Chronic stable angina revascularization

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Editors-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Cafer Zorkun, M.D., Ph.D. [2]; Associate Editors-In-Chief: John Fani Srour, M.D.; Smita Kohli, M.D.

Overview

The goal of treatment for chronic stable angina is: to reduce symptoms, delay the progression of atherosclerosis, and prevent cardiovascular events. To achieve this, medical therapy with revascularization may be used in applicable patients. The main indication for revascularization therapy (PCI or CABG), in chronic stable angina, are:

• Patients with symptoms uncontrolled by optimal medical therapy (see Pharmacotherapy and Lifestyle modifications for stable angina).

The definition of inadequate response to medical therapy can be fairly broad and depend largely on the patient's lifestyle, occupation and expectations.

At one extreme are patients who are limited by angina pectoris despite optimal drug treatments and lifestyle modifications, including achievement of optimal weight and cessation of smoking.

At the other end are patients in whom we can consider medical therapy to have failed if control of angina pectoris requires higher doses of anti-anginal medications that cause side effects.

• Patients who would have a survival benefit from revascularization (PCI or CABG).

This depends on the location, severity, and number of lesions; the presence or absence of left ventricular dysfunction is an important factor as well.

There is evidence and/or general agreement that coronary angiography should be performed to risk stratify patients with chronic stable angina in the following settings:

• Disabling anginal symptoms (Canadian Cardiovascular Society CCS classes III and IV) despite medical therapy.
• High-risk criteria on noninvasive testing independent of the severity of angina (The amount and distribution of viable but jeopardized left ventricular myocardium and the percentage of irreversibly scarred myocardium).
• Survivors of sudden cardiac death or serious ventricular arrhythmia.
• Symptoms and signs of heart failure.
• Clinical features that suggest that the patient has a high likelihood of severe coronary artery disease.

On the other hand, angiography is not recommended for patients with CCS class I or II angina that responds to medical therapy and, on noninvasive testing, shows no evidence of ischemia.

There are currently two well-established revascularization approaches for the treatment of chronic stable angina caused by coronary atherosclerosis: CABG and PCI. Since the introduction of coronary artery bypass surgery in 1967 and percutaneous transluminal coronary angioplasty (PTCA) in 1977, research has supported the effective usage of both strategies for treatment of patients with chronic stable angina. However, as with any treatment method, both methodologies have weaknesses. The choice between PCI and CABG is based upon anatomy and other factors such as left ventricular function and the presence or absence of diabetes. In general, PTCA is reserved for single or some cases of two vessel disease, while CABG is reserved for patients with two or three vessel disease or left main disease. With the availability of drug-eluting stents, PCI is increasingly being performed for many lesions including more complex ones.

Revascularization approaches for the treatment of stable angina

You can read in greater detail about specific revascularization approaches for the treatment of chronic stable angina by clicking on the link below for that topic.

PCI | CABG | PCI vs CABG | ACC/AHA Guidelines for Revascularization

See Also

• The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

• The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina

• The ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

• The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina