chronic%20stable%20angina
CHRONIC STABLE ANGINA
Chronic stable angina 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 or emotional stress and relieved by rest 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.

Surgical Intervention

Revascularization
  • Aims to improve survival and diminish or eradicate symptoms
    • May be considered in combination with optimal medical therapy
  • Decision should be based on the presence of significant obstructive coronary artery stenosis, the amount of related ischemia, and the expected benefit to prognosis and/or symptoms
  • Clinical (eg age, gender), anatomical (eg single/multivessel disease, syntax score), technical [eg incomplete/complete vascularization, post coronary artery bypass graft (CABG)/percutaneous coronary intervention (PCI)] and environmental factors (eg patient preference, local cost) should be discussed before the benefit of revascularization can be anticipated
Indications for Myocardial Revascularization
  • Optimal pharmacological therapy is unsuccessful in controlling symptoms
  • Non-invasive tests reveal a substantial area of myocardium at risk
    • Significant left main stem disease (>50% stenosis)
    • Significant proximal multi-vessel disease with symptoms of angina or in which large area of ischemia has been demonstrated on functional testing
    • Multi-vessel disease with impaired left ventricular (LV) function with proven viable myocardium
  • High likelihood of success and acceptable risk of morbidity and mortality
  • Patient prefers an interventional rather than a pharmacological therapy and is fully informed of the benefits andrisks of the procedure
Factors to be Considered for the Selection of the Method of Revascularization
  • Risk of peri-procedural morbidity and mortality
  • Likelihood of success with consideration of the technical suitability of lesions for angioplasty or surgical bypass
  • Risk of restenosis or graft occlusion
  • Completeness of revascularization
  • Presence of comorbid illnesses
  • Expertise of the cardiac and medical team
  • Hospital facilities in cardiac surgery and interventional cardiology
  • Patient’s preference
Appropriate Use Criteria (AUC) for Revascularization
  • Recommended by the American College of Cardiology (ACC) Appropriate Use Criteria Task Force, American Association for Thoracic Surgery (AATS), American Heart Association (AHA), American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Cardiovascular Computed Tomography (SCCT), and the Society of Thoracic Surgeons (STS)
  • Based on indication, symptoms, present therapy, and history of revascularization
  • For patients with one-vessel disease:
    • PCI only:
      • Patients with one-vessel disease without proximal left anterior descending coronary artery or proximal left dominant left circumflex artery involvement with low- to high-risk findings on non-invasive testing, with no stress test results or stress tests results are indeterminate, and fractional flow reserve of ≤0.80, who are currently on ≥2 antianginal medications
    • Both PCI and CABG:
      • Patients with one-vessel disease with proximal left anterior descending coronary artery or proximal left dominant left circumflex artery involvement with intermediate- to high-risk findings on non-invasive testing who are currently on 1 antianginal medication
      • Patients with one-vessel disease with proximal left anterior descending coronary artery or proximal left dominant left circumflex artery involvement with low- to high-risk findings on non-invasive testing, with no stress test results or stress test results are indeterminate, and fractional flow reserve of ≤0.80, who are currently on ≥2 antianginal medications 
  • For patients with two-vessel disease:
  • Findings on Non-invasive Testing No stress test done or stress test results indeterminate and FFR ≤0.80 in both vessels Ischemic symptoms present Current Antianginal Therapy Recommended Revascularization Method
    Low-risk Intermediate to High-risk None 1 ≥2 PCI CABG
    No proximal left anterior descending coronary artery involvement + + + + +
    + + + +
    + + + + + +
    Proximal left anterior descending coronary artery involvement and (-) diabetes + + + + +
    + + + +
    + + + + + +
    + + + + + +
    Proximal left anterior descending coronary artery involvement and (+) diabetes + +1 +
    + + + +
    + + + + +
    + + + +
    + + + + + +
    + + + + + +
    1Also applicable for patients with antianginal therapy.
    Adapted from: Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2017 Mar;69.

