Coronary Revascularization and Long-Term Survivorship in Chronic Coronary Syndrome

Figure 1. Time trends in mortality attributable to acute coronary syndrome (classified as acute myocardial infarction) and chronic coronary syndrome (classified as other ischemic heart disease) between 1980 and 2018, and main breakthroughs and research data in coronary revascularization and medical therapy during the last century. Data provided by the National Statistics Institute (I.N.E.) in Spain [56]. After the expansion of PCI in STEMI, a marked reduction in mortality was noted in acute myocardial infarction patients. This trend was not evident in patients with chronic coronary syndrome despite the widespread availability and use of CABG and PCI. Different groups of pharmacological therapies with beneficial effects on cardiovascular mortality have been incorporated into clinical practice during recent decades, and thus the “optimal medical treatment” has been improving over time. Abbreviations: ASA, Acetylsalicylic acid; BMS, Bare-metal stent; CABG, Coronary artery bypass grafting; DES, Drug-eluting stent; PCI, Percutaneous coronary intervention; RAAS, Renin–angiotensin–aldosterone system; STEMI, ST-segment elevation acute myocardial infarction.

Figure 2. Effect of stress CMR-related revascularization on all-cause mortality in a large real-life registry of patients with known or suspected CCS. Adapted from Marcos-Garces et al. [62] following the STM Permissions Guidelines (2014). Results derived from a large registry of patients with known or suspected CCS undergoing stress CMR. In non-revascularized patients, the risk of all-cause mortality increased in parallel with ischemic burden (number of segments with inducible perfusion defects on stress first-pass perfusion) but the opposite trend was observed in revascularized patients, with lines crossing at five ischemic segments. Shaded areas correspond to patient profiles that were “probably” not included in the ISCHEMIA trial. Abbreviations: CCS, Chronic coronary syndrome; CMR, Cardiac magnetic resonance.

Figure 3. Comprehensive management of chronic coronary syndrome. Lifestyle changes (if needed) and guideline-directed medical treatment must be implemented; patient preferences have to be carefully considered. A comprehensive assessment of symptoms, clinical characteristics of patients, LVEF, and of the anatomical and/or physiological repercussion of coronary lesions will be needed to appropriately guide the use of revascularization in CCS. Abbreviations: CCS, Canadian Cardiovascular Society angina score; CMR, Cardiac magnetic resonance; FFR, Fractional flow reserve; LAD, Left anterior descending artery; LGE, Late gadolinium enhancement; LMCA, Left main coronary artery; LVEF, Left ventricular ejection fraction; QoL, Quality of life; SPECT, Single-photon emission computed tomography; PD, Perfusion defect; PET, Positron emission tomography.

Figure 4. Patient profiles in chronic coronary syndrome to guide a revascularization strategy. Based on symptoms, LVEF, and the anatomical and/or physiological repercussion of coronary lesions, three patient profiles can be established. In patient profiles 1 (“low-risk”, medical management first) and 3 (“high-risk”, low threshold for revascularization), decision-making is relatively easy. In patient profile 2 (“intermediate-risk”, think twice to revascularize), factors depicted in Figure 3 have to be cautiously considered. Abbreviations: CMR, Cardiac magnetic resonance; LAD, Left anterior descending artery; LGE, Late gadolinium enhancement; LMCA, Left main coronary artery; LVEF, Left ventricular ejection fraction; PD, Perfusion defect.