Contemporary Management of Stable Coronary Artery Disease

Abstract

Coronary artery disease (CAD) continues to be the leading cause of mortality and morbidity in developed countries. Assessment of pre-test probability (PTP) based on patient's characteristics, gender and symptoms, help to identify more accurate patient's clinical likelihood of coronary artery disease. Consequently, non-invasive imaging tests are performed more appropriately to rule in or rule out CAD rather than invasive coronary angiography (ICA). Coronary computed tomography angiography (CCTA) is the first-line non-invasive imaging technique in patients with suspected CAD and could be used to plan and guide coronary intervention. Invasive coronary angiography remains the gold-standard method for the identification and characterization of coronary artery stenosis. However, it is recommended in patients where the imaging tests are non-conclusive, and the clinical likelihood is very high, remembering that in clinical practice, approximately 30 to 70% of patients with symptoms and/or signs of ischemia, referred to coronary angiography, have non obstructive coronary artery disease (INOCA). In this contest, physiology and imaging-guided revascularization represent the cornerstone of contemporary management of chronic coronary syndromes (CCS) patients allowing us to focus specifically on ischemia-inducing stenoses. Finally, we also discuss contemporary medical therapeutic approach for secondary prevention. The aim of this review is to provide an updated diagnostic and therapeutic approach for the management of patients with stable coronary artery disease.

Keywords: Angina; Chronic coronary syndrome; Coronary artery disease; Coronary computed tomography angiography; Fractional flow reserve; Percutaneous coronary intervention.

Fig. 1

Physiology guided discrimination of focal CAD. a Focal lesion in the proximal right coronary artery, with FFR 0.67 and a Pullback curve with a focal drop. PPG of 0.87; b combined lesion in the left descending artery (LAD) with FFR 0.79 and a Pullback curve showing diffuse disease with a proximal focal drop. PPG of 0.56; c diffuse coronary artery disease in an LAD with FFR 0.78 and a pullback curve without focal drops. PPG of 0.34. FFR fractional flow reserve, PPG pullback pressure gradient.

Fig. 2

Significant calcified lesion in proximal and middle left anterior descending artery. a Coronary angiography. Yellow dashed lines represent the proximal and distal edge of the implanted stents during the PCI. b OCT pre-PCI showing calcific lesion with significant stenosis and MLA of 1.12 mm². c OCT post-PCI showing total stent length of 56 mm length and optimal stent expansions of 88%. PCI percutaneous coronary intervention, OCT optical coherence tomography, MLA minimum lumen area.

Fig. 3

Left anterior descending coronary artery with calcified lesion and significant stenosis in the proximal segment. a Coronary computed tomography angiography–curved multiplanar reconstruction and cross-sectional views. b FFRCT patient-specific model with distal value of FFRCT<0.70. c 3D reconstruction model with visualization of plaque components.

Fig. 4

Diagnostic flowchart for non-invasive and invasive assessment. CCTA coronary computed tomography angiography, FFR fractional flow reserve, OMT optimal medical therapy, PPG pullback pressure gradient, OCT optical coherence tomography, IVUS intravascular ultrasound.