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PekkaPorela

Chronic Coronary Syndrome (Coronary Heart Disease)

  • Chronic coronary syndrome (CCS) encompasses asymptomatic coronary atherosclerosis, symptomatic coronary heart disease as well as the disease following invasive treatment or acute coronary syndrome.
  • If obstructive coronary heart disease (CHD) is suspected:
  • The clinical pretest probability of CHD can be assessed based on the patient's age and sex and the type of chest pain, as well as on the number of risk factors (see Central Illustration in http://www.sciencedirect.com/science/article/pii/S0735109720373678).
  • The probability of developing CHD/myocardial infarction or dying of arterial disease can be estimated using various risk calculators (e.g. SCORE 2 http://www.escardio.org/Education/Practice-Tools/CVD-prevention-toolbox/HeartScore and relevant local tools).
  • If the pretest probability of CHD is very low (< 5%), other possible causes of chest pain should be individually assessed.
    • Provide instruction and guidance concerning established risk factors.
    • If difficult symptoms persist without any detectable cause, consultation of a specialist should be considered.
  • If the pretest probability of CHD is low (6-15%), a prognostically significant CHD is only rarely found and diagnostic examinations should be utilized with consideration.
  • If the pretest probability of CHD is increased (> 15%), the benefit of diagnostic examinations is at its highest.
  • When suspecting obstructive CHD, diagnostic examinations include coronary CT angiography, (invasive) coronary angiography and demonstration of ischaemia by an exercise test or physiological imaging. The most suitable examination is selected depending on the individual situation; see picture Investigation Strategy Guidelines for a Patient with Chest Painwhen Suspecting Chronic Obstructive Coronary Heart Disease (Chd).
  • Prevention is essential in the treatment of CCS, utilizing both lifestyle methods and, as necessary, prognosis-improving medication.
  • The treatment of CHD consists of careful reduction of risk factors as well as symptom management by drug therapy and, if necessary, by invasive interventions.
    • Optimal drug therapy combined with lifestyle changes is crucial for the prognosis.
    • If symptoms of CHD persist despite optimal drug therapy, the patient should be referred for assessment within specialized care to assess the need for invasive interventions, if such assessment has not yet been performed or if the symptoms have increased during drug therapy.

Causes and clinical manifestation

Risk factors of CHD

Classic risk factorsOthers
Increased blood LDL cholesterol concentrationLow blood HDL cholesterol concentration
SmokingIncreased blood triglyceride concentration
HypertensionInsulin resistance
DiabetesObesity
AgePhysical inactivity
Genetic factors (family history) http://www.dynamed.com/condition/coronary-artery-disease-cad#HISTORY_OF_PRESENT_ILLNESS__HPI___ANC_1475611144Psychological factors
Factors associated with blood clotting and flow
Nutritional factors
Inflammation
  • Obstructive atherosclerotic plaques, endothelial dysfunction, microcirculatory dysfunction and coronary artery spasm reduce blood flow in the coronary arteries thus reducing the oxygen supply to the myocardium, which, in turn, produces the typical symptom of CHD, chest pain (angina pectoris).
  • Other symptoms include exertional dyspnoea, fatigue and nausea on exertion.
  • For differential diagnosis of chest pain, see article Acute coronary syndrome and myocardial infarction, table Acute Coronary Syndrome and Myocardial Infarction).

Symptoms and clinical diagnosis

  • Stable angina is a clinical diagnosis which indicates the repeated occurrence of chest pain, induced by an exercise level typical for the patient.
  • The pain is relieved by rest and shows no great daily variation, occurring at predictable levels of exercise, i.e. when the rate-pressure product exceeds the patient's personal threshold.
  • Typical angina pain
    1. starts gradually during exertion, more quickly if the exertion is sudden, and becomes worse as the exertion continues. Sometimes continuing the exertion does not increase the pain but instead brings about relief (the walk-through angina phenomenon).
      • Emotional stress may also provoke pain as the rate-pressure product increases.
    2. is felt across the chest as widespread constrictive, heavy or tight pain that may make the person slow down or stop
      • The pain may also radiate to the neck, jaw, arms, epigastric region or between the shoulder blades. The sites of radiation usually stay constant.
    3. is relieved in a few minutes by rest or glyceryl trinitrate.
  • If the pain meets all three characteristics, it is highly probable that the patient has typical angina.
  • If the pain only meets two of the above characteristics, the patient has atypical angina.
  • Symptom of dyspnoea is equal to atypical angina as regards the pretest probability.
  • If the pain only meets one or none of the above typical characteristics, the patient is likely to have non-cardiac chest pain.
    • Characteristics suggestive of non-cardiac origin include:
      • The patient's exercise tolerance is usually normal
      • Pain occurs at rest and is sharp or stabbing in nature and may last for several hours or even days
      • Tthe location of pain may vary, and the pain sites are sometimes palpable
      • Pain is associated with chest wall movements
      • Glyceryl trinitrate does not help or takes more than 10 minutes to bring pain relief.
  • Grading of angina pectoris (CCS, Canadian Cardiac Society): see table T2.

