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Chapter Summary

This chapter reviews the epidemiology, diagnosis, and management of chronic coronary syndromes (see Fuster & Hurst’s Central Illustration). Assessment of pretest probability of coronary artery disease (CAD) aids in appropriate risk stratification of patients with suspected chronic coronary syndromes. The Duke, updated Diamond–Forrester, and CORSCORE risk models are the most accurate in predicting CAD. The ischemic cascade is based on progressive mismatch between coronary blood flow and myocardial oxygen demand and, since perfusion defects occur earlier than do wall motion abnormalities, tests that rely on detection of perfusion defects (such as SPECT) are more sensitive than those that detect wall motion abnormalities (such as stress echocardiography), which are more specific for the detection of obstructive CAD. Detection of CAD by coronary computed tomography angiography is associated with a reduced incidence of myocardial infarction. Goal-directed medical therapy consists of intensive and comprehensive secondary prevention and includes lifestyle and pharmacological approaches. Patients with refractory symptoms despite goal-directed medical therapy, and/or elevated clinical or angiographic risk profiles and suitable coronary anatomy, may benefit from revascularization. Coronary artery anatomy, left ventricular systolic function, systemic factors (eg, diabetes), and patient values and preferences should be considered when choosing the revascularization strategy (ie, percutaneous coronary intervention versus coronary artery bypass graft surgery).

eFig 21-01 Chapter 21: Chronic Coronary Syndromes


Coronary artery disease (CAD) is a leading cause of death and disability nationally and internationally. In the United States, 18.2 million adults have coronary heart disease and 9.4 million have angina.1 Although deaths from CAD have been steadily declining, it is still responsible for 1 in 7 deaths per year in the United States, which in 2017 totaled 365,914 fatalities.1 Annually, it is estimated that 720,000 Americans are hospitalized or die from an initial myocardial infarction (MI), 335,000 suffer from recurrent MI, and an additional 170,000 individuals develop a clinically silent MI.1

Chronic CAD has been variously termed stable ischemic heart disease (SIHD) or stable angina by the American College of Cardiology/American Heart Association (ACC/AHA) guidelines or chronic coronary syndromes (CCS) by the European Society of Cardiology (ESC) guidelines. Atherosclerosis is a chronic, most often progressive process and the natural history varies based on the underlying comorbidity burden, degree of atherosclerosis, and primary and secondary preventative measures (Fig. 21–1). The condition can have long, stable periods but can also become unstable at any time, typically due to an acute atherothrombotic event caused by plaque rupture or erosion. This chapter reviews the epidemiology, natural history, etiology, and diagnostic, clinical, and therapeutic approaches of patients with CCS.

Figure 21–1.

Natural history of chronic stable ischemic heart disease. Reproduced with permission from Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic ...

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