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.; Rim Halaby; Arzu Kalayci, M.D. [3]

Overview

The goal of the treatment of chronic stable angina is to reduce the symptoms, delay the progression of atherosclerosis, and prevent cardiovascular events. In order to achieve these goals, lifestyle modifications and medical therapy are the first line treatment. Revascularization is done to increase survival in specific conditions where the stenosis of the coronary arteries is anatomically and functionally significant and the symptoms are refractory to medical therapy. 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

Indications for Revascularization Therapy

Increase Survival

  • Increased survival following revascularization depends on the location, severity, and number of lesions; the presence or absence of left ventricular dysfunction is an important factor as well. Therefore, revascularization is recommended in the following situations:
    • More than 50% stenosis of the left main coronary:
      • CABG is indicated
      • PCI is not indicated when patients are good candidates for CABG or when the anatomy is not favorable.
    • More than 70% stenosis of three major coronary artery or proximal left anterior descending artery:
  • Patients who would also have a survival benefit from revascularization (PCI or CABG) are survivors of sudden cardiac death secondary to ischemia induced tachycardia, where ischemia is caused by more than 70% stenosis of a major coronary artery:

Relief of Symptoms Refractory to Medical Therapy

  • Coronary angiography should be performed in the following settings:
    • More than 70% stenosis of a non left main artery or more than 50% stenosis of left main artery
  • The definition of inadequate response to medical therapy can be fairly broad and depends 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.
  • The following patients should also be considered:

Considerations

  • PCI should not be done in patients that will not be compliant with dual antiplatelet therapies.
  • Patients with diabetes and advanced three-vessel coronary artery disease have shown lower mortality and myocardial infarction rates and higher risk of strokes when undergoing CABG compared to PCI with drug eluting stents.[2]

Revascularization: Further Readings

ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/ STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease

Revascularization to Improve Survival Compared With Medical Therapy (DO NOT EDIT)

Anatomic Setting COR LOE
UPLM or complex CAD
CABG and PCI I—Heart Team approach recommended C
CABG and PCI IIa—Calculation of STS and SYNTAX scores B
UPLM
CABG I B
PCI IIa - For SIHD when both of the following are present:

1) Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (e.g., a low SYNTAX score of ≤ 22, ostial or trunk left main CAD) 2) Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., STS-predicted risk of operative mortality ≥ 5%)

B
PCI IIa—For UA/NSTEMI if not a CABG candidate B
PCI IIa—For STEMI when distal coronary flow is TIMI flow grade <3 and PCI can be performed more rapidly and safely than CABG C
PCI IIb—For SIHD when both of the following are present:1) Anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (e.g., low-intermediate SYNTAX score of <33, bifurcation left main CAD) 2) Clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderate—severe COPD, disability from prior stroke, or prior cardiac surgery; STS-predicted operative mortality >2%) B
PCI III: Harm—For SIHD in patients (versus performing CABG) with unfavorable anatomy for PCI and who are good candidates for CABG B
3-vessel disease with or without proximal LAD artery disease
CABG I B
IIa—It is reasonable to choose CABG over PCI in patients with complex 3-vessel CAD (e.g., SYNTAX score >22) who are good candidates for CABG. B
PCI IIb—Of uncertain benefit B
2-vessel disease with proximal LAD artery disease
CABG I B
PCI IIb—Of uncertain benefit B
2-vessel disease without proximal LAD artery disease
CABG IIa—With extensive ischemia B
CABG IIb—Of uncertain benefit without extensive ischemia C
CABG IIb—Of uncertain benefit B
1-vessel proximal LAD artery disease
CABG IIa—With LIMA for long-term benefit B
PCI IIb—With LIMA for long-term benefit B
1-vessel proximal LAD artery disease
CABG III: Harm B
PCI III: Harm B
LV dysfunction
CABG IIa—EF 35% to 50% B
CABG IIb—EF <35% without significant left main CAD B
PCI Insufficient data
Survivors of sudden cardiac death with presumed ischemia-mediated VT
CABG I B
PCI I C
No anatomic or physiological criteria for revascularization
CABG III: Harm B
PCI III: Harm B
CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; COR, class of recommendation; EF, ejection fraction; LAD, left anterior descending; LIMA, left internal mammary artery; LOE, level of evidence; LV, left ventricular; N/A, not available; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; STEMI, ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons; SYNTAX, Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery; TIMI, Thrombolysis In Myocardial Infarction; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; UPLM, unprotected left main disease; and VT, ventricular tachycardia.

