CCS 2022 Symposium: Rethinking the Optimal Approach to the Chronic Coronary Syndrome Patient

Over time, the causes of mortality in humanity have varied according to the technology, scientific and medical knowledge of the time. Today, there is no doubt that cardiovascular disease is the leading worldwide cause of death. It is not only responsible for the number one cause of death worldwide but also for morbidity and mortality, as well as for changes in the quality of life and disability of people everywhere.1

What we know today as chronic coronary syndrome is a multifactorial entity, which cannot be attributed to a single cause. We have of course epicardial coronary artery disease, however, microvascular angina and vasospastic angina also play an extremely important role. The mechanisms of action of these entities may overlap with each other, so what studies have shown is that to date there is no single optimal treatment that can be used in absolutely all patients in the same way.2,3

Interventional cardiology promised 50 years ago to be the solution to the disease, but many studies such as ISCHEMIA or ORBITA have made us wonder what we expect from the different therapeutic strategies. Changing the approach is important as well as establishing objectives in the interventional and therapeutic treatments that we offer to the patient. It should be explained that interventional treatments will not make a significant change in the patient's 10-year survival, except in refractory angina or acute syndromes.4,5

A stepwise approach to the treatment of chronic coronary syndrome has been used in recent years, usually starting with symptomatic assessment of the patient and the addition of beta-blockers. Depending on clinical parameters such as blood pressure, heart rate or persistence of angina, other agents, usually hemodynamic, continue to be added and finally metabolic agents are added. However, it has been shown that the use of two hemodynamic agents in combination does not offer a real benefit in terms of morbidity, mortality, and symptoms in patients. Sometimes they can even be deleterious, therefore, the optimal approach is to target and target the specific disease mechanism by which the patient is suffering angina, in a safe manner.3,6,7

Based on the ISCHEMIA study, we know that a patient with chronic stable angina over the next three months will not have a significant change in the occurrence of major cardiovascular events. Once a base treatment with beta-blockers has been initiated in most patients, a short evaluation should be performed after 1 or 2 months and then a second drug should be added, preferably from the metabolic action group such as Trimetazidine, preferably in a single long-acting dose.4

Among the metabolic drugs, it should be noted that Trimetazidine, especially Trimetazidine OD 80, has been shown to significantly reduce angina attacks and therefore the use of short-acting nitrates; improve tolerance and exercise capacity, as well as demonstrate a significant improvement in the quality of life of patients.8

An important point in the treatment of chronic coronary syndrome is adherence, around 40% of patients, regardless of the revascularization strategy, suffer symptoms secondary to poor adherence to their cardiovascular therapy; it has been widely demonstrated in recent years that the use of drugs favors a decrease in therapeutic abandonment, improves symptoms associated with lack of adherence, and, with greater adherence, contributes to a decrease in morbidity and mortality.9

SCAC-08/22-DM-182-VAS – For professional healthcare use only

1. https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)

2. Ferrari R et al. Expert consensus document: A 'diamond' approach to personalized treatment of angina. Nat Rev Cardiol. 2018;15²:120-132​

3. 2019 ESC Guidelines

4. International Study of Comparative Health Effectiveness With Medical and Invasive Approaches – ISCHEMIA

5. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial

6. Fox KM et al. The Total Ischaemic Burden European Trial (TIBET). Effects of atenolol, nifedipine SR and their combination on the exercise test and the total ischaemic burden in 608 patients with stable angina. The TIBET Study Group. Eur Heart J. 1996;17¹:96-103​

7. Combination therapy with metoprolol and nifedipine versus monotherapy in patients with stable angina pectoris. Results of the International Multicenter Angina Exercise (IMAGE) Study

8. Effectiveness of Long-acting Trimetazidine in Different Clinical Situations in Patients with Stable Angina Pectoris: Findings from ODA Trial

9. International Observational Analysis of Evolution and Outcomes of Chronic Stable Angina: The Multinational CLARIFY Study