Strategies in Stable Chronic Coronary Disease
Stable coronary artery syndromes include patients with angina caused by obstructive coronary artery disease, by a disorder of coronary vascular function, or by a combination of these two clinical entities. The diagnostic pathway in patients presenting with chest pain and suspected stable coronary artery disease (SCAD) can be challenging because of variations in the pre-test probability of CAD and in the accuracy and local availability of diagnostic tests. There is uncertainty regarding the comparative effectiveness of non-invasive imaging-based diagnostic strategies for the detection of CAD and their role in directing ongoing management. In this chapter, we review the evidence base and clinical practice guideline recommendations underpinning non-invasive and invasive diagnostic strategies.
Optimal medical therapy (OMT) forms the cornerstone of treatment of SCAD. Nevertheless, myocardial revascularisation reduces ischaemia and improves symptoms to a greater extent than OMT alone. In contrast to revascularisation in the context of acute coronary syndromes, randomised controlled trials of revascularisation in SCAD have not demonstrated a mortality benefit. Revascularization decisions must take into account the totality of clinical data, namely, the coronary anatomy, patient-specific clinical factors such as age and co-morbidity, and the feasibility of complete revascularisation. We discuss the key evidence and clinical practice guideline recommendations for myocardial revascularisation of patients with SCAD.
Finally, we describe the conundrum of patients presenting with angina and no obstructive CAD. We discuss the requirement for a comprehensive invasive assessment of coronary physiology in these patients to clarify the diagnosis and to direct ongoing care.
KeywordsStable coronary artery disease Angina Optimal medical therapy Revascularisation PCI CABG Ischaemia Microvascular
- 1.Task Force M, Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949–3003.CrossRefGoogle Scholar
- 3.Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, preventive cardiovascular nurses association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2012;60(24):e44–e164.CrossRefPubMedGoogle Scholar
- 4.Valdiviezo C, Motivala AA, Hachamovitch R, Chamarthy M, Navarro PC, Ostfeld RJ, et al. The significance of transient ischemic dilation in the setting of otherwise normal SPECT radionuclide myocardial perfusion images. J Nucl Cardiol Off Publ Am Soc Nucl Cardiol. 2011;18(2):220–9.CrossRefGoogle Scholar
- 5.Shah R, Yow E, Jones WS, Kohl LP 3rd, Kosinski AS, Hoffmann U, et al. Comparison of visual assessment of coronary stenosis with independent quantitative coronary angiography: findings from the prospective multicenter imaging study for evaluation of chest pain (PROMISE) trial. Am Heart J. 2016;184:1–9.CrossRefPubMedPubMedCentralGoogle Scholar
- 8.Van Belle E, Rioufol G, Pouillot C, Cuisset T, Bougrini K, Teiger E, et al. Outcome impact of coronary revascularization strategy reclassification with fractional flow reserve at time of diagnostic angiography: insights from a large French multicenter fractional flow reserve registry. Circulation. 2014;129(2):173–85.CrossRefPubMedGoogle Scholar
- 9.Curzen N. RIPCORD 2 slide, FFR in the diagnostic phase. Lecture, ETP coronary physiology in the catheterization laboratory course, European Society of Cardiology. 2015.Google Scholar
- 12.Greenwood JP, Ripley DP, Berry C, McCann GP, Plein S, Bucciarelli-Ducci C, et al. Effect of care guided by cardiovascular magnetic resonance, myocardial perfusion Scintigraphy, or NICE guidelines on subsequent unnecessary angiography rates: the CE-MARC 2 randomized clinical trial. JAMA. 2016;316:1051.CrossRefPubMedGoogle Scholar
- 13.National Institute for Health Care and Excellence (NICE). Chest pain of recent onset: assessment and diagnosis. 2010. Available from: https://www.nice.org.Zuk/guidance/cg95.
