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European guidelines onthe management of

stable coronary arterydisease

Dr Nikko Nugraha

ESC2013


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These guidelines should be applied topatients suspected coronary artery

disease (SCAD)


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Stable coronary artery disease

SCAD characterized by episodes of reversiblemyocardial demand/supply mismatch, related toischaemia or hypoxia, inducible by exercise,emotion or other stress, or spontaneously

he prevalence ! to "# in $omen aged %!&'%

years to ()&(*# in $omen aged '!&+% and % to"# in men aged %!&'% years to (*&(%# inmen aged '!&+%

mortality rates (* to *%#, incidence of cardiac

death bet$een )' and (%# and of non-fatalmyocardial infarction .01 2 )'# and *"#


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Symptoms and Signs

he characteristics of discomfort caused bymyocardial ischaemia is usually located in thechest, near the sternum, but may be feltany$here from the epigastrium to the lo$er 3a$

or teeth, bet$een the shoulder blades or in eitherarm to the $rist and 4ngers

described as pressure, tightness or heaviness5sometimes strangling, constricting or burning

he diagnosis and assessment of SCAD involvesclinical evaluation, including biochemical riskfactors and speci4c cardiac investigations


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Non-invasive cardiacinvestigations


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Three maor steps used fordecision-ma!ing


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"rinciples of diagnostictesting


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Stress testing for diagnosingischaemia

6lectrocardiogram exercise testing he maindiagnostic 6C7 abnormality during 6C7 exercisetesting consists of a horizontal or do$n-sloping S-

segment depression )( m8, persisting for at least

))'&))+ s after the 9-point, in one or more 6C7leads

he main value of exercise 6C7 testing is in patients$ith normal resting 6C7s

0nconclusive exercise 6C7s are common and in these

patients an alternative non-invasive imaging test often$ith pharmacological stress should be selected 0npatients at lo$ intermediate pre-test probability,

coronary CA is another option


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Stress imaging


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yocardial perfusion scintigraphy .S:6C/:612echnetium ;;m .;;mc1 radiopharmaceuticalsare the most commonly used tracers, employed$ith single photon emission computed

tomography .S:6C1 in association $ith asymptom-limited exercise test on either abicycle ergometer or a treadmill

Stress cardiac magnetic resonance2 Cues @ccasional side- eects include oral,intestinal and perianal ulceration

rimetazidine is an anti-ischaemic metabolic modulatorrimetazidine added to beta-blockade improved eort-in- ducedmyocardial ischaemia


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Event prevention

Antiplatelet in prevention of ischaemic events andaspirin is the drug of choice he use of antiplateletagents is associated $ith a higher bleeding risk

Clopidogrel is a second-line treatment for aspirin-intolerant C8D patients

:rasugrel and ticagrelor are ne$ :*I(* antagonists thatachieve greater platelet inhibition, compared $ithclopidogrel

Dual antiplatelet therapy combining aspirin and athienopyridine is the standard of care for patients $ith

ACS :latelet function testing in SCAD patients undergoing :C0

is not recommended as a routine


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SCAD patients should be treated $ith statin $ith a target of D-C J

(+ mmol/l and/or =!)# reduction AC6 inhibitors reduce total mortality, 0 stroke and heart failure in

patients $ith co-existing hypertension, 86F %)#, diabetes orCKD A


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Adding ivabradine 7.5 mg twice daily to atenolol therapy gave better control of heart rate and

anginal symptoms.

In 1507 patients with prior angina enrolled in the MorbidityMortality !val"ation of the If Inhibitor

Ivabradine in #atients $ith %oronary Artery &isease and 'eft (entric"lar &ysf"nction

)*!A+,I-+' trial/ ivabradine reduced the composite primary end point of CV death,

hospitalization with MI and !, and reduced hospitalization for MI. ,he effect was

predominant in patients with a heart rate 70 bpm.

Ivabradine is thus an effective anti"anginal agent, alone or in combination with #"bloc$ers .

Ne& ESC guidelines and$vabradine

Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coona! ate! disease" #he #as$ %oce on the management of stable coona! ate!

disease of the Euo&ean Societ! of Cadiolog!. Eur Heart J. 2013'3()3*+"2(-3003.

Ne& ESC guidelines and


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Ne& ESC guidelines andTrimeta+idine

Trimetazidine is an anti-ischemic metabolic modulator, with similar anti-

anginal efficacy to propranolol in doses of 20 mg thrice daily.

Trimetazidine (35 mg twice daily) added to -blockade (atenolol)improved effort-induced myocardial ischemia, as re!iewed by the E"# in

June 20$2.

%n diabetic persons Trimetazidine improved !b"#c and glycemia, while

increasing forearm glucose u&ta'e.

Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coona! ate! disease" #he #as$ %oce on the management of stable coona! ate!

disease of the Euo&ean Societ! of Cadiolog!. Eur Heart J. 2013'3()3*+"2(-3003.


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,evasculari+ation

?are metal stents .?S1 are associated $ith a*)&G)# rate of angiographic stenosis $ithin '&;months after implantation

Drug-eluting stents .D6S1 reduce the incidenceof restenosis and ischaemia-driven repeatrevascularization

Coronary artery bypass surgery

Lhen technically feasible, $ith an acceptablelevel of risk and a good life expectancy,revascularization is indicated in chronicangina refractory to @


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,evasculari+ation "rocedure


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Women

Lomen more fre>uently have CAD $ith stable angina and noobstructive coronary disease

Lomen are more likely to have complications from revascularization

Diabetic patients Need dierent risk factor management

lder patients Eigh-risk group $ith higher mortality and higher rates of myocardial

infarction

Msually undertreated, receiving less drugs

Dicult diagnosis due to atypical symptoms

Eigher risk of complications during and after coronary revascularization

Comorbidities!intolerance Depending on comorbidities/tolerance, it is indicated to use second-line

therapies as 4rst-line treatment in selected patients

Speci%c patient pro%les


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Conclusion

ESC Guidelines highlighted two aims fo the &hamacological management

of stable CA &atients" obtain elief of s!m&toms and &e/ent cadio/asculae/ents.

CA &atients should all ecei/e aspirin and a statin, plus an ACE inhibitor

in case of comobidities.

-blockers or CCBs should be &escibed as fist-line teatment to educe

angina.

Ivabradine and Trimetazidine )as ell as long-acting nitates, nicoandil and

anolaine+ ae ecommended second-line, in combination ith fist-lineteatment, in &atients emaining s!m&tomatic.

h!sicians should conside optimal medical treatment befoe

e/asculaiation &ocedues.

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