Grading of angina pectoris (Canadian Cardiac Society)

GradeActivity provoking chest painLevel of exercise
CCS grade 1Strenuous exertion only120 W or more
CCS grade 2Walking rapidly or uphill80-120 W
CCS grade 3Walking at normal pace on the level20-80 W
CCS grade 4Rest, talking or dressingLess than 20 W

Workup

  • Examinations in primary health care:
    • Clinical examination (status)
    • 12-lead ECG
    • Laboratory tests
    • Chest X-ray (differential diagnosis), as necessary
    • depending on regional procedures (chains of care), additionally echocardiography.
  • Further investigations include clinical exercise test Exercise Stress Test, invasive coronary angiography, myocardial perfusion scan, exercise echocardiography or coronary CT angiography. See picture Investigation Strategy Guidelines for a Patient with Chest Painwhen Suspecting Chronic Obstructive Coronary Heart Disease (Chd)..
    • Further investigations are mainly carried out in specialized care.
    • Local practices affect the selection of further investigations.
    • Coronary CT angiography is selected when the pretest probability is low.
    • Invasive coronary angiography is selected as the first-line examination when the pretest probability is high and it is likely that the examination leads to invasive treatment.

Clinical findings

  • Height and weight
  • Auscultation of the heart, lungs and arterial trunks, palpation of peripheral pulses
    • A patient with CHD may have concomitant carotid artery disease and/or arteriosclerosis.
  • Blood pressure measurement

12-lead resting ECG

  • The ECG is usually normal at rest.
  • Reversible ST segment depression that appears during pain and disappears as the pain subsides is highly suggestive of CHD.
  • A Q wave, signifying a prior myocardial infarction (MI), is suggestive of CHD. For Q wave criteria, see Acute coronary syndrome and myocardial infarction, table Acute Coronary Syndrome and Myocardial Infarction).

Laboratory tests

  • Basic blood count with platelet count, sodium, potassium, creatinine
  • Cholesterol, HDL cholesterol, LDL cholesterol, triglycerides
  • Fasting blood glucose and HbA1c and, as necessary, 2-hour oral glucose tolerance test
  • ALT, no later than before statin therapy is started
  • ProBNP if heart failure is suspected

Imaging studies

  • Chest x-ray
    • Differential diagnosis
  • Echocardiography Echocardiography as an Outpatient Procedure
    • Done to examine systolic (ejection fraction) and diastolic left ventricular function and the presence of any disturbance of septal motion.
    • The findings are often normal but the examination gives even more information on the function of the heart, including the valves (murmurs).

Further investigations

  • In addition to pharmacotherapy, invasive investigations (coronary angiography) should be considered if
    • the patient's exercise tolerance and quality of life are clearly reduced due to chest pain despite optimal drug therapy
    • signs of myocardial ischaemia are evident during an exercise test at a low exercise workload (< 100 W) or a low heart rate (< 120 bpm) or
    • signs of left ventricular dysfunction are present.
  • Angiography, see Diagnostic Coronary Angiography
  • The exercise stress test provides information on the patient's performance and ischaemic threshold; see Exercise Stress Test.
    • Suitable for patient with known CCS.
  • Myocardial perfusion scan
    • The sensitivity is higher than that of an exercise test but the specificity is roughly the same.
    • Can be performed using either physical or pharmacologic stress.
    • May be carried out if
      • an exercise test is not diagnostic but CHD is very likely
      • the patient is physically handicapped
  • Exercise echocardiography
    • Ischaemia induces myocardial wall motion abnormalities, which can be detected by echocardiography during exercise compared with the result of resting echocardiography.
    • The test is more sensitive and more accurate than an exercise test but requires an experienced operator.
    • May be considered when ECG abnormalities interfere with the interpretation of an exercise test.
  • Coronary CT angiography

