Paradigm Shift in Stable Angina Management: Key Points

Boden WE, Marzilli M, Crea F, et al.
Evolving Management Paradigm for Stable Ischemic Heart Disease Patients: JACC Review Topic of the Week. J Am Coll Cardiol 2023;81:505-514.

The following are key points to remember from this review on the evolving management paradigm for stable ischemic heart disease patients:

  1. Management of stable coronary artery disease (CAD) or chronic coronary artery disease has been based on the assumption that flow-limiting atherosclerotic obstructions are the proximate cause of angina and myocardial ischemia in most patients and represent an important target for revascularization.
  2. However, the role of revascularization in reducing long-term cardiac events in these patients has been limited mainly to those with left main disease, three-vessel disease with diabetes, or decreased ejection fraction.
  3. Evolving evidence indicates that nonepicardial coronary causes of angina and ischemia, including coronary microvascular dysfunction, vasospastic disorders, and derangements of myocardial metabolism, are more prevalent than flow-limiting stenoses, raising concerns that many important causes other than epicardial CAD are neither considered nor probed diagnostically.
  4. Assessments of ischemia that do not delineate abnormal coronary angiographic findings should not necessarily shift diagnostic and therapeutic considerations to noncardiac causes of angina but rather to exploring nonepicardial coronary causes (e.g., coronary microvascular disease and vasospastic disorders).
  5. There is a need for a more inclusive management paradigm that uncouples the singular association between epicardial CAD and revascularization and better aligns diagnostic approaches that tailor treatment to the underlying mechanisms and precipitants of angina and ischemia in contemporary clinical practice.
  6. In patients without obstructive stenosis, the functional assessment of coronary circulation, including acetylcholine testing for spasm, coronary flow reserve, and microvascular resistance, may be considered to guide subsequent pharmacologic treatment. Such additional diagnostic testing should be performed only after obstructive CAD has been excluded and only if symptoms do not improve (or if they worsen) despite appropriate antianginal therapy of ≥2 drug classes.
  7. We also need to invest in developing newer management strategies and health care delivery models that may better align with treatments proven to benefit patients and society.
  8. A conservative approach to management, including noninvasive testing, lifestyle interventions, and goal-directed multifaceted medical therapy, is evidence based and often effective in patients with stable angina.
  9. Proven secondary prevention strategies and lifestyle interventions in contemporary goal-directed medical therapy continue to be underutilized, particularly in the United States, where as few as 40-50% of eligible CAD subjects are treated according to established clinical practice guidelines, including those who have been revascularized.
  10. Finally, pharmacologic and procedural approaches to stable ischemic heart disease are complementary, and integrating these can optimize outcomes.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Cardiac Surgery and SIHD, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging, Chronic Angina

Keywords: Acetylcholine, Angina, Stable, Cardiac Surgical Procedures, Coronary Angiography, Coronary Artery Disease, Coronary Stenosis, Diabetes Mellitus, Diagnostic Imaging, Ischemia, Life Style, Microvascular Angina, Myocardial Ischemia, Myocardial Revascularization, Pharmaceutical Preparations, Secondary Prevention, Spasm, Stroke Volume

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