Revascularization and Medical Therapy for Chronic Coronary Syndromes: Lessons Learnt from Recent Trials, a Literature Review

Abstract

Stable coronary artery disease (CAD) has recently been replaced by a new entity described as chronic coronary syndrome (CCS). This new entity has been developed based on a better understanding of the pathogenesis, the clinical characteristics, and the morbi-mortality associated to this condition as part of the dynamic spectrum of CAD. This has significant implications in the clinical management of CCS patients, that ranges from lifestyle adaptation, medical therapy targeting all the elements contributing to CAD progression (i.e., platelet aggregation, coagulation, dyslipidaemia, and systemic inflammation), to invasive strategies (i.e., revascularization). CCS is the most frequent presentation of coronary artery disease which is the first cardiovascular disease worldwide. Medical therapy is the first line therapy for these patients; however, revascularization and especially percutaneous coronary intervention remains beneficial for some of them. European and American guidelines on myocardial revascularization were released in 2018 and 2021, respectively. These guidelines provide different scenarios to help physicians choose the optimal therapy for CCS patients. Recently, several trials focusing on CCS patients have been published. We sought to synthetize the place of revascularization in CCS patients according to the latest guidelines, the lessons learnt from recent trials on revascularization and medical therapy, and future perspectives.

Keywords: CCS; chronic coronary syndromes; coronary artery disease; revascularization.

Figure 1

Impactful randomized clinical trials on revascularization in chronic coronary syndrome and current clinical guidelines. Abbreviations: ACC, American College of Cardiology; AHA, American Heart Association; BARI 2D, Bypass Angioplasty Revascularization Investigation 2 Diabetes; COURAGE, Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation; EACTS, European Association for Cardio-Thoracic Surgery; ESC, European Society of Cardiology; FAME, Fractional Flow Reserve vs. Angiography for Multivessel Evaluation; ISCHEMIA, International Study of Comparative Health Effectiveness With Medical and Invasive Approaches; ORBITA, Objective Randomised Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina; REVIVED BCIS2, Revascularization for Ischemic Ventricular Dysfunction; SCAI, Society for Cardiovascular Angiography and Interventions, STICH, Surgical Treatment for Ischemic Heart Failure; STICHES, Surgical Treatment for Ischemic Heart Failure Extension Study.

Figure 2

Therapeutic targets and medical treatment novelties in chronic coronary syndrome. Platelet aggregation, coagulation, cholesterol, and systemic inflammation all play a pivotal role in coronary artery disease progression and thus represent the targets for medical therapeutical interventions. Here represented are the recent advances in antiplatelet, anticoagulant, anti-inflammatory, and lipid-lowering medical therapy. Abbreviations: DAPT, dual anti-platelet therapy; LDL, low-density lipoprotein; PCSK9, proprotein convertase subtilisin kexin type 9.

Figure 3

PCI optimization strategies to improve clinical outcome. Physiology assessment with FFR pullback (A). Coronary CTA showing anatomical 3D and multiplanar reconstructions (B). Post-PCI OCT and IVUS evaluation of stent expansion and apposition (C,D).