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Before and after the new Guidelines on Stable Coronary Artery Disease – have they changed my daily practice?

The ESC Clinical Practice Guidelines on stable coronary artery disease was published in August 2013 and represents a major update compared to the 2006 guidelines on angina pectoris. However, they must be viewed as a part of a continued process of updating our knowledge base taking in to consideration the guidelines on prevention from 2012, and the revascularization guidelines from 2010 (an update will come summer 2014).

This article is written by Per Anton Sirnes, FESC,  former chair of the Council of Cardiology Practice. He runs a solo cardiology private practice in the city of Moss, Norway.

Chronic Ischaemic Heart Disease (IHD)


What have been the 10 most important impacts on my daily clinical practice?

1.    Diagnosis and assessment. The classical chain pain classification from the previous Guidelines has been kept, but the table which uses this classification to  the probability of having obstructive coronary artery disease has been updated and the graphics greatly improved. This is now a tool that can be used both in communication with patients and primary physicians.  I often get women aged under 40 years with non-anginal chest pain referred for exercise testing. Both the General Practitioners and the patients expect that an exercise ECG will solve the question – is this chest pain dangerous?  With the tables below it is easier to explain why further diagnostic tests is unnecessary. Furthermore, as we all know, any ST segment changes will only produce more questions than answers.

Figure 1  Figure 2

All tables and figures are from the 2013 ESC guidelines on the management of stable coronary artery disease.

2.    Basic imaging. In the 2006 Guidelines echocardiography was primarily recommended in patients with suspected valve disease, heart failure or LBBB.  A basic echo exam in all patients suspected of having SCAD is now recommended with IB and ultrasound of the carotid artery as well to detect early atherosclerosis.  This is the way many of us cardiologists in practice outside hospitals work: doing the whole battery of tests at the first visit, while many hospital out-patient departments often only offer an exercise test in the first place and have to give another appointment for an echo and sometimes a third for carotid ultrasound.  The new Guidelines thus reinforce the integrated approach used in many general cardiologist practices.

Figure 3

3.    Which test for which patient ? The algorithm for further evaluation of patients with a pre-test probability of 15-85% has been simplified and allows to chose the modality for ischemia detection according to local facilities resources and knowledge.  The baseline evaluation of LVEF is central and while the British NICE guidelines have removed exercise ECG from the evaluation of SCAD, the good old exercise test has been kept as an option in the ESC Guidelines. I think this is a wise decision. In many cardiology practices throughout Europe, the exercise ECG is still a work-horse in daily use and will remain so in spite of its well known inborn problems of specificity and sensitivity.  The exercise test also gives important data regarding prognosis and functional capacity.

FIgure 4

More use of CTA.  The role of computed tomography angiography (CTA) and coronary calcium score is now more extensively discussed both in the main paper and in the web addendum. CTA has been given a IIa indication as an alternative to stress testing to rule out obstructive CAD in patients in the lower range of pre-test probability or with a non-conclusive exercise test.

Figure 5

Many commercial actors have promoted the use of CT coronary calcium detection directly to the public. The 2013 Guidelines clearly state that this method should not be used to identify individuals with suspected coronary artery stenosis. But the addendum also discusses diagnostic aspects in asymptomatic individuals without known coronary artery disease and opens for the use of imaging methods such as carotid ultrasound and calcium scoring to assess CVD risk in individuals with moderate risk by reclassifying them as either high or low-risk individuals.

Figure 6

5.    Risk stratification.  The 2013 SCAD Guidelines point out the importance of using all available information: clinical parameters, LV function, the degree of ischemia, as well as anatomical information from angiography to risk stratify the SCAD patient. Optimal medical therapy is recommended as the first step in SCAD patients with low risk (<1 % annual mortality), while patients with high risk (> 3%) should go directly to coronary angiography  and evaluation for revascularization. The Guidelines increased emphasis on OMT in stable patients with low event risk.

6.    Revascularization strategy. This is discussed thoroughly both in the main text and the web addendum. Again risk stratification is essential. The concept of the heart team which was introduced in the 2010 revascularization guidelines, is further emphasized.  The clear recommendation of CABG as the primary strategy for diabetic patients with multi-vessel disease has influenced my practice. I now inform patients with diabetes in whom I suspect multi-vessel disease, that surgery probably will be a good option for them if the angiogram shows that several vessels are affected. I have become reluctant to refer such patients to centres where the decision for PCI is mainly taken with the patient on the cath table without a heart team discussion and where the operator has an economic interest in the chosen revascularization strategy.

7.    Microvascular and vasospastic angina.  The guidelines and the web addendum discuss the various clinical and pathophysiological aspects of SCAD and the sections on angina in patients without epicardial coronary stenosis were very worth reading. Both microvascular and vasospastic angina have become more real clinical entities for me after reading these sections. The clinical picture is different from classical angina and is discussed in the text. Unfortunately, invasive diagnostic procedures such as coronary acetylcholine injections are seldom done in centres where I can refer patients. Evaluation of flow reserve in LAD with transthoracic echo after maximal vasodilatation with adenosine is an attractive approach. Long time ECG monitoring catching an episode may sometimes give an answer. A more active attitude towards the patient with angina and normal epicardial arteries and revision of the treatment regime towards vasospasm has resulted in several treatment successes with satisfied patients.

8.    Pharmacology for SCAD.  The main therapeutic strategy for optimal medical treatment has not changed much in the last decade. Medications for risk reduction (platelet inhibitors, statins and ACE inhibitors if other indications) and symptomatic relief (beta-blockers, calcium antagonists and nitrates) are discussed and there is a nice table (Table 27) on major side effects and contraindications.  Compared to the 2006 guidelines there have been more data on secondary drugs such as ranolazine and ivabradine. None of these has been marketed in my country, but I have prescribed them to some suitable patients on special request with clinical success.

9.    Refractory angina. This is discussed in the web addendum and contains new recommendations as compared to the 2006 Guidelines Section. Non-pharmacological treatments such as enhanced external counterpulsation (EECP) and transcutaneous nerves stimulation (TENS) and spinal cord stimulation (SCS) have now more recommendations, the first of these methods with IIa and the last two with IIb. For me these recommendations mean that my patients who have refractory angina in spite of every revascularization effort and pharmacological adjustment have treatment alternatives with documented efficacy.

10.    Follow up and re-assessments of patients with SCAD. These are important recommendations, which are mentioned throughout the document. Annual control of lipids and glucose metabolism has a class IC recommendation. A follow up visit every 4-6 months the first year after an intervention is recommended primarily to assess lifestyle modifications, medication adherence, biochemistry and clinical  status. After the first year annual visits, ECG is recommended annually as well as after change in clinical status, but repetition of exercise ECG may only be considered after at least 2 years with unchanged clinical status. Reassessment of the prognosis using stress testing may be considered in asymptomatic patients after the expiration of the period for which the previous test was felt to be valid (3-5 years). Routine repeat echo is discouraged: “There is no indication for repeated use of resting echocardiography on a regular basis in patients with uncomplicated SCAD in the absence of a change in clinical status”.

References

2013 ESC Guidelines on the management of stable coronary artery disease (Eur Heart J 2013;34:2949–3003 - doi:10.1093/eurheartj/eht296)