Chronic Coronary

Syndrome
Introduction

 CAD is a pathological process characterized by atherosclerotic plaque

accumulation in the epicardial arteries, whether obstructive or non
obstructive
 Clinical Presentation : ACS & CCS
 CCS are defined by the different evolutionary phases of CAD, excluding
situations in which an acute coronary artery thrombosis dominates the
clinical presentation (i.e. ACS).
Clinical Scenario

1. Suspected CAD and stable Anginal Symptoms and/or dyspnoea

2. New onset of Heart Failure or left Ventricular dysfunction and suspected CAD
3. Asymptomatic and Symptomatic patients with stabilized symptoms < 1 year
after ACS / recent vascularization
4. Asymptomatic and Symptomatic patients > 1 year after initial diagnosis or
revascularization
5. Angina and suspected vasospastic or microvascular disease
6. Asymptomatic subjects in whom CAD is detected at screening
Patients with Angina and/or Dyspnoea,
and Suspected Coronary Artery Disease
Basic Assesment, Diagnosis and Risk Assessment
 Symptoms and Sign
History

CVD manifestation
Risk factors (family history of
CVD, dyslipidemia, diabetes,
hypertension, smoking, other
lifestyle factor
Unstable Angina
 Rest Angina for prolonged period (>20 menit)
 New onset angina
 Crescendo Angina

• ACS Guidelines
Symptoms and Sign
Basic Assesment, Diagnosis and Risk Assessment
Step 3 : Resting ECG, Biochemistry, Chest X-ray,
Echocardiography
Resting ECG
Basic Assesment, Diagnosis and Risk Assessment
Pre test Probability
Basic Assesment, Diagnosis and Risk Assessment
Appropriate testing

Functional Non Invasive Anatomical Non Invasive

 ECG • Coronary CTA
 Stress CMR/Echocardigraphy
 Perfusion changes Single Photon
Emission CT (SPECT), Positron
emission tomography (PET), myocardial
contrast echocardiography
Lifestyle Management
Pharmacological Management
Anti-ischaemic Drug
Event Prevention
 Nitrat
• Anti platelet
 Beta blocker
 CCB • Anti coagulant
 Ivabradin • Anti coagulant in AF
 Nicorandil • PPI
 Ranolazine
• Cardiac surgery and
 Trimetazidine antithrombotic therapy
• Non-cardiac surgery and
antithrombotic therapy
Revascularization

 Indication : CCS patients who receive Guideline-recommemnded optimal medical

therapy and continue to be symptomatic and/or in whom revascularization may
ameliorate prognosis
 Options : PCI or CABG
Decision tree for patients undergoing
invasive coronary angiography. Decisions
for revascularization by percutaneous
coronary intervention or coronary artery
bypass grafting are based on clinical
presentation (symptoms present or
absent), and prior documentation of
ischaemia (present or absent). In the
absence of prior documentation of
ischaemia, indications for
revascularization depend on invasive
evaluation of stenosis severity or
prognostic indications. Patients with no
symptoms and ischaemia include
candidates for transcatheter aortic valve
implantation, valve, and other surgery.
CAD = coronary artery disease; FFR =
fractional flow reserve; iwFR =
instantaneous wave-free ratio; LV = left
ventricle; LVEF = left ventricular ejection
fraction; MVD= multivessel disease.
Patients with New Onset Heart Failure or
Reduced Left Ventricular Function
 Patients with symptomatic HF should be managed clinically
according to the 2016 ESC heart failure Guidelines
 History : assessment of symptoms suggestive of HF, especially
exercise intolerance and dyspnoea on exertion. All major past events
related to CAD including MI and revascularization procedures are
recorded, as well as all major cardiovascular comorbidity requiring
treatment such as AF, hypertension, or valvular dysfunction, and
non-cardiovascular comorbidity such as CKD, diabetes, anaemia, or
cancer. Current medical therapy, adherence, and tolerance should be
reviewed.
 Physical examination : nutritional status, biological age, cognitive
ability. Recorded physical signs include heart rate, heart rhythm,
supine BP, murmurs suggestive of aortic stenosis or mitral
insufficiency, signs of pulmonary congestion with basal rales or
pleural effusion, signs of systemic congestion with dependant
oedema, hepatomegaly, and elevated jugular venous pressure.
 Routine ECG
 Imaging : echocardiography with Doppler, X-ray, coronary CTA
 Laboratory : natriuretic Peptide
Patients with A Long Standing Diagnosis
of Chronic Coronary Syndromes
Angina Without Obstructive Disease in
the Epicardial Coronary Arteries
 Microvascular Angina  exercise related angina, evidence of ischemia in non
invasive test, no stenoses or mild to moderate stenoses (40-60%) revealed by ICA
or CTA  BB, ACEI, statin, lifestyle changes
 Vasospastic Angina  anginal symptoms predominantly at rest with maintained
effort tolerance. Likelihood increases if attacks follow circadian pattern, more
episodes at night and in the early morning hour  CCB & LAN