Evaluation and Management of Patients With Stable Angina

Ferraro R, Latina JM, Alfaddagh A, et al.
Evaluation and Management of Patients With Stable Angina: Beyond the Ischemia Paradigm: JACC State-of-the-Art Review. J Am Coll Cardiol 2020;76:2252-2266.

The following are key points to remember from this state-of-the-art review on the evaluation and management of patients with stable angina:

  1. Coronary heart disease (CHD) is a chronic disease with a wide range of associated symptoms and clinical outcomes. Adverse events from CHD are reduced or avoided through lifestyle and risk factor modifications and medical therapy. Currently, annual health care expenditures related to CHD exceed 3 trillion dollars. An estimated 5% of the US population between the ages of 25 and 64 years undergo stress testing each year for suspected angina, resulting in an estimated cost of over 11 billion dollars.
  2. Observational studies have observed that patients with stable CHD most often report no or mild angina. The risk for major adverse cardiovascular events (MACE) is relatively low among patients with CHD and stable chest pain. Risk factor modification with medical and lifestyle therapy is the primary recommendation for such patients. Coronary revascularization is considered if optimal medical therapy (OMT) is not effective.
  3. Data suggest that symptoms will lessen or resolve with either medical therapy or revascularization among most patients with angina. The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial observed improved quality-of-life scores with OMT alone or in conjunction with percutaneous coronary intervention (PCI).
  4. The recent ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial enrolled over 5,000 patients with stable CHD who also demonstrated moderate to severe ischemia on stress testing. The investigators compared revascularization with OMT to OMT alone, with a primary endpoint of myocardial infarction (MI), cardiovascular death, hospitalization for unstable angina (UA), heart failure, or resuscitated cardiac arrest. No significant difference was noted for the primary endpoint. No difference between study arms was noted for the secondary endpoints of cardiovascular or all-cause mortality, myocardial infarction (MI), cardiac arrest, or stroke. Hospitalization for UA was lower in the revascularization group. However, hospitalization for heart failure was higher. A higher risk for MI was also noted in the revascularization group, which was lower later in follow-up. Ischemia severity was not predictive of outcomes; however, the atherosclerotic burden did predict MACE risk.
  5. Acute coronary events (acute coronary syndrome [ACS]) are usually associated with plaque disruption which is associated with the atherosclerotic burden. This suggests anatomic testing such as computed tomography angiography assists in the identification of patients at higher risk for ACS, as opposed to physiologic tests such a stress testing.
  6. Several studies have observed PCI is associated with reducing ischemic burden in patients with stable CHD, without improvement in survival or reduced risk for recurrent MI. It should be noted that revascularization for patients with stable CHD and left main disease, three-vessel CHD, and two-vessel disease with proximal left anterior descending coronary artery remains beneficial. Benefit has also been observed for patients with reduced left ventricular ejection fraction and those with diabetes and multivessel CHD.
  7. In summary, data from large clinical trials support the use of OMT rather than revascularization for initial management of the majority of patients with stable CHD. Revascularization should be considered for specific patients with severe symptoms despite OMT or anatomical disease such as left main stenosis, which increase the risk for adverse events. Last, efforts to align incentives, resources, and patients’ expectations to increase use of OMT are needed.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging, Chronic Angina

Keywords: Acute Coronary Syndrome, Angina, Stable, Angina, Unstable, Chest Pain, Coronary Angiography, Coronary Artery Disease, Heart Failure, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Plaque, Atherosclerotic, Quality of Life, Risk Factors, Secondary Prevention, Tomography, X-Ray Computed, Ventricular Function, Left

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