One Vessel Disease

Appropriate Use Score (1-9)
One-Vessel Disease Asymptomatic Ischemic Symptoms
One-Vessel Disease Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
No Proximal LAD or Proximal Left Dominant LCX Involvement
Low-risk findings on noninvasive testing R (2) R (1) R (3) R (2) M (4) R (3) A (7) M (5)
Intermediate- or high-risk findings on noninvasive testing M (4) R (3) M (5) M (4) M (6) M (4) A (8) M (6)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 M (4) R (2) M (5) R (3) M (6) M (4) A (8) M (6)
Proximal LAD or Proximal Left Dominant LCX Involvement Present
Low-risk findings on noninvasive testing M (4) R (3) M (4) M (4) M (5) M (5) A (7) A (7)
Intermediate- or high-risk findings on noninvasive testing M (5) M (5) M (6) M (6) A (7) A (7) A (8) A (8)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 M (5) M (5) M (6) M (6) M (6) M (6) A (8) A (7)
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; LAD, left anterior descending coronary artery; LCX, left circumflex artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

Two-Vessel Disease

Appropriate Use Score (1-9)
Two-Vessel Disease Asymptomatic Ischemic Symptoms
Two-Vessel Disease Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
No Proximal LAD Involvement
Low-risk findings on noninvasive testing R (3) R (2) M (4) R (3) M (5) M (4) A (7) M (6)
Intermediate- or high-risk findings on noninvasive testing M (5) M (4) M (6) M (5) M (6) M (4) A (7) M (6)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels M (5) M (4) M (6) M (4) A (7) M (5) A (8) A (8)
Proximal LAD Involvement and No Diabetes Present
Low-risk findings on noninvasive testing M (4) M (4) M (5) M (5) M (6) M (6) A (7) A (7)
Intermediate- or high-risk findings on noninvasive testing M (6) M (6) A (7) A (7) A (7) A (7) A (8) A (8)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels M (6) M (6) M (6) M (6) A (7) A (7) A (8) A (8)
Proximal LAD Involvement With Diabetes Present
Low-risk findings on noninvasive testing M (4) M (5) M (4) M (6) M (6) A (7) A (7) A (8)
Intermediate- or high-risk findings on noninvasive testing M (5) A (7) M (6) A (7) A (7) A (8) A (8) A (9)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels M (5) M (6) M (6) A (7) A (7) A (8) A (7) A (8)
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

Three-Vessel Disease

Appropriate Use Score (1-9)
Three-Vessel Disease Asymptomatic Ischemic Symptoms
Three-Vessel Disease Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
Low Disease Complexity (e.g., Focal Stenoses, SYNTAX ≤22)
Low-risk findings on noninvasive testing M (4) M (5) M (5) M (6) M (6) M (6) A (7) A (7)
Intermediate- or high-risk findings on noninvasive testing - No diabetes M (6) A (7) A (7) A (7) A (7) A (8) A (8) A (8)
Low-risk findings on non-invasive testing - Diabetes present M (4) M (6) M (5) M (6) A (6) A (7) A (7) A (8)
Intermediate- or high-risk findings on noninvasive testing - Diabetes present M (6) A (7) M (6) A (8) A (7) A (8) A (7) A (9)
Intermediate or High Disease Complexity (e.g. Multiple Features of Complexity as Noted Previously, SYNTAX >22)
Low-risk findings on noninvasive testing - No diabetes M (4) M (6) M (4) A (7) M (5) A (7) M (6) A (8)
Intermediate- or high-risk findings on noninvasive testing - No diabetes M (5) A (7) M (6) A (7) M (6) A (8) M (6) A (9)
Low-risk findings on noninvasive testing - Diabetes present M (4) A (7) M (4) A (7) M (5) A (8) M (6) A (9)
Intermediate- or high-risk findings on noninvasive testing - Diabetes present M (4) A (8) M (5) A (8) M (5) A (8) M (6) A (9)
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; M, may be appropriate; PCI, percutaneous coronary intervention; and SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery trial. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

Left Main Coronary Artery Stenosis

Appropriate Use Score (1-9)
Left Main Disease Asymptomatic Ischemic Symptoms
Left Main Disease Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
Isolated LMCA disease - Ostial or midshaft stenosis M (6) A (8) A (7) A (8) A (7) A (9) A (7) A (9)
Isolated LMCA disease - Bifurcation involvement M (5) A (8) M (5) A (8) M (5) A (9) M (6) A (9)
LMCA disease - Ostial or mid shaft stenosis - Concurrent multi vessel disease - Low disease burden (e.g., 1–2 additional focal stenoses, SYNTAX score ≤22) M (6) A (8) M (6) A (9) A (7) A (9) A (7) A (9)
Ostial or mid shaft stenosis - Concurrent multi vessel disease - Intermediate or high disease burden (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) M (4) A (9) M (4) A (9) M (4) A (9) M (4) A (9)
Ostial or mid shaft stenosis - Concurrent multi vessel disease - Intermediate or high disease burden (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) M (4) A (9) M (4) A (9) M (4) A (9) M (4) A (9)
LMCA disease - Bifurcation involvement - Low disease burden in other vessels (e.g., 1–2 additional focal stenosis, SYNTAX score ≤22) M (4) A (8) M (5) A (8) M (5) A (9) M (6) A (9)
LMCA disease - Bifurcation involvement - Intermediate or high disease burden in other vessels (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) R (3) A (8) R (3) A (9) R (3) A (9) R (3) A (9)
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; LMCA, left main coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; R, rarely appropriate; and SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery trial. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

