Professional Documents
Culture Documents
2013
European guidelines on
the management of
stable coronary artery
disease
Dr Nikko Nugraha
Non-invasive cardiac
investigations
Principles of diagnostic
testing
Stress imaging
Non-invasive techniques to
assess coronary anatomy
Computed tomography. Calcium scoring (without
contrast injection) has no role in symptomatic
patients for diagnosing or excluding coronary
stenosis.
high Agatston score >400, not to proceed with
coronary CTA if the calcium score exceeds 400
Magnetic resonance coronary angiography. This
technique is primarily a research tool.
Because of its simplicity and widespread availability,
treadmill or bicycle exercise testing, using 12-lead
ECG monitoring, remains a useful option
Vasospastic Angina
Patients with microvascular angina have angina with mostly
typical features although the duration of symptoms may be
prolonged and relation to exercise is somewhat inconsistent.
Often, these patients have abnormal results of stress tests.
Patients with vasospastic angina present with typically
located anginal pain, which occurs at rest but does notor
occurs only occasionallywith exertion (typically at night and
in the early morning hours). The ECG during vasospasm is
classically described as showing ST-elevation. Nitrates usually
relieve the pain within minutes. Angiographically, these
patients may show focal occlusive spasm (Prinzmetal's angina
or variant angina)
Pharmacological management
of SCAD
To obtain relief of angina symptoms the guidelines
advise:
Short-acting nitrates to provide immediate relief of angina
symptoms.
Lifestyle changes, regular exercise training and patient
education.
To prevent the occurrence of cardiovascular events
the guidelines advise:
To reduce the incidence of acute thrombotic events and the
development of ventricular dysfunction by
pharmacological or lifestyle interventions.
A combined pharmacological and revascularization strategy
in patients with severe lesions in coronary arteries
Anti-ischaemic drugs
Nitrates offer coronary arteriolar and venous
vasodilatation, and by the reduction of preload. For
acute effort angina short-acting nitrates as sublingual
nitroglycerin is the standard initial therapy.
In post-MI patient b-blockers achieved a 30% risk
reduction for CV death and MI. b-blockers may be the
rst line anti- anginal therapy in stable CAD patients
without contraindica- tions.
Calcium channel blockers reduce the peripheral
vascular resistance. Group of non-dihydropyridine ,
verapamil has a large range of approved indications,
including all varieties of angina
Event prevention
Antiplatelet in prevention of ischaemic events and
aspirin is the drug of choice. The use of antiplatelet
agents is associated with a higher bleeding risk.
Clopidogrel is a second-line treatment for aspirinintolerant CVD patients.
Prasugrel and ticagrelor are new P2Y12 antagonists that
achieve greater platelet inhibition, compared with
clopidogrel.
Dual antiplatelet therapy combining aspirin and a
thienopyridine is the standard of care for patients with
ACS
Platelet function testing in SCAD patients undergoing PCI
is not recommended as a routine.
SCAD patients should be treated with statin with a target of LDL-C <
1.8 mmol/l and/or >50% reduction
ACE inhibitors reduce total mortality, MI stroke and heart failure in
patients with co-existing hypertension, LVEF 40%, diabetes or
CKD. ARB treatment may be an alternative when ACE is not
tolerated.
Aldosterone blockade with spironolactone or eplerenone is
recommended in post-MI patients without signicant renal
dysfunction or hyperkalaemia, who are already receiving therapeutic
doses of an ACE inhibitor and a b-blocker, have an LVEF 40% and
have either diabetes or heart failure.
It is recommended in the rst line a b-blocker or a CCB to a shortacting nitrate.
Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery
disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.
Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery
disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003.
Revascularization
Bare metal stents (BMS) are associated with a
2030% rate of angiographic stenosis within 69
months after implantation.
Drug-eluting stents (DES) reduce the incidence
of restenosis and ischaemia-driven repeat
revascularization.
Coronary artery bypass surgery
When technically feasible, with an acceptable
level of risk and a good life expectancy,
revascularization is indicated in chronic
angina refractory to OMT
Revascularization Procedure
Diabetic patients
Need different risk factor management.
Older patients
High-risk group with higher mortality and higher rates of myocardial
infarction.
Usually undertreated, receiving less drugs.
Difficult diagnosis due to atypical symptoms.
Higher risk of complications during and after coronary revascularization.
Comorbidities/intolerance
Depending on comorbidities/tolerance, it is indicated to use second-line
therapies as rst-line treatment in selected patients.
Conclusion
ESC Guidelines highlighted two aims for the pharmacological management
of stable CAD patients: obtain relief of symptoms and prevent cardiovascular
events.
CAD patients should all receive aspirin and a statin, plus an ACE inhibitor
in case of comorbidities.
-blockers or CCBs should be prescribed as first-line treatment to reduce
angina.
Ivabradine and Trimetazidine (as well as long-acting nitrates, nicorandil and
ranolazine) are recommended second-line, in combination with first-line
treatment, in patients remaining symptomatic.
Physicians should consider
revascularization procedures.
optimal
medical
treatment
before