CHAPTER SUMMARY AND CENTRAL ILLUSTRATION
Survival After Invasive or Conservative Management of Stable Coronary Disease: The ISCHEMIA EXTEND Interim Report (ISCHEMIA-EXTEND)
ISCHEMIA was an international, multicenter, randomized controlled trial comparing an initial invasive versus an initial conservative management strategy for patients with chronic coronary disease and moderate or severe ischemia, not including patients with unprotected left main disease, heart failure with LVEF ≤35% or NYHA class III/IV symptoms, kidney disease, recent acute coronary syndrome, or refractory angina. Read More
RESPECT EPA Trial
The RESPECT EPA trial is an open-label trial of 3,844 Japanese patients (mean age 68 years) with CAD already on statin therapy. Read More
PANTHER: What is the optimal antiplatelet monotherapy for established coronary artery disease?
To date, the antiplatelet agent of choice for secondary prevention in coronary artery disease has been aspirin. Read More
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
EPIDEMIOLOGY AND NATURAL HISTORY
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