Treatment Guideline Chart
Chronic coronary syndromes, also called stable coronary artery disease (CAD), stable ischemic heart disease (SIHD), chronic stable angina or stable angina pectoris, is a clinical syndrome characterized by squeezing, heaviness or pressure discomfort in the chest, neck, jaw, shoulder, back, or arms which is usually precipitated by exertion and/or emotional stress and relieved by rest and/or Nitroglycerin.
It is caused by myocardial ischemia that is commonly associated with narrowing of the coronary arteries.
Angina is stable when it is not a new symptom and when there is no deterioration in frequency, duration or severity of episodes.

Chronic%20coronary%20syndromes Patient Education

Patient Education

  • Effective education about chronic coronary syndromes (CCS) and ischemic heart disease (IHD) is important
    • Educate patients about the etiology, manifestations, provoking factors, treatment options and prognosis of CCS and IHD to encourage active participation of the patients in their treatment decisions
    • Patients are more likely to participate in therapeutic and preventive measures if they have a full understanding of the potential benefits
    • Education about risks of CCS typically relieves patient’s anxieties and concerns
    • Reasonable reassurance is essential and patients may also benefit from relaxation techniques and other ways of stress control
  • Education should be a part of every patient encounter and should be tailored to the patient’s level of understanding
  • Individualize education plan to optimize care and promote wellness
    •  Develop a plan with the patient and hold discussions over time so that the patient is not overwhelmed by changing several behaviors all at one time (eg smoking, diet, exercise, etc)
    •  Educate them on self-monitoring skills, recognition of worsening cardiovascular symptoms and appropriate actions to take
    •  Inform them about the common symptoms of stress and depression to lessen stress-related angina symptoms
  •  Discuss treatment goals and strategies to improve compliance
  •  Enlist family members into the educational process to assist the patient in achieving lifestyle modifications

Lifestyle Modification

  • It is important to assess the presence of ischemic heart disease (IHD) risk factors and to treat these effectively
    • Studies that involved risk modification, that includes weight control, exercise, healthy diet and smoking cessation, have demonstrated benefits in patients with angina and coronary disease
Dietary Therapy1
  • Goals:
    • Reduce intake of saturated fats to <10% of total calories, trans fatty acids to <1% of total calories and cholesterol to <200 mg/day by avoiding red meat, whole milk products and pastries
    • Limit sodium intake to <5 g/day
    • Eat fresh fruits (≥200 g/day), vegetables (≥200 g/day), legumes, nuts, soy products, low-fat dairy products and whole grain breads, cereals and pastas
    • Light to moderate alcohol consumption of 1 glass/day or 10 g/day for women and 2 glasses/day or 20 g/day of alcohol for men (1 drink is equivalent to 4 ounces of wine, 12 ounces of beer or 1 ounce of spirits per day)
    • Increase intake of polyunsaturated fat which is high in omega-3 fatty acids by eating oily fish, walnuts, sesame seeds, pumpkin seeds, vegetable oils or taking omega-3 fatty acid supplements (1g/day)
    • Increase intake of soluble fiber 30-45 g/day
    • Energy intake should be limited to the amount of energy needed to maintain or obtain a healthy weight [body mass index (BMI) <25 kg/m2]
  • Start all patients on dietary therapy and adopt a healthy eating habit
  • Effective adjunct measure if properly implemented
  • Has favorable effects on many coronary artery disease (CAD) risk factors such as hypertension, hypercholesterolemia,obesity and diabetes mellitus (DM)
  • The Prospective Urban Rural Epidemiology (PURE) study recently showed that high carbohydrate intake (>60% of energy) was associated with an adverse effect on total and non-cardiovascular disease mortality whereas a high fat intake (including saturated and unsaturated fatty acids) was associated with lower risk of total mortality, non-cardiovascular disease mortality and stroke
    • Limit overall carbohydrate intake especially from refined sources
  • Recent studies have shown that a diet supplemented by extra-virgin olive oil or nuts reduce the incidence of major cardiovascular events in patients at high risk of cardiovascular (CV) events but without prior CV disease
  • Antioxidants and other vitamins are not recommended
    • Vitamins B, C, E, beta-carotene, folate, coenzyme Q10, selenium and chromium are not recommended to prevent cardiovascular risks or improve clinical outcome

