2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines | Circulation
Identifying And Managing Coronary Artery Disease
Heart disease, specifically coronary disease, is a common health issue affecting around 18 million American adults. The coronary arteries play a vital role in supplying the heart muscle with essential nutrients such as oxygen. When these arteries become diseased in coronary artery disease, it leads to a reduced supply of blood and nutrients to the heart muscle.
The most prevalent form of coronary artery disease involves the gradual buildup of plaque in the arteries, causing a decrease in blood and oxygen supply to the heart. This can result in symptoms like chest pain, shortness of breath, palpitations, and weakness.
Typical symptoms of coronary artery disease include chest pain, pressure in the chest, pain in the shoulders and arms, and shortness of breath. Less common symptoms may include fatigue, dizziness, nausea, fainting, and swelling in the legs.
Modifiable risk factors for coronary artery disease include high blood pressure, diabetes, smoking, high cholesterol, obesity, and a sedentary lifestyle. Other factors such as a family history of heart disease at a young age can also contribute to the risk.
It is important to consult with your doctor to determine if you are at an increased risk of coronary heart disease or if you may already have coronary artery disease. Common tests may be conducted, including diabetes screenings, cholesterol checks, and electrocardiograms. Additional tests like echocardiograms, stress tests, and CT scans of the heart arteries may be used to assess plaque buildup.
If diagnosed with coronary artery disease, your doctor may prescribe medications such as aspirin to prevent artery blockages and heart attacks. It is crucial to closely monitor your blood pressure, manage diabetes, and adopt a healthy lifestyle, which includes regular exercise, balanced nutrition, and quitting smoking. Aim for at least 30 minutes of moderate physical activity on most days of the week to help maintain heart health.
Dr. Shahzad Ahmed MD, FACC, FSCAI, RPVIInterventional Cardiologist, Director of CardiologyBMC Cardiology Practice, 215-785-5100
Dr. Ahmed holds board certifications in Interventional Cardiology, Cardiovascular Medicine, Echocardiography, Nuclear Cardiology, Vascular Ultrasound, and Internal Medicine. He received the esteemed Fellow of American College of Cardiology (FACC) award in 2019 and was honored as a Fellow of the Society of Cardiovascular Interventions in 2020 (FSCAI). Dr. Ahmed completed his training in internal medicine, cardiovascular, and interventional cardiology at Drexel University College of Medicine. His expertise and dedication have led to his appointment as Assistant Professor of Medicine at Drexel University College of Medicine.New ESC Guidelines Highlight Advances In Chronic Coronary Syndrome Management
Released today, these guidelines emphasise a comprehensive approach to managing both traditional large artery blockages and emerging issues related to smaller blood vessel dysfunction within the heart.
CCS has been synonymous with obstructive coronary artery disease (CAD), where blockages in major heart arteries cause symptoms like angina.
However, the new guidelines, co-chaired by Professor Christiaan Vrints of Antwerp University Hospital, Belgium, show that over half of patients suspected of CCS may suffer from nonobstructive coronary artery disease (ANOCA/INOCA). These conditions, often missed by standard tests, involve either coronary artery spasms or dysfunction in the microcirculation, leading to persistent symptoms and recurrent hospitalisations.
Risk assessment toolTo address these complexities, the guidelines advocate for advanced diagnostic models and technologies. A new risk assessment tool, integrated into the guidelines, helps predict the likelihood of obstructive CAD more accurately than previous models, optimising the selection of diagnostic tests. For instance, coronary computed tomography angiography (CCTA) is highlighted as highly effective in ruling out significant artery blockages or assessing the risk of cardiovascular events based on disease anatomy.
In cases where CCTA shows intermediate blockages, additional stress tests such as echocardiography or cardiac magnetic resonance imaging are recommended to evaluate the functional impact, especially for diagnosing ANOCA/INOCA. For patients with confirmed large artery blockages, the guidelines stress the importance of personalised treatment strategies, including surgical or percutaneous interventions based on individual clinical profiles and anatomical considerations.
According to Professor Felicita Andreotti from the Catholic University Medical School, Rome, Italy, who co-chairs the guidelines, the recommendations for coronary revascularisation remain largely unchanged from previous editions. Surgical intervention is preferred for patients with extensive disease, diabetes, or reduced heart function, whereas percutaneous procedures benefit from advanced imaging techniques to enhance precision and long-term outcomes.
Chronic coronary syndromes pacients treatment decisionsBeyond procedural advancements, the guidelines place a strong emphasis on patient education and involvement in treatment decisions. Professors Vrints and Andreotti emphasize the potential of mobile-health interventions and simplified medication regimens to improve patient adherence and long-term monitoring, crucial for managing disease complications effectively.
In conclusion, these guidelines represent a pivotal update in the field of cardiovascular medicine, aiming to reduce mortality rates associated with coronary syndromes globally. By integrating cutting-edge diagnostic tools, personalised treatment approaches, and enhanced patient engagement strategies, the ESC sets a new standard for managing chronic coronary syndromes in the 21st century.
New Chronic Coronary Syndrome Guidelines Expand Diagnostic Tools And Ways To Prevent Major Adverse Events
The 2024 European Society of Cardiology (ESC) Guidelines on the management of chronic coronary syndromes (CCS) include a focus on both larger and smaller blood vessels of the heart; new models to estimate chances of blocked large arteries (so-called obstructive coronary artery disease); optimal selection and sequence of tests; drugs and interventions to prevent disease complications and improve symptoms, and the fundamental role of patient involvement.
"The new guidelines prompt cardiologists to rethink chronic coronary syndromes as caused not only by blockages in large arteries but also by dysfunction of smaller vessels (microcirculation)," explains Guidelines co-chair Professor Christiaan Vrints, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium.
"Over half of individuals suspected of CCS may have angina/ischemia with nonobstructive coronary arteries (ANOCA/INOCA) caused by coronary artery spasm or microcirculatory dysfunction. This condition is often missed—on average it is diagnosed only after seeing three cardiologists—because the usual tests don't work well to detect it. Patients may suffer severely from persistent symptoms that can cause repeated hospitalizations and even heart failure."
Published in the European Heart Journal, the guidelines highlight that persistently symptomatic patients with suspected ANOCA/INOCA who do not respond to guideline-derived medical therapy should undergo invasive coronary functional testing to determine underlying endotypes and to guide appropriate medical therapy.
A further new recommendation strongly endorsed by the guidelines