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ABSTRACT
Introduction
Chronic coronary syndrome (CCS) remains the leading cause of death worldwide with high admission/re-admission rates. Medical databases were searched on CCS & its management.
Areas covered
This review discusses phenotypes per stress-echocardiography, noninvasive/invasive testing (coronary computed-tomography angiography-CCTA; coronary artery calcium – CAC score; echocardiography assessing wall-motion, LV function, valvular disease; biomarkers), multidisciplinary management (risk factors/anti-inflammatory/anti-ischemic/antithrombotic therapies and revascularization), newer treatments (colchicine/ivabradine/ranolazine/melatonin), cardiac rehabilitation/exercise improving physical activity and quality-of-life, use of the implantable-defibrillator, and treatment with extracorporeal shockwave-revascularization for refractory symptoms.
Expert opinion
CCS is age-dependent, leading cause of death worldwide with high hospitalization rates. Stress-echocardiography defines phenotypes and guides prophylaxis and management. CAC is a surrogate for atherosclerosis burden, best for patients of intermediate/borderline risk. Higher CAC-scores indicate more severe coronary abnormalities. CCTA is preferred for noninvasive detection of CAC and atherosclerosis burden, determining stenosis’ functional significance, and guiding management. Combining CAC score with CCTA improves diagnostic yield and assists prognosis. Echocardiography assesses LV wall-motion and function and valvular disease. Biomarkers guide diagnosis/prognosis. CCS management is multidisciplinary: risk-factor management, anti-inflammatory/anti-ischemic/antithrombotic therapies, and revascularization. Newer therapies comprise colchicine, ivabradine, ranolazine, melatonin, glucagon-like peptide-1-receptor antagonists. Cardiac rehabilitation/exercise improves physical activity and quality-of-life. An ICD protects from sudden death. Extracorporeal shockwave-revascularization treats refractory symptoms.
Article highlights
CCS is the leading cause of death worldwide with high hospitalization/re-hospitalization rates with several phenotypes defined by stress echo via the ABCDE protocol (A, asynergy on echocardiogram; B, B-lineson chest X-ray; C, LV contractility; D, Doppler or coronary microcirculation, and; E, ECG or chronotropic reserve)
The prevalence of CCS is age-dependent ranging from <1% at ages 20–39, to ~7% for ages 40–59, 13–22% for ages 60–79 and 21–34% for ages >80 years.
Coronary artery calcium (CAC), best detected noninvasively by CCTA, depicts coronary atherosclerosis burden, is optimally used in select patients who are at intermediate/borderline risk of atherosclerosis; it also determines functional significance of coronary stenosis, and guides management by assessing patient’s true risk and need for primary prevention agents (e.g. statins, aspirin). Importantly, when such initial testing indicates zero CAC score in individuals with low clinical likelihood of CAD, non-invasive coronary angiography could be avoided, facilitating the management of the increasing demand for coronary CT and the reduction of radiation dose. Combining CAC score with CCTA findings improves diagnostic yield and assists in prognosis.
Echocardiography assesses wall-motion and LV function and detects concomitant valvular heart disease.
Assessment of biomarkers (e.g. troponin and lipid levels, inflammatory markers, and renal function indices) can further aid and guide diagnosis and prognosis.
CCS management is multidisciplinary involving treatment for CV risk factors, anti-inflammatory, anti-ischemic and antithrombotic therapies and revascularization via percutaneous or surgical techniques. Newer treatment modalities may comprise colchicine, ivabradine, ranolazine, melatonin, and glucagon-like peptide-1 receptor antagonists. Cardiac rehabilitation and exercise improve physical activity and QoL/Use of an ICD can protect from SCD and extend longevity. Finally, extracorporeal shockwave myocardial revascularization may treat refractory symptoms when coronary revascularization has failed or is not an option.
Abbreviations
| ACS | = | Acute coronary syndrome |
| CABG | = | Coronary artery bypass grafting |
| CAC | = | Coronary artery calcium |
| CAD | = | Coronary artery disease |
| CCS | = | Chronic coronary syndrome |
| CCTA | = | Coronary computed tomography angiography |
| CKD | = | Chronic kidney disease |
| CRP | = | C-reactive protein |
| CV | = | Cardiovascular |
| DM | = | Diabetes mellitus |
| HF | = | Heart failure |
| HFrEF | = | Heart failure with reduced ejection fraction |
| ECG | = | Electrocardiogram |
| HDL | = | High-density lipoprotein |
| ICD | = | Implantable cardioverter defibrillator |
| LDL | = | Low density lipoprotein |
| MACE | = | Major adverse cardiac event (s) |
| MI | = | Myocardial infarction |
| LV | = | Left ventric-cle (−ular) |
| PCI | = | Percutaneous coronary intervention |
| RCT | = | Randomized controlled trial |
| SCD | = | Sudden cardiac death |
| SYNTAX | = | SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery |
Declaration of interest
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.