Population: Patients with CAD experiencing angina.

Organizations

ACCF/AHA/ACP/AATS/PCNA/SCAI/STS 2012, 2014, ACC/AHA/ASE/CHEST/SAEM/SCCT/SCMR 2021

Recommendations

–In patients with moderate to severe CAD presenting with new chest pain, perform risk stratification:

• Choose exercise treadmill test if the baseline ECG is normal, the patient can exercise, and the pretest likelihood of coronary disease is intermediate (10%–90%).

• If unable to perform an exercise treadmill and the pretest likelihood is >10%, choose either a nuclear myocardial perfusion imaging study (MPI) or exercise echocardiogram.

• Repeat exercise and imaging studies when there is a change in clinical status or if needed for exercise prescription.

• Consider coronary computed tomography angiogram (CTA) in patients with an intermediate pretest probability of CAD in whom symptoms persist despite prior normal testing, with equivocal stress tests, or in patients who cannot be studied otherwise. Coronary CTA is not indicated if known moderate or severe coronary calcification or in the presence of prior stents.

• Obtain an echocardiogram to assess resting LV function and valve disease in patients with suspected CAD, pathological Q waves, presence of HF, or ventricular arrhythmias.

–Treat patients who have stable coronary disease with:

• Lifestyle guidance (diet, weight loss, smoking cessation, and exercise education).

• Blood pressure control per guidelines.

• Associated risk factor assessment: Presence of chronic kidney disease and psychosocial factors such as depression, anxiety, and poor social support have been added to the classic risk factors.

• ASA 75–162 mg daily, moderate-dose statin.

–Treat chronic angina in CAD by either

• Increasing O₂ supply to heart muscle (nitrates and CCBs).

• Decreasing the muscles’ O₂ demand (BB, CCB, ranolazine, ivabradine).

• BB and CCB are first line. If these are contraindicated, poorly tolerated, or insufficient then long-acting nitrates and ranolazine can be used.

–Consider coronary angiography in patients who survive sudden cardiac death, who have high-risk noninvasive test results (large areas of silent ischemia are often associated with malignant ventricular arrhythmias) and in whom anginal symptoms cannot be controlled with optimal medical therapy.

Sources

–JACC. 2021;78(22):e187-e285.

–Circulation. 2020;141:e779-e806.

–Circulation. 2014;130(19):1749-1767.

–Circulation. 2012;126(25):3097-3137.