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2022, Number S5

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Cardiovasc Metab Sci 2022; 33 (S5)

Chronic coronary syndrome

Velásquez-Zapata, Leonardo1; Díaz-Pérez, Ysmenia2; Varleta, Paola3; Acevedo, Mónica4

Language: English
References: 10
Page: s458-460
PDF size: 139.58 Kb.






INTRODUCTION

Coronary heart disease (CHD) is a pathological process with an accumulation of atherosclerotic plaques in the epicardial coronary arteries. It is a chronic, progressive condition that can remain asymptomatic until the occurrence of a plaque event (acute coronary syndrome, ACS.

Chronic coronary syndrome (CCS) encompasses pathological conditions produced by a chronic or repetitive mismatch between supply and demand in myocardial oxygen consumption. The most common cause of ischemia is atherosclerotic obstruction of the coronary arteries. Less frequent are microvascular dysfunction, vasospasm, congenital anomalies, or non-atherosclerotic myocardial injuries.1,2 The main clinical manifestation of CCS is angina. The reproduction and the duration of the pain with exercise or stress allow this picture to be differentiated from ACS.



FORMS OF PRESENTATION:

Six forms of presentation are distinguished:1

  • 1. Patients with chronic stable angina with or without dyspnea with suspected obstructive coronary disease (CAD). The study of these includes evaluation of symptoms, physical examination, comorbidities, and quality of life. It is fundamental to evaluate the pretest probability to choose an appropriate diagnostic method and to establish a prognosis for future CV events.2
  • 2. Patients with a recent episode of heart failure or left ventricular (LV) dysfunction. CAD is the leading cause of heart failure.
  • 3. Patients with stable symptoms after < 1 year of an ACS or revascularization.
  • They should be followed for the first year after the event, and ventricular function should be evaluated 8 to 12 weeks later.
  • 4. Patients after one year of ACS or revascularization. An annual clinical evaluation is recommended with emphasis on adherence to optimal medical therapy, ECG, and evaluation of ventricular function and silent ischemia every 3 to 5 years.1,2
  • 5. Patients with angina and suspected microvascular dysfunction or vasospasm with non-obstructive CHD. They are associated with an unfavorable prognosis. The microvascular disease presents angina without significant obstructive lesions. Vasospastic events occur at rest and usually follow a circadian rhythm with transient ST changes.
  • 6. Asymptomatic patients with CD detection by check-up: a careful assessment of CV risk is suggested.



DIAGNOSIS OF CHRONIC CORONARY SYNDROME

There are six essential steps:1,2

  • 1. Take a detailed clinical history for the diagnosis of angina and its classification (typical, atypical, non-anginal chest pain). Then assess symptoms and signs using the Canadian Society of Cardiology classification.1
  • 2. Concomitant diseases, quality of life, presence of anemia, arterial hypertension, valvular disease, hypertrophic cardiomyopathy, heart rhythm disturbances, peripheral vascular disease, thyroid disease, kidney disease, and diabetes must be registered
  • 3. Perform resting ECG, laboratory tests (complete hemogram, kidney function, diabetes screening, lipid profile, thyroid profile), transthoracic echocardiography, and chest X-ray.1
  • 4. Assess the pretest probability (PTP) and the clinical likelihood of ischemic heart disease. When the PPT is < 15%, do not carry out further studies; between 15 and 65%, coronary computed tomography (CTA) is recommended; between 65 and 85%, consider CTA or another ischemia test, and if PTP > 85%, perform coronary angiography.2,3
  • 5. The appropriate diagnostic test will depend on the PTP, the patient's comorbidities, and availability. In symptomatic patients in whom obstructive CAD cannot be ruled out, a non-invasive functional imaging test or coronary CT angiography should be performed. The stress test is recommended only in subjects to assess tolerance to exercise, the appearance of symptoms, arrhythmias, pressor response, and the risk of CV events. It can also be considered when non-invasive images are unavailable or in patients already treated to observe symptoms and or signs of ischemia on the ECG. Angio-CT is an alternative to coronary angiography if other non-invasive tests are not diagnostic. Coronary angiography is recommended in patients with high clinical probability, symptoms resistant to therapy, or mild effort angina. Invasive functional assessment should be carried out in cases with doubt about stenosis severity.3
  • 6. Risk assessment of CV events based on clinical evaluation and studies performed for diagnosis.



