goals on statin + ezetimibe 2

ACE Inhibitors/ARBs

Recommended for patients with heart failure, diabetes, or hypertension. 2

Annual Influenza Vaccination

Mandatory, especially in elderly patients. 1, 2

Antianginal Therapy Algorithm

Immediate Symptom Relief

Short-acting sublingual nitroglycerin for acute angina episodes. 1, 2

Contraindication: Never use nitrates in hypertrophic obstructive cardiomyopathy or with phosphodiesterase inhibitors. 1, 2

First-Line Chronic Symptom Control

Beta-blockers and/or calcium channel blockers (CCBs) are first-line, tailored to patient characteristics, comorbidities, and underlying pathophysiology. 1, 2

Second-Line Add-On Therapy

For patients with left ventricular systolic dysfunction (LVEF <40%) and inadequate symptom control, ivabradine should be considered as add-on therapy or as part of initial treatment in selected patients. 1

Ivabradine is NOT recommended in patients with LVEF >40% and no clinical heart failure, and must never be combined with non-dihydropyridine CCBs or strong CYP3A4 inhibitors. 1

Emerging Therapies with Proven Benefit

SGLT2 Inhibitors

For patients with type 2 diabetes and CCS, SGLT2 inhibitors with proven cardiovascular benefit are mandatory to reduce cardiovascular events, independent of HbA1c levels. 1

GLP-1 Receptor Agonists

Semaglutide should be considered in CCS patients without diabetes but with overweight/obesity (BMI >27 kg/m²) to reduce cardiovascular mortality, MI, or stroke. 1

Low-Dose Colchicine

In CCS patients with atherosclerotic CAD, colchicine 0.5 mg daily should be considered to reduce myocardial infarction, stroke, and need for revascularization. 1

Lifestyle Interventions (Non-Negotiable)

Multidisciplinary behavioral approaches are mandatory alongside pharmacological management. 1, 2

Exercise Prescription

Aerobic physical activity: 150-300 minutes per week of moderate intensity OR 75-150 minutes per week of vigorous intensity, with reduction in sedentary time. 1, 2

Exercise-based cardiac rehabilitation is mandatory and reduces mortality. 1, 2

Mobile Health Interventions

Home-based cardiac rehabilitation and mobile health interventions (apps, wearable devices, text messages) should be considered to increase long-term adherence and reduce hospitalizations. 1, 2

Follow-Up and Monitoring

Review patient response to medical therapies 2-4 weeks after drug initiation. 1, 2

Annual visits to assess risk factor control and disease status changes. 2

Reassess CAD status if left ventricular function deteriorates. 2

Simplify medication regimens using fixed-dose combinations to improve adherence. 2

Critical Clinical Pitfalls to Avoid

Never classify chest pain as non-cardiac without thorough evaluation including objective exclusion of myocardial ischemia. 2

Recognize that symptom severity does not correlate with obstructive CAD severity, particularly in women. 2

Assess bleeding risk using validated tools before initiating antithrombotic therapy. 2

For complex cases where CABG and PCI hold equal recommendation levels, Heart Team discussion is mandatory. 1