1Dietary recommendations may vary between countries. Please refer to available nutritional guidelines from local health authorities

Smoking Cessation

  • Goals: Complete smoking cessation and avoidance of exposure to secondhand smoke
  • Effective way for the prevention of coronary events
  • Most important reversible risk factor
  • Smoking status including passive smoking should be assessed systematically
  • Implement the algorithm for smoking cessation “Ask, Advice, Assess, Assist, Arrange, and Avoid”
    • Ask the patient about tobacco use at every visit
    • Advise the smoker to quit
    • Assess the smoker’s willingness to make a quit attempt
    • Assist the smoker by providing medications and referral for counseling
    • Arrange for follow-up
    • Avoid exposure to environmental tobacco smoke at home and at work
  • Most effective smoking cessation therapies include both non-pharmacological and pharmacological therapies
    • Physician’s advice has a significant effect on quit rates
    • Self-help programs, telephone counseling, behavioral therapy and exercise programs have modest effects
    • Nicotine-replacement therapy, Bupropion and Varenicline increase the chances of success of quit attempt
      • However, there are concerns of possible increase in the risk of cardiovascular disease (CVD), worsening of preexisting depression and risk of suicide due to Varenicline based on few studies
  • There are observational studies that show cigarette smoking increases the risk for CV events
    • Dose-response relationship exists between cigarettes smoked and CV risks
Physical Activity
  • Goals:
    • Moderate-to-vigorous intensity aerobic exercise training ≥3 times a week and for 30 minutes per session is recommended in patients with previous acute MI, CABG, PCI, stable angina pectoris or stable chronic heart failure
    • Light-intensity exercise programs should be started in sedentary patients after adequate exercise-related risk stratification
    • Increase daily lifestyle activities (eg brisk walking, walking to work, household chores, gardening)
  • Exercise improves cardiorespiratory fitness, functional capacity and quality of life 
  • Exercise training when incorporated into a multifactorial risk factor reduction effort (eg smoking cessation, lipid management, etc) has been shown to improve exercise tolerance in CCS patients 
  • Exercise training may offer an alternative means of symptom alleviation and improved prognosis in patients with significant CAD who are candidates for revascularization
    • Complimentary resistance training for at least 2 days per week is reasonable
  • Assess risk with a physical activity history and/or exercise test to guide prognosis and prescription of exercise program
    • Exercise test is not necessary for medical and economic reasons if the patient will undergo a low- or moderate-intensity level program
  • Nitroglycerin may be used prior to sexual intercourse to help prevent ischemia
    • Phosphodiesterase type 5 inhibitors may be given to patients with CAD with erectile dysfunction except for patients on nitrate therapy

Cardiac Rehabilitation

  • Exercise-based cardiac rehabilitation is an effective way of managing risk factors and achieving a healthy lifestyle in CCS patients 
  • Reduces CV mortality and hospitalizations in patients with CAD 
  • Most patients referred for cardiac rehabilitation are those who had an acute MI or underwent revascularization
Weight Management
  • Goals:
    • BMI:
      • Asian adults: 18.5-22.9 kg/m2
      • American/European adults: 18.5-24.9 kg/m2
    • Waist circumference:
      • Asian: Male <33.5 inches (85 cm), female <31.5 inches (80 cm)
      • American/European: Male <40 inches (102 cm), female <35 inches (89 cm)
  • Initial weight loss goal is 5-10% from baseline with further reductions if necessary
  • Measure BMI and/or waist circumference every clinic visit
  • Risks for cardiovascular events are higher in overweight and obese patients
    • Cardiovascular risk is particularly increased in central obesity and those with extreme obesity
    • Obesity also contributes to other cardiovascular risk factors such as DM, dyslipidemia and hypertension
  • Encourage weight maintenance or reduction through an appropriate balance of physical activity, structured exercise, caloric intake and formal behavior programs
  • Medications or bariatric surgery may be considered in selected patients who cannot achieve adequate weight loss by lifestyle modifications
  • Please see Obesity disease management chart for further information
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