  • For patients with three-vessel disease:
  • Findings on Non-invasive Testing
    Diabetes
    Ischemic symptoms present
    Current Antianginal Therapy Recommended Revascularization Method
    Low-risk Intermediate to High-risk Present Absent None 1 ≥2 PCI CABG
    Low Disease Complexity + + + + + +
    + + +1 +
    + + + + +
    + + + + + + +
    + + + + +
    + + + + + +
    + + +1 +
    + + + +
    + + + + + + +
    Intermediate or High Disease Complexity + + + +
    + + + + + +
    + + +1 +
    + + + + + +
    + + + +1 +
    + + + + + + +
    1Also applicable for patients with antianginal therapy.
    Adapted from: Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2017 Mar;69.
Contraindications to Revascularization
  • Patients with 1- or 2-vessel disease without significant proximal left anterior descending artery stenosis who are asymptomatic or with only mild symptoms and have no adequate trial of pharmacological therapy or have no demonstrable ischemia or only a limited area of ischemia/viability on non-invasive testing
  • Borderline coronary stenosis (50-70%) in locations other than the left main coronary artery and no ischemia on non-invasive tests
  • Non-significant coronary stenosis (<50%)
  • High risk of procedure-related morbidity or mortality (>10-15% mortality risk) unless the risk is balanced by an expected significant improvement in quality of life or survival
Percutaneous Coronary Intervention (PCI)
  • Found to have improved symptoms in patients with:
    • >1 significant coronary artery stenoses (≥70% diameter) amenable to revascularization and unacceptable angina despite optimal medical therapy
    • >1 significant coronary artery stenoses (≥70% diameter) and unacceptable angina for whom guideline-directed medical therapy cannot be implemented because of pharmacological therapy contraindications, adverse effects,or patient preferences
    • Previous CABG, >1 signifcant coronary artery stenoses (≥70% diameter) associated with ischemia, and unacceptable angina despite guideline-directed medical therapy
  • Contraindications include:
    • Significant unprotected left main coronary artery disease (CAD) [≥50% diameter stenoses] with unfavorable anatomy for PCI and patients are good candidates for CABG
    • >1 coronary stenoses that are not anatomically or functionally significant (eg <70% diameter non-left main coronary artery stenosis, fractional flow reserve (FFR) >0.80, no or mild ischemia on noninvasive testing), involve only the left circumflex or right coronary artery, or subtend only a small area of viable myocardium
    • Unable to meet anatomic (≥50% diameter left main or ≥70% non-left main stenosis diameter) or physiological criteria for revascularization (eg abnormal FFR)
  • Less invasive procedure compared to CABG with lower procedure-related mortality
  • PCI is more effective than pharmacological therapy in decreasing symptoms and increasing exercise capacity, with modest improvement in quality of life
    • However, PCI has not been demonstrated to improve survival in patients with stable angina
    • It may also increase the short-term risk of myocardial infarction (MI) and does not lower the long-term risk of MI
Coronary Artery Bypass Graft (CABG)
  • May be considered with the primary intent of improving survival in patients with stable ischemic heart disease (SIHD) with severe LV systolic dysfunction [ejection fraction (EF) <35%] whether or not viable myocardium is present
  • Found to have improved symptoms in patients with:
    • >1 significant coronary artery stenoses (>70% diameter) amenable to revascularization and unacceptable angina despite guideline-directed medical therapy
    • >1 significant coronary artery stenoses (≥70% diameter) and unacceptable angina for whom guideline-directed medical therapy cannot be implemented because of pharmacological therapy contraindications, adverse effects, or patient's preference
    • Complex 3-vessel CAD, with or without proximal left anterior descending (LAD) artery involvement, who are good candidates for CABG
    • Previous CABG, >1 significant coronary artery stenoses (>70% diameter) not amenable to PCI, and unacceptable angina despite guideline-directed medical therapy
  • Contraindications include:
    • >1 coronary stenoses that are not anatomically or functionally significant (eg <70% diameter non-left main coronary artery stenosis, fractional flow reserve (FFR) >0.80, no or mild ischemia on noninvasive testing),involve only the left circumflex or right coronary artery, or subtend only a small area of viable myocardium
    • Unable to meet anatomic (≥50% diameter left main or ≥70% non-left main stenosis diameter) or physiologicalcriteria for revascularization (eg abnormal FFR)
  • CABG is more effective than pharmacological therapy for relieving anginal symptoms in patients with left main CAD or 3-vessel CAD
    • Presence of LV dysfunction increases the absolute prognostic advantage of surgery over pharmacological therapy
    • Concurrent administration of guideline-directed medical therapy may substantially improve long-term outcomes in patients treated with CABG compared to those who are receiving pharmacological therapy alone
  • CABG has shown to reduce symptoms and ischemia, improve quality of life and provide a better prognosis especially in moderate- to high-risk patients
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