'Stable' CAD Reconsidered in New ESC Chronic Coronary Syndrome Guideline

September 01, 2019

Last year the European Society of Cardiology (ESC) introduced a new name for what has been known as stable coronary artery disease (CAD), one that brings the nomenclature more in line with contemporary understanding of its development, progression, and management.

Now the society has published its first guideline incorporating the new name, chronic coronary syndrome (CCS), which recognizes CAD as a "dynamic process" of atherosclerosis and altered arterial function "that can be modified by lifestyle, pharmacological therapies, and revascularization, which result in disease stabilization or regression," the report states.

"The term 'stable' was not, in our opinion, thought the best for describing different clinical situations where you have a chronic disease which is evolving and sometimes regressing," Juhani Knuuti, MD, University of Turku, Finland, told theheart.org | Medscape Cardiology.

The name CCS also sees the condition as a kind of out-of-hospital counterpart to the acute coronary syndromes (ACS).

Knuuti said the name change from stable CAD to CCS has, to his knowledge, been generally well received, although "not everybody likes it." He is one of two chairs of the task force charged with developing the CCS guidelines, with William Wijns, MD, PhD, National University of Ireland, Galway, as the other chair.

The document was published August 31 in the European Heart Journal as a prelude to its coverage at presentations this week here at ESC Congress 2019.

It defines six clinical scenarios that reflect the heterogeneous nature of CCS, each defined by its own set of diagnostic and therapeutic concerns, Knuuti said.

The scenarios are:

  • Suspected CAD with "stable" angina-like symptoms, with or without dyspnea

  • Suspected CAD with new-onset heart failure (HF) symptoms or left ventricular (LV) dysfunction

  • Asymptomatic or stabilized symptomatic within a year of an ACS episode or following coronary revascularization

  • Asymptomatic or symptomatic more than 1 year after the initial diagnosis or revascularization

  • Angina and suspected vasospastic or microvascular disease

  • Asymptomatic with CAD detected at screening

Although it may surprise some that the document includes sections on healthy lifestyle behaviors and other tenets of preventive cardiology, lifestyle choices continue to influence CAD progression in patients who already have the chronic disease, Knuuti said.

In many cases, doctors may be inclined to focus on drugs and other interventions for their patients with chronic disease and, as it progresses, may overlook "basic things like diet and exercise, which can have a major impact on clinical outcomes even if they have advanced disease."

Also new in the document are recommendations for antithrombotic therapy in patients with CAD  in sinus rhythm or in atrial fibrillation (AF), Knuuti observed. They include a IIa recommendation for the addition of a second antithrombotic drug to aspirin for secondary prevention in patients at high ischemic risk but low bleeding risk.

There are also new recommendations for antithrombotic therapy following coronary revascularization in patients with AF, including guidance on the timing of double and triple antithrombotic therapy.

The document puts new emphasis on percutaneous coronary intervention (PCI) guided by measurements of fractional flow reserve (FFR), following recent data suggesting that FFR-guided PCI can lower the risk for acute myocardial infarction (MI) compared to medical therapy in stable CAD, Knuuti said.

"Usually it has been very challenging to prove that PCI will have that kind of outcome. But this is known now, based on the combination of several prospective trials showing that the risk of MI goes down if you do FFR-guided PCI."

The new document assigns the recently introduced heart failure drug sacubitril/valsartan (Entresto, Novartis) to indications consistent with the ESC heart failure guidelines: that is, in heart failure with reduced ejection fraction not responsive to more conventional renin-angiotensin inhibitors and β-blockers.

Recommended lipid-modifying therapy in patients with CCS is consistent with the newly developed ESC guidelines on dyslipidemia management. And for patients with both CCS and diabetes, the document favors the use of glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter 2 inhibitors, with IA recommendations.

Other organizations affiliated with the ESC that contributed to the document, the report notes, include the Acute Cardiovascular Care Association (ACCA), Association of Cardiovascular Nursing & Allied Professions (ACNAP), European Association of Cardiovascular Imaging (EACVI), European Association of Preventive Cardiology (EAPC), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), and Heart Failure Association (HFA).

Eur Heart J. Published online August 31, 2019. Full text

European Society of Cardiology (ESC) Congress 2019.

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