Chronic Coronary Syndrome

Medical Management

Anti-anginal preventative therapy.

• Beta blockers
  • Indicated in most patients with angina
  • Contraindicated with vasospastic/Prinzmetal angina due to increased theoretical risk of coronary vasospasm and low efficacy regardless
  • Proven to prevent reinfarction (the only intervention shown to do so) and to improve survival in those suffering AMI
• Calcium channel blockers
  • Used in combination with beta blocker or as monotherapy
  • Avoid in significant LV systolic dysfunction
  • Prefer long-acting diltiazem, verapamil, or the DHP amlodipine/felodipine
• Nitrates
  • Used in combination with beta blocker or as monotherapy
  • Improves symptoms
  • May lead to nitrate tolerance
• Ranolazine new
  • Can be used in combination with above treatments if refractory or not nontreated
  • MOA: late sodium channel blocker, which reduces intracellular calcium, producing myocardial relaxation

Anti-anginal acute therapy.

• Short-acting nitrates are the first line therapy for acute angina

Mortality-reducing interventions.

• Smoking cessation, exercise, diet
• Optimize risk factors
  • Hypertension – consider ACEi for "vascular protection" per HOPE (2000) -- ramipril, EUROPA (2003) -- perindopril.
  • Dyslipidemia – target LDL-C < 2.0 mM and >50% reduction
  • DM – target A1C < 7%
  • OSA – does not change CV outcomes, but may help control HTN
• Antithrombotics
  • ASA 81 mg daily
  • ECASA 100 mg daily + rivaroxaban 2.5 mg BID (per COMPASS 2017)

Revascularization

OMT has the same benefit as revascularization (PCI/CABG).

• COURAGE trial (2007)
  • As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy.
• ISCHEMIA trial (2019)
  • No evidence that initial invasive strategy (angiography and revascularization via CABG when feasible), as compared with an initial conservative strategy (medical therapy alone and angiography if medical therapy failed), reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years
  • No difference in primary outcome at 3.3 years follow up 13.3% invasive vs 15.5% OMT