CCS

Summary

This lecture for the Philippine Heart Association discusses chronic coronary syndrome (CCS), updating its definition and emphasizing its dynamic nature. It covers diagnosis through history, examination, and tests, highlighting the importance of optimizing medical treatment before invasive procedures. Management focuses on preventing cardiovascular events, improving life quality through symptom relief, and tailoring treatment to individual patient profiles, including comorbidities.

Takeaways

• 📚 The session is designed to provide an overview and update on the diagnosis and management of chronic coronary syndrome (CCS), emphasizing the importance of both scientific evidence and expert perspectives.
• 🔍 The term 'chronic coronary syndrome' was introduced by the European Society of Cardiology in 2019 to replace 'stable ischemic heart disease', highlighting the dynamic nature of coronary artery disease.
• 🔄 The American College of Cardiology and American Heart Association have recently termed the disease entity as 'chronic coronary artery disease', indicating that these terms can be used interchangeably.
• 🚑 CCS involves a spectrum of disease caused by atherosclerosis, with clinical presentations that can range from acute coronary syndrome to stable conditions, and patients can develop acute coronary syndrome at any point.
• 🩺 Diagnosis of CCS involves a comprehensive approach including history taking, clinical examination, baseline ECG, and various diagnostic tests such as echocardiogram, chest x-ray, and biochemical tests.
• 🏃‍♂️ Exercise treadmill stress test and non-invasive functional imaging tests are used for risk stratification and diagnosis, with coronary CT angiogram and invasive coronary angiography being additional diagnostic tools.
• 💊 Management of CCS focuses on optimizing medical treatment before considering invasive testing, with clinical trials showing that optimal medical therapy is not inferior to revascularization in terms of major adverse cardiovascular events.
• 🌟 The two main objectives in managing CCS are to decrease cardiovascular events and improve survival, and to relieve symptoms and improve the quality of life.
• 💊 Anti-anginal therapy includes a variety of medications such as beta-blockers, calcium channel blockers, nitrates, and others, with the choice of therapy often individualized based on the patient's clinical profile and comorbidities.
• 🔬 The use of combination therapy and individualized strategies in managing angina is emphasized, considering the multiple mechanisms involved in angina and the need to tailor treatment to each patient's specific needs.

Q & A

What is the current terminology used for what was previously known as stable ischemic heart disease?

The current terminology used for what was previously known as stable ischemic heart disease is 'chronic coronary syndrome' (CCS), as updated by the European Society of Cardiology in 2019. However, in the 2023 guidelines by the American College of Cardiology and American Heart Association, it is termed 'chronic coronary artery disease'.

Why was the terminology for coronary artery disease updated?

The terminology was updated to emphasize that coronary artery disease is not dormant and that the term 'stable' does not adequately describe the complex pathological process. The change highlights that coronary artery disease is part of a spectrum of diseases caused by atherosclerosis.

What are the clinical presentations of coronary artery disease?

The clinical presentations of coronary artery disease can be categorized as either acute coronary syndrome or chronic coronary syndrome.

What are the typical symptoms of angina in patients with chronic coronary syndrome?

Typical symptoms of angina include intermittent substernal chest heaviness, sometimes described as throbbing, pressure, or dull pain in the center of the chest, which may radiate to the left shoulder and arm, the jaw, or even the epigastric area. It is usually precipitated by effort and relieved by rest or intake of nitroglycerine.

What are the non-modifiable risk factors for atherosclerosis?

The non-modifiable risk factors for atherosclerosis include age, gender, and family history.

What are the modifiable risk factors for atherosclerosis?

Modifiable risk factors for atherosclerosis include hypertension, diabetes, insulin resistance, smoking, high LDL cholesterol and triglycerides, low HDL cholesterol, obesity, lipoprotein(a), stress, and physical inactivity.

What role does the physical examination play in the diagnosis of chronic coronary syndrome?

Physical examination is vital as it may reveal important findings related to the patient's condition and comorbidities. It can point to factors that can worsen angina, such as hypertension and tachycardia, and guide the choice of pharmacologic treatment. Signs of heart failure, valvular abnormalities, and other conditions relevant to angina may also be discovered.

Why is a baseline standard 12-lead electrocardiogram (ECG) mandatory in the diagnostic workup of chronic coronary syndrome?

A baseline standard 12-lead ECG is mandatory as it may reveal findings of ischemia, such as non-specific ST-T changes, T wave inversion, or Q waves signifying a previous old infarct. It also helps in assessing signs of chamber enlargement, rhythm, and can guide management strategies.

What are the recommended non-invasive diagnostic tests for diagnosing coronary artery disease in symptomatic patients?

The recommended non-invasive diagnostic tests include exercise treadmill stress test, non-invasive functional imaging for myocardial ischemia, coronary CT angiogram, and sometimes multiple imaging tests may be required to guide management.

What is the primary goal of managing chronic coronary syndrome?

The primary goal of managing chronic coronary syndrome is to decrease cardiovascular events and improve survival, while also relieving symptoms like angina to improve the quality of life.

What are the key strategies for decreasing cardiovascular events in patients with chronic coronary syndrome?

Key strategies include lifestyle modification, control of risk factors, statin therapy to reduce LDL cholesterol, control of blood pressure, antiplatelet therapy, and revascularization in selected patients.

How does the management of angina in chronic coronary syndrome differ from the management of other aspects of the disease?

The management of angina focuses on anti-anginal medications and revascularization in selected patients to decrease the frequency of angina, improve exercise capacity, and enhance well-being. It involves a combination of therapies and an individualized approach based on the patient's clinical profile, hemodynamic status, and comorbidities.

What are the common anti-anginal medications used in the treatment of chronic coronary syndrome?

Common anti-anginal medications include beta-blockers, calcium channel blockers, long-acting nitrates, ivabradine, ranolazine, trimetazidine, and nicorandil.