Special features in the diagnosis of CHD in women

  • In women, CHD is diagnosed on average 5-10 years later than in men.
    • The incidence of CHD increases noticeably after menopause.
    • By the age of 70-79 years, the gender differences in both the incidence and the mortality due to CHD have levelled out.
  • The risk factors for CHD are the same for both sexes.
    • Women who develop CHD before menopause have more risk factors than those who develop the disease at a later age.
    • If CHD develops in a middle-aged woman she is likely to have several risk factors: smoking, dyslipidaemia, diabetes, hypertension.
  • It is more difficult to diagnose CHD in women than in men.
    • In women, the chest pain is more often atypical.
    • It is still particularly important to investigate the symptom carefully even if this takes more time.
    • After menopause, the diagnostic accuracy of symptoms improves. In women aged over 65-70 years, the diagnostic accuracy of chest pain is similar to that in men.
    • The predictive value of exercise testing Exercise Stress Test is lower in women. This is due to the greater number of false-positive test results in premenopausal women.
    • Coronary CT angiography is often the recommended first-line examination; see Coronary Computed Tomography Angiography (Ccta)

Management of CHD risk factors Effect of Dietary Interventions on Diet and Cardiovascular Risk Factors, Multiple Risk Factor Interventions for Primary Prevention of Coronary Heart Disease, Low Glycaemic Index Diets for Cardiovascular Disease, Reduced Saturated Fat for Preventing Cardiovascular Disease, Psychological Interventions for Coronary Heart Disease, Patient Education in the Management of Coronary Heart Disease, Mediterranean-Style Diet for the Primary and Secondary Prevention of Cardiovascular Disease, Promoting Patient Utilisation of Cardiac Rehabilitation, Music for Coronary Heart Disease Patients, Home-Based Versus Centre-Based Cardiac Rehabilitation, Yoga for Cardiovascular Disease Prevention, Homocysteine Lowering Interventions for Preventing Cardiovascular Events, Omega-3 Fatty Acids for Prevention of Cardiovascular Disease, Hormone Therapy for Preventing Cardiovascular Disease in Post-Menopausal Women

Pharmacotherapy: aims and modes of action

  • If suspicion of symptomatic CHD arises, aspirin, a statin and a glyceryl trinitrate product for the symptoms can be started at the very first visit and, additionally, a beta-blocker if sufficient laboratory tests have been performed. The effect of the treatment is checked in a follow-up visit.

Medication improving the prognosisClopidogrel Plus Aspirin Vs Aspirin Alone for Preventing Cardiovascular Events, Intensive Versus Moderate Statin Therapy, Efficacy and Safety of Cholesterol Lowering by Statins

Symptom-relieving medication

Revascularization (PCI and CABG)

  • Coronary artery revascularization may be performed either by angioplasty (PCI) or by coronary artery bypass graft surgery (CABG) http://www.dynamed.com/management/management-of-stable-angina#EFFICACY_OF_CORONARY_ARTERY_BYPASS_GRAFT.
    • Coronary artery patency is sustained better with stenting than with balloon dilatation (i.e. percutaneous transluminal coronary angioplasty, PTCA) alone.
    • Drug-eluting stents are impregnated with a cell growth inhibitor that is slowly released into the surrounding tissues over several months. Drug-eluting stents have clearly reduced the frequency of restenosis compared with metal stents or PTCA alone, but drug-eluting stents may be associated with development of thrombosis.
    • A drug-eluting balloon releases a cell growth inhibitor during balloon angioplasty of an occluded coronary artery.
  • The decision regarding the need for revascularization and the preferred method (PCI/CABG) is based not only on the severity, location and number of coronary occlusions but also on the assessment of left ventricular function, potential valvular diseases, severity of symptoms and comorbidity (diabetes, renal disease) and risks related to surgery.
  • The advantages of PCI include the short duration of treatment, shorter recovery period and faster return back to work. The more frequent need for later repeat revascularization compared with CABG may be considered a disadvantage.
    • CABG is the recommended treatment method especially for patients with diabetes combined with multivessel disease.
  • In outpatient care, after revascularization it is most important to monitor the patient's state and risk factors and to use pharmacological treatment improving the prognosis, according to the applicable guidelines. Symptom-relieving drug therapy can often be at least reduced.

References

  • Krooninen sepelvaltimo-oireyhtymä [Chronic coronary syndrome]. A Current Care Guideline. Working group appointed by the Finnish Medical Society Duodecim and the Finnish Cardiac Society. Helsinki: the Finnish Medical Society Duodecim, 2022. (in Finnish) http://www.kaypahoito.fi/hoi50102
  • Knuuti J, Wijns W, Saraste A et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020;41(3):407-477. [PubMed]
  • Winther S, Schmidt SE, Mayrhofer T et al. Incorporating Coronary Calcification Into Pre-Test Assessment of the Likelihood of Coronary Artery Disease. J Am Coll Cardiol 2020;76(21):2421-2432. [PubMed]
  • SCOT-HEART Investigators., Newby DE, Adamson PD et al. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. N Engl J Med 2018;379(10):924-933. [PubMed]
  • McNeil JJ, Nelson MR, Woods RL et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med 2018;379(16):1519-1528. [PubMed]

Evidence Summaries