Paradigm change for stable coronary disease in chronic coronary syndrome: Novelties in the guidelines of the European Society of Cardiologists from 2019

Although the English physician Heberden described angina pectoris (AP) two and a half centuries ago, our understanding of this syndrome, as a cause, an optimal diagnostic approach and treatment, continues to develop. The new guidelines of the European Society of Cardiology(ESC) from year 2019 brings, first of all, a paradigm shift for stable coronary artery disease (SCAD) to the comprehensive term chronic coronary syndromes (CCS), which essentially means that chronic coronary artery disease (CAD) has complex clinical scenarios and may have periods of instability, at any evolutionary stage. The results of the essential COURAGE study and the latest studies: ISCHEMIA, ORBITA and metha-analysis on CCS as well as the key messages of the European Guidelines for Diagnosis and Treatment of Chronic Coronary Syndromes (CCS) shed light on the issue of coronary heart disease. Chronic coronary artery disease (CCAD) has long stable periods but due to acute atherothrombotic events, erosion or rupture of atherosclerotic plaque can progress to some of the acute coronary syndromes (ACS). The disease is chronic, usually progressive and therefore serious even in asymptomatic stages. The dynamic nature of CAD is manifested in various clinical presentations, which we categorize into either acute or chronic coronary syndromes. The paradigm shift emphasizes the fact that the dynamic processes of accumulation in atherosclerotic plaques and functional alterations of the coronary circulation can be modified by lifestyle changes, pharmacological therapy and myocardial revascularization (MR), which lead to stabilization or regression of the disease but unfortunately not complete cure. Careful evaluation of the anamnesis, characterization of anginal and other symptoms and evaluation of risk factors and manifestations of previous cardiovascular diseases (CVD), as well as assessment of the adequacy of physical activity and exercise tolerance, are of cardinal importance. The current guide to CCS identifies 6 leading and most common clinical syndromes: 1. Patients with suspected CCS and stable angina pectoris and / or dyspnea on exertion; 2. Patients with newly developed heart failure (HF) or left ventricular dysfunction (LVD) and suspected CAD; 3. Asymptomatic and symptomatic patients with stabilized symptoms lasting less than one 1 year after ACS or recent myocardial revascularization (MR); 4. Asymptomatic and symptomatic patients more than 1 year after ACS or Mr; 5. Patients with AP and suspected vasospastic or microvascular disease; 6. Asymptomatic individuals in whom CAD was detected at screening. Each of these scenarios is classified as CCS and is a consequence of different evolutionary phases of chronic CAD, and has a different risk for future adverse cardiovascular (CV) events. Pre-test probability (PTP) of CAD, based on age, sex and quality of symptoms, has been revised and changed from the previous guide from year 2013. A new term has been introduced: Clinical probability of obstructive coronary artery disease (CPCAD) which includes both PTP and various risks factors of atherosclerotic CAD and serves to exclude or confirm the suspicion of CAD. The general methodological approach for initial diagnosis for patients with AP and suspected obstructive CAD involves 6 steps. STEP 1-Assessment of symptoms and signs to identify patients with possible unstable AP and other forms of ACS; STEP 2 is an assessment of the general condition and quality of life that decide on treatment planning; STEP 3 includes basic diagnostic procedures and assessment of left ventricular (LV) function of the heart; STEP 4 makes the determination of Pre-test and Clinical probability of obstructive CAD; STEP 5 is the selection of a diagnostic test by physical or pharmacological stress via ECG and imaging methods including MSCT coronary angiography (CTA) to establish the diagnosis of CAD. Finally, STEP 6 is the assessment of the risk of adverse CV events, especially mortality, and based on that, make definitive therapeutic decisions with invasive coronary angiography (ICA) and possible Mr. If obstructive CAD cannot be ruled out by clinical evaluation, either a noninvasive functional imaging test or anatomical imaging by CTA is performed as an initial test to exclude or confirm the diagnosis of CAD. Anatomical and functional assessment should be considered for a decision on RM, except in severe coronary stenosis> 90%. A high risk of adverse CV events identifies patients who would have great prognostic benefit from Mr, even if asymptomatic. The role of myocardial revascularization (MR) has been placed in the context of recent evidence relating to the prognostic role of percutaneous coronary interventions (PCI) or coronary artery bypass graft (CABG) in this low-risk population. Mr is reserved for patients where there is strong evidence to improve prognosis based on evidence of regional ischemia by perfusion imaging. Patients at high risk of mortality of 3% per year or more undergo coronary flow fractional reserve (FFR) or coronary flow reserve (CFR) due to perform Mr even if they have no symptoms. The application of a healthy lifestyle reduces the risk of subsequent adverse CV events and is part of adequate secondary prevention therapy. Regular vaccination against influenza is necessary for everyone with CCS. Optimal medical therapy (OMT): nonpharmacological and pharmacological therapy of CCS is given great attention as the main type of treatment of CCS, not Mr. The modern role of anti-ischemic (antianginal) drugs is emphasized: First lines - beta-blockers (BB) and calcium antagonists (CCB) with sublingual nitroglycerin, and Second lines - longacting nitrates (LAN), with newer options: ivabradine, nicorandil, trimethazidine, allopuronol, etc. Drugs that improve the prognosis of CCS are statins and acetylsalicylic acid (ASA) and other antiplatelet drugs and recently low dose rivaroxaban and additionally angiotensin converting enzyme inhibitors (ACEI) and again BB in specific indications. Anti-ischemic treatment must be tailored to the individual patient based on comorbidities, other concomitant therapies, expected tolerances and adherence, and patient preferences. The choice of anti-ischemic drugs for the treatment of CCS should be adjusted to the heart rhythm, blood pressure and heart function. BB and ACEI are recommended for patients with LVD or HF with reduced left ventricular ejection fraction (HFrEF). Antithrombotic therapy is a key part of secondary prevention in patients with CCS. Patients with previous acute myocardial infarction (AMI), who are at high risk of ischemic events and low risk of fatal bleeding, should consider long-term dual antiplatelet therapy with aspirin and either P2Y12 receptor inhibitor or a very low-dose rivaroxaban, unless there is an indication for oral anticoagulation, is atrial fibrillation (AF). Proton pump inhibitors are recommended in patients receiving only aspirin or a combination of antithrombotic therapy who are at risk of gastrointestinal bleeding. Statins are recommended for all patients with CCS, regardless of LDL level. ACEIs (or angiotensin receptor blockers, ARBs) are recommended in the presence of SI, diabetes, and hypertension and should be considered in patients at high risk for adverse events.