STABLE CORONARY

ARTERY DISEASE

Prof. Doina Dimulescu

FESC
Clinica de Cardiologie SUU Elias
Bucuresti

Stable Coronary Artery Disease

Epidemiology

Annual incidence 1% for males 45-65

y
Steep increase with age 4% in
population of 75-84 y
Decrease in mortality rates although
prevalence did not decrease
(improved prognosis)
Missing data on vasospastic and
microvascular angina (clinical data:
2/3 of stable angina pts have no

Eur Heart J 2013

Diagnostic and Prognostic Evaluation of

the Patient with Suspected SCAD

Step 1: clinical assessment of pre-test

probability of the presence of CAD (PTP)
Step 2: non-invasive testing to establish
the presence of SCAD in patients with
intermediate probability of SCAD
Step 3:optimal medical therapy (OMT) and
risk stratification (usually non-invasive) to
select patients who benefit from invasive
investigation and revascularization

Diagnostic Assessment in SCAD

Traditional Classification of Chest Pain

Eur Heart J 2013

ESC Congress 2013

ESC Congress 2013

Bhatt DL et al JAMA 2006;295:180-189

Clinical Pre-test Probabilities in Patients

With SCAD

Eur Heart J 2013

Classification of Angina Severity according

to Canadian Cardiovascular Society

Eur Heart J 2013

Blood Tests in Assessment of Known or

Suspected SCAD to Optimize Medical Therapy

Eur Heart J 2013

The Ischemic Cascade

Resting ECG for Initial Diagnostic

Assessment of SCAD

Eur Heart J 2013

Echocardiography in SCAD

Eur Heart J 2013

Ambulatory ECG Monitoring for Initial

Diagnostic Assessment in SCAD

Eur Heart J 2013

Investigation in patients with

Suspected Coronary Microvascular
Angina

Eur Heart J 2013

Characteristics of Tests Commonly

Used to Diagnose SCAD (and available
in Romania)

Dobutamine Echo Stress-testing

Zamorano J, The ESC Textbook of

Cardiovascular Imaging, Springer 2010

SPECT Stress Testing

Inducible Ischemia VS Myocardial Infarction

Zamorano J, The ESC Textbook of

Cardiovascular Imaging, Springer 2010

Coronary MSCT

Zamorano J, The ESC Textbook of

Cardiovascular Imaging, Springer 2010

MRI Stress Testing with Dobutamine

Zamorano J, The ESC Textbook of

Cardiovascular Imaging, Springer 20

Costs of Cardiac Imaging Procedures

relative to Echo

Sensitivity and specificity of exercise

stress test and immaging stress tests

Exercise ECG for Initial Diagnosis and

Pharmacologic Imaging Stress Tests

Eur Heart J 2013

Coronary MSCT for the Diagnosis of SCAD

Eur Heart J 2013

The Risk Assessment

Strategy

Risk
Risk
Risk
Risk

stratification
stratification
stratification
stratification

by
by
by
by

clinical evaluation
ventricular function
response to stress testing
coronary anatomy

Low event rate annual mortality<1%

Intermediate event rate annual mortality >1%
and<3%
High event rate annual mortality >3%

ESC Congress 2013

ESC Congress 2013

Rates of MI and Cardiac Death According to

Severity of Myocardial Perfusion
Abnormalities and LVSD

Risk stratification
Definitions for Risk for Various Non-invasiveTest
Modalities

Risk Stratification by Coronary Anatomy

Patients with LM severe disease have a poor

prognosis on medical treatment
Three vessel disease and >95% proximal
LAD 59% survival at 5y
Medically treated patients survival at 12y in
CASS Registry

91%
74%
59%
50%

normal coronary arteries at invasive angio

one vessel disease
two vessel disease
three vessel disease

Management Based on Risk Determination for

Prognosis in Patients with Suspected SCAD

Nitrates mechanism of
action

Beta receptors

Pharmacologic properties of
BB

Beta blockers in SCAD

Calcium channel blockers

Dihydropyridine, diltiazem, verapamil

Site of Action of Current and Emerging

Antithrombotic Drugs

Antman E, Cardiovascular Therapeutics ELSEV

2013

Statin therapy

ACEIs in SCAD

Beta-blockers post-MI and in SCAD

(REACH Registry)

Revascularization vs optimal medical

therapy in SCAD