- 15.Pickett CA, Hulten EA, Goyal M, Surry L, Villines TC. Accuracy of traditional age, gender and symptom based pre-test estimation of angiographically significant coronary artery disease in patients referred for coronary computed tomographic angiography. Am J Cardiol. 2013;112(2):208–11.CrossRefPubMedGoogle Scholar
- 25.Sianos G, Morel MA, Kappetein AP, Morice MC, Colombo A, Dawkins K, et al. The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease. EuroIntervention J EuroPCR Collab Work Group Interv Cardiol Eur Soc Cardiol. 2005;1(2):219–27.Google Scholar
- 30.Hueb W, Soares PR, Gersh BJ, Cesar LA, Luz PL, Puig LB, et al. The medicine, angioplasty, or surgery study (MASS-II): a randomized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: one-year results. J Am Coll Cardiol. 2004;43(10):1743–51.CrossRefPubMedGoogle Scholar
- 33.Zimmermann FM, De Bruyne B, Pijls NH, Desai M, Oldroyd KG, Park SJ, et al. Rationale and design of the fractional flow reserve versus angiography for multivessel evaluation (FAME) 3 trial: a comparison of fractional flow reserve-guided percutaneous coronary intervention and coronary artery bypass graft surgery in patients with multivessel coronary artery disease. Am Heart J. 2015;170(4):619–26. e2.CrossRefPubMedGoogle Scholar
- 35.Pijls NH, Fearon WF, Tonino PA, Siebert U, Ikeno F, Bornschein B, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease: 2-year follow-up of the FAME (fractional flow reserve versus angiography for multivessel evaluation) study. J Am Coll Cardiol. 2010;56(3):177–84.CrossRefPubMedGoogle Scholar
- 36.van Nunen LX, Zimmermann FM, Tonino PA, Barbato E, Baumbach A, Engstrom T, et al. Fractional flow reserve versus angiography for guidance of PCI in patients with multivessel coronary artery disease (FAME): 5-year follow-up of a randomised controlled trial. Lancet. 2015;386(10006):1853–60.CrossRefPubMedGoogle Scholar
- 38.Mohr FW, Morice MC, Kappetein AP, Feldman TE, Stahle E, Colombo A, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet. 2013;381(9867):629–38.CrossRefPubMedGoogle Scholar
- 39.Hueb WA, Bellotti G, de Oliveira SA, Arie S, de Albuquerque CP, Jatene AD, et al. The Medicine, Angioplasty or Surgery Study (MASS): a prospective, randomized trial of medical therapy, balloon angioplasty or bypass surgery for single proximal left anterior descending artery stenoses. J Am Coll Cardiol. 1995;26(7):1600–5.CrossRefPubMedGoogle Scholar
- 41.Makikallio T, Holm NR, Lindsay M, Spence MS, Erglis A, Menown IB, et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet. 2016;388(10061):2743–52.CrossRefPubMedGoogle Scholar
- 43.Nerlekar NHF, Verma KP, Bennett MR, Cameron JD, Meredith IT, Brown AJ. Percutaneous coronary intervention using drug-eluting stents versus coronary artery bypass grafting for unprotected left main coronary artery stenosis a meta-analysis of randomized trials. Circ Cardiovasc Interv. 2016;9(12):e004729.CrossRefPubMedGoogle Scholar
- 45.Petrie MC, Jhund PS, She L, Adlbrecht C, Doenst T, Panza JA, et al. Ten-year outcomes after coronary artery bypass grafting according to age in patients with heart failure and left ventricular systolic dysfunction: an analysis of the extended follow-up of the STICH trial (surgical treatment for ischemic heart failure). Circulation. 2016;134(18):1314–24.CrossRefPubMedPubMedCentralGoogle Scholar
- 46.Shaw LJ, Berman DS, Maron DJ, Mancini GB, Hayes SW, Hartigan PM, et al. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the clinical outcomes utilizing revascularization and aggressive drug evaluation (COURAGE) trial nuclear substudy. Circulation. 2008;117(10):1283–91.CrossRefPubMedGoogle Scholar
- 47.Shaw LJ, Weintraub WS, Maron DJ, Hartigan PM, Hachamovitch R, Min JK, et al. Baseline stress myocardial perfusion imaging results and outcomes in patients with stable ischemic heart disease randomized to optimal medical therapy with or without percutaneous coronary intervention. Am Heart J. 2012;164(2):243–50.CrossRefPubMedGoogle Scholar
- 52.Echavarria-Pinto M, van de Hoef TP, Serruys PW, Piek JJ, Escaned J. Facing the complexity of ischaemic heart disease with intracoronary pressure and flow measurements: beyond fractional flow reserve interrogation of the coronary circulation. Curr Opin Cardiol. 2014;29(6):564–70.CrossRefPubMedGoogle Scholar