Chronic coronary syndromes in Europe: there is much room for improvement

This editorial refers to ‘Impact of chronic coronary syndromes on cardiovascular hospitalization and mortality: the ESC-EORP CICD-LT registry’ by M. Kerneis et al., https://doi.org/10.1093/eurjpc/zwac089. In 2019, European Society of Cardiology (ESC) guidelines introduced a nomenclature change from stable coronary artery disease (CAD) to chronic coronary syndromes (CCSs), which were defined by the different evolutionary phases of CAD, excluding situations in which an acute coronary artery thrombosis dominates the clinical presentation (i.e. acute coronary syndromes).1 CCS may include very different clinical scenarios: from patients with suspected CAD and stable anginal symptoms and/or dyspnoea to patients with recent revascularizations or asymptomatic subjects in whom CAD was detected at screening. Recent trials on patients with CCS, such as the Cardiovascular OutcoMes for People Using Anticoagulation StrategieS (COMPASS) trial2 or the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHAEMIA) trial,3 reported low rates of adverse events, probably due to progress in percutaneous coronary intervention techniques, pharmacology and secondary lifestyle prevention. On the other hand, international surveys, such as European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) V,4 demonstrated that risk factor control did not reach guideline-recommended targets in a majority of patients with CCS. In the present issue of the Journal, Kerneis et al.5 present data on a large European registry of CCS patients (ESC EURObservational Research Programme (EORP) Chronic Ischemic Cardiovascular Disease Long-Term (CICD-LT) registry). The registry included 9174 patients across 154 centres from 20 countries between 2015 and 2018; 1-year follow-up data were available for 6655 (72.5%) patients. Median age of patients was 67 years, 73% were male, and 30.2% had diabetes mellitus. Overall, 2.5% died during the first year of follow-up, mainly due to cardiovascular causes (1.5%). Women had a significantly higher rate of cardiovascular mortality compared to men (2.0% vs 1.3%, P value = 0.02). 27.1% were hospitalized at least one time during 1 year, mostly for cardiovascular reasons (20.6%). CAD-related hospitalization was the main cause for hospitalization (11.2%), followed by heart failure (4.7%) and vascular causes (2.0%). In a Cox regression analysis, comorbidities, such as left ventricular ejection fraction (LVEF) < 40%, stroke or liver disease, were independent determinants for the occurrence of cardiovascular death or hospitalization. The data show that despite relatively low mortality, about one fourth of the patients with CCS had at least one hospitalization during 1-year follow-up, in particular those with comorbidities. It is therefore crucial to consider coexisting illnesses in the management of CCS, because comorbidities are frequent in this population and predict event rates. In this European registry, significant regional differences could be observed with respect to mortality, hospitalization rates and cardiovascular risk factor control. Although selection bias cannot completely be excluded, data suggest that homogenization of treatment of CCS in Europe is still a challenge. An important result of the paper was that global risk factor control was not sufficient. At 1 year, two thirds of the documented patients with CCS had LDL cholesterol levels above the guideline-recommended targets; more than one third had body mass index ≥ 30 kg/m2. The vast majority of patients (83.3%) had at least one of the parameters LDL cholesterol, blood glucose or blood pressure not at target. These ‘real-world’ findings reveal a gap between clinical practice of secondary prevention and international guidelines.6 Even the major limitation of the study—the rate of 27.4% missing data at follow-up after 1 year—demonstrates that clinical follow-up of patients with CCS (including repetitive control of modifiable risk factors) is suboptimal. Different strategies have been suggested by prevention experts to improve risk factor control in patients with CAD:6,7 Educational programmes and financial incentives may increase preventive awareness of physicians who are treating patients with CCS.7 In addition, implementation of prevention programmes based on non-physician coworkers is promising. Numerous studies demonstrated that nurse-based prevention programmes improve long-term risk factor control with sustainable lifestyle modifications and better medical adherence.8–10 It is crucial to adapt preventive strategies to special patient subgroups: Kerneis et al.5 reported that in the CICD-LT registry, women and elderly were more likely to have uncontrolled risk factors compared with men and patients <75 years old. On the other hand, Osteresch et al.10 found that long-term prevention is most challenging in young patients with CAD. It seems to be important that various preventive offers are available to be used in different subgroups and following patients’ preferences. Besides repetitive personal contacts of physicians and non-physician coworkers with patients, digital health offers new opportunities for preventive care. Ongoing studies investigate if new technologies, such as apps, wearables, e-learning and e-mail communications, are effective to improve long-term secondary prevention in patients with CAD.7,11 The ‘real-world’ data of the CICD-LT registry help us to overview the current situation of patients with CCS in Europe. Unfortunately, it also informs us that risk factor control in this population is still insufficient and there is much room for improvement and implementation of more effective preventive strategies.