Chronic coronary syndrome (CCS) is a term that defines coronary artery disease as a chronic progressive course. It has been introduced to replace the previous term ‘stable coronary artery disease’.
17. Genders et al 2011 ESC
SCAD 2013 guidelines
Juarez-Orozco et al. EHJ CI 2019
ESC CCS 2019 guidelines
In 2019 57% of pts
with chest pain has
PTP<15%
Pre-test probability of coronary artery disease 2013 2019
Non-anginal pain Typical angina
Atypical angina
44. Aims of Pharmacological
Management
• Reduce angina symptoms
and exercise-induced
ischaemia.
• Prevent cardiovascular
events.
• Treatment that
satisfactorily controls
symptoms and prevents
cardiac events.
• With maximal patient
adherence and minimal
adverse events.
Optimal Treatment
45. “Optimal” Anti-Ischaemic Treatment in CCS Patients
• No universal definition of which drug/combination is “optimal” .
• Anti-ischaemic drug therapies must be adapted to each
patient’s characteristics and preferences.
• Initial drug therapy usually consists of one or two antianginal
drugs, as necessary, plus drugs for secondary prevention of CVD.
– depends on expected tolerance related to the individual patient’s
profile and comorbidities,
– potential drug interactions with co-administered therapies,
– patient’s preferences after being informed of potential adverse effects,
– drug availability.
46. Padala SK, et al. J Cardiovasc Pharmacol Ther 2017;22:499-510
47.
48.
49.
50.
51. Clinical Case
55 y.o male
Smoker, T2DM, dyslipidemia
Anterior STEMI
DES in LAD + RCA
EF 45%
Discharged with ASA + Ticagrelor
Follow-up 1 y (CCS patient) No
Smoking Cessation HBA1c
8.5%
LDL chol 1.7 mmol/l with atorvastatin
40 mg
No bleeding BARC 2 and above
How To optimize event prevention ?
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69. Clinical Case
55 y.o male
Smoker, T2DM, dyslipidemia
Anterior STEMI
DES in LAD + RCA
EF 45%
Discharged with ASA + Ticagrelor
Follow-up 1 y:
No Smoking Cessation
HBA1c 8.5%
LDL chol 1.7 mmol/l with atorvastatin
40 mg
No bleeding BARC 2 and above
How To optimize event prevention ?
Smoking cessation, appropriate life style
Optimized antithrombotic strategy after 1Y
Low bleeding risk /High ischemic risk
Good drug tolerance
Reach LDL objective: Increase statin +/- Ezetimibe
Improve Diabetes control
87. Long-standing diagnosis of CCS (>12 months)
Antithrombotic therapy in CCS patients in sinus rhythm
www.escardio.org/guidelines
Recommendations Class Level
Adding a second antithrombotic drug to aspirin for long-term secondary
prevention should be considered in patients with a high risk of ischaemic
events and without high bleeding risk
IIa A
Adding a second antithrombotic drug to aspirin for long-term secondary
prevention may be considered in patients with at least a moderately
increased risk of ischaemic events and without high bleeding risk
IIb A
High risk of ischemic events include diffuse multivessel CAD with at least one of the following: diabetes mellitus requiring medication, recurrent MI, PAD, or CKD
with eGFR 15-59 mL/min/1.73 m2.
Moderate risk of ischemic events include at least one of the following: multivessel/diffuse CAD, diabetes mellitus requiring medication, recurrent MI, PAD, HF or,
CKD with eGFR 15-59 mL/min/1.73 m2.
High bleeding risk include prior history of intracerebral haemorrhage or ischaemic stroke, history of other intracranial pathology, recent gastrointestinal bleeding
or anaemia due to possible gastrointestinal blood loss, other gastrointestinal pathology associated with increased bleeding risk, liver failure, bleeding diathesis or
coagulopathy, extreme old age or frailty, or renal failure requiring dialysis or with eGFR <15 mL/min/1.73 m2.
88. Long-standing diagnosis of CCS (>12 months)
Decision-making on optional antithrombotic therapy
www.escardio.org/guidelines
Drug option Dose Indication Additional cautions
Clopidogrel 75 mg o.d.
Post-MI in patients who have
tolerated DAPT for 1 year
Prasugrel
10 mg o.d. or 5 mg o.d.
if body weight <60 kg
or age >75 years
Post-PCI for MI in patients who
have tolerated DAPT for 1 year
Age >75 years
Rivaroxaban 2.5 mg b.i.d. Post-MI >1 year or multivessel CAD
Creatinine clearance
15-29 mL/min
Ticagrelor 60 mg b.i.d.
Post-MI in patients who have
tolerated DAPT for 1 year
Treatment options for dual antithrombotic therapy in combination with aspirin 75-100 mg daily are reported for patients who have a high or moderate risk of
ischaemic events, and do not have a high bleeding risk.
89. Risk score(s) stratification
e.g., ABC-CHD risk model
Cardiovascular death at 1 year
24
www.escardio.org/guidelines
22
ABC-CHD score points
4 6 8 10 12 14 16 18 20
2
0
Age (A) Biomarkers (B) Clinical variables (C)
Age
NT-proBNP (ng/L) Smoking
Hs-Troponin T (mg/L) Diabetes
LDL Peripheral artery disease
High discriminatory ability for CV death (c-index 0.81 in the derivation cohort [n=13,164], 0.78 in the validation cohort), with adequate calibration in both
cohorts
0.001 0.005 0.01 0.02 0.03 0.05 0.1 0.2 0.3 0.5
Lindholm D, et al. J Am Coll Cardiol. 2017;70:813-826
92. Patients with a long-standing diagnosis of
chronic coronary syndromes
Coronary anatomy definition in asymptomatic patients
Recommendation Class Level
In patients with mild or no symptoms receiving medical
treatment in whom non-invasive risk stratification indicates a
high risk, and for whom revascularization is considered for
improvement of prognosis, invasive coronary angiography
(with iwFR/FFR when necessary) is recommended.
I C
Invasive coronary angiography is not recommended solely for
risk stratification.
III C
Coronary CTA is not recommended as a routine follow-up test
for patients with established CAD.
III C
Asymptomatic
www.escardio.org/guidelines
93. Patients with a long-standing diagnosis of
chronic coronary syndromes
Clinical evaluation in symptomatic patients
www.escardio.org/guidelines
Symptomatic
Recommendation Class Level
Invasive coronary angiography (with iwFR/FFR when necessary) is
recommended for risk stratification in patients with severe CAD,
particularly if the symptoms are refractory to medical treatment or if
they have a high-risk clinical profile.
I C
Recommendation Class Level
It is recommended to expeditiously refer patients with
significant worsening of symptoms for evaluation.
I C
Reassessment of CAD status is recommended in patients with
deteriorating LV systolic function that cannot be attributed to a
reversible cause (e.g. long-standing tachycardia or myocarditis). I C
Risk stratification is recommended in patients with new or worsening
symptom levels, preferably using stress imaging or, alternatively,
exercise stress ECG.
I B
124. Final word on non-invasive tests
• Mainstay diagnostic step in the 21st century
• Can substitute FFR in decision making in patients with high
clinical likelihood of CAD
• Provides indications for revascularization in asymptomatic
patients
• Assessment in follow-up and patient response to treatment
• Treatment success in testing for residual ischemia