TREATMENT

The main objectives are improving symptoms/quality of life and cardiac event-free survival. The treatment pillars are summarized in Figure 1.1,2

  • 1. Lifestyle and healthy behavior: Table 1.
  • 2. CV rehabilitation: consists in a supervised exercise program. Its benefits are multiple. It has been shown in meta-analyses that it can reduce CV mortality and hospitalizations. However, < 25% of patients are referred to these programs.4,5
  • 3. Anti-ischemic therapy: β-blockade and calcium channel blockers are the first lines to reduce angina, but they have not shown an effect on survival. Short-acting nitrates are reserved as a rescue medication, while long-acting nitrates are used as the second line. Ranolazine could be used in patients with refractory symptoms despite therapy.1,2
  • 4. Antithrombotic therapy: acetylsalicylic acid (ASA) is the mainstay of treatment for obstructive CAD. Dual antiplatelet therapy is maintained ± 12 months after an ACS. The use after one year of dual treatment therapy a reduction in the risk of CV events ≈ by 25-28%. The addition of the anticoagulant rivaroxaban at a dose of 2.5 mg BID plus ASA reduced the relative risk of events by 24%.6
  • 5. Lipid-lowering agents: the LDL goal is < 55 or < 70 mg/dL in Europe and USA, respectively. Management includes lifestyle changes and additive intensive drug therapy with statins, ezetimibe, and PSCK9 inhibitors, in that order.1,2,7
  • 6. Revascularization: the ISCHEMIA8 study, and recently REVIVE,9 showed equal survival in patients with optimal medical treatment versus coronary revascularization. This last strategy, however, achieves better symptom control.


REFERENCES

  1. Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020; 41: 407-477.

  2. Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the evaluation and diagnosis of chest pain: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021; 144: e368-e454.

  3. Juarez-Orozco LE, Saraste A, Capodanno D, Prescott E, Ballo H, Bax JJ et al. Impact of a decreasing pre-test probability on the performance of diagnostic tests for coronary artery disease. Eur Heart J Cardiovasc Imaging. 2019; 20: 1198-1207.

  4. Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2001: CD001800.

  5. Benzer W, Rauch B, Schmid JP, Zwisler AD, Dendale P, Davos CH et al. Exercise-based cardiac rehabilitation in twelve European countries results of the European cardiac rehabilitation registry. Int J Cardiol. 2017; 228: 58-67.

  6. Parker WA, Storey RF. Antithrombotic therapy for patients with chronic coronary syndromes. Heart. 2021; 107: 925-933.

  7. Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020; 41: 111-188.

  8. Maron DJ, Hochman JS, Reynolds HR, Bangalore S, O'Brien SM, Boden WE, Chaitman BR et al. Initial invasive or conservative strategy for stable coronary disease. N Engl J Med. 2020; 382: 1395-1407.

  9. Perera D, Clayton T, O'Kane PD, Greenwood JP, Weerackody R, Ryan M et al. Percutaneous revascularization for ischemic left ventricular dysfunction. N Engl J Med. 2022; 387: 1351-1360.

  10. Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review. JAMA. 2003; 290: 86-97.



AFFILIATIONS

1 Cardiology Resident, Division of Cardiovascular Diseases, School of Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile.

2 Technological Institute of Santo Domingo (INTEC), Associated Cardiovascular Medicine National Polyclinic Center, Santo Domingo, Dominican Republic.

3 Cardiovascular Prevention, Cardiac Rehabilitation Unit, Cardiovascular Center Hospital DIPRECA, Santiago, Chile.

4 Division of Cardiovascular Diseases, School of Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago de Chile.



CORRESPONDENCE

Mónica Acevedo. E-mail: macevedo@med.puc.cl


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