IMA to LAD Patent and Without Significant Stenoses

Appropriate Use Score (1-9)
IMA to LAD Patent and Without Significant Stenoses Asymptomatic Ischemic Symptoms
Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
Stenosis Supplying 1 Territory Disease (Bypass Graft or Native Artery) to Territory Other Than Anterior
Low-risk findings on noninvasive testing R (3) R (1) R (3) R (2) M (6) R (3) A (7) M (4)
Intermediate- or high-risk findings on noninvasive testing M (5) R (3) M (5) R (3) A (7) M (4) A (8) M (5)
No stress test performed or, if performed, the results are indeterminate - FFR of stenosis ≤0.80 M (4) R (3) M (4) R (3) M (6) M (4) A (8) M (5)
Stenoses Supplying 2 Territories (Bypass Graft or Native Artery, Either 2 Separate Vessels or Sequential Graft Supplying 2 Territories) Not Including Anterior Territory
Low-risk findings on noninvasive testing R (3) R (2) M (4) R (3) M (6) R (3) A (7) M (5)
Intermediate- or high-risk findings on noninvasive testing M (5) R (3) M (5) M (4) A (7) M (5) A (8) M (6)
A indicates appropriate; AA, Antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; IMA, internal mammary artery; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

IMA to LAD Not Patent

Appropriate Use Score (1-9)
IMA to LAD Not Patent Asymptomatic Ischemic Symptoms
Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
Stenosis Supplying 1-Territory Disease (Bypass Graft or Native Artery)–Anterior (LAD) Territory
Low-risk findings on noninvasive testing M (4) R (3) M (5) R (3) M (6) M (4) A (7) M (5)
Intermediate- or high-risk findings on noninvasive testing M (6) M (4) M (6) M (4) A (7) M (5) A (8) M (6)
No stress test performed or, if performed, the results are indeterminate - FFR of stenosis ≤0.80 M (5) M (4) M (6) M (4) A (7) M (5) A (7) M (6)
Stenoses Supplying 2 Territories (Bypass Graft or Native Artery, Either 2 Separate Vessels or Sequential Graft Supplying 2 Territories) LAD Plus Other Territory
Low-risk findings on noninvasive testing M (5) M (4) M (6) M (4) A (7) M (5) A (7) M (6)
Intermediate- or high-risk findings on noninvasive testing M (6) M (5) A (7) M (6) A (7) A (7) A (8) A (8)
Stenoses Supplying 3 Territories (Bypass Graft or Native Arteries, Separate Vessels, Sequential Grafts, or Combination Thereof) LAD Plus 2 Other Territories
Low-risk findings on noninvasive testing M (5) M (5) M (6) M (5) M (6) M (6) A (7) A (7)
Intermediate- or high-risk findings on noninvasive testing A (7) A (7) A (7) A (7) A (7) A (7) A (8) A (8)
A indicates appropriate; AA, Antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; IMA, internal mammary artery; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

2014 Focused update of 2012 AHA guidelines for the management of chronic stable angina[3][4]

Heart Team Approach Revascularization Guidelines[3][4]

Class I
"1. A Heart Team approach to revascularization is recommended in patients with diabetes mellitus and complex multivessel CAD"(Level of Evidence:C ) "
Class I
"1. Calculation of the STS and SYNTAX scores is reasonable in patients with unprotected left main and complex CAD "(Level of Evidence:B ) "

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:

References

  1. 1.0 1.1 Qaseem A, Fihn SD, Dallas P, et al. Management of patients with stable ischemic heart disease: Executive summary of a clinical practice guideline from the American College of Physicians, American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012.
  2. Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M; et al. (2012). "Strategies for Multivessel Revascularization in Patients with Diabetes". N Engl J Med. doi:10.1056/NEJMoa1211585. PMID 23121323.
  3. 3.0 3.1 Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ; et al. (2014). "2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 64 (18): 1929–49. doi:10.1016/j.jacc.2014.07.017. PMID 25077860.
  4. 4.0 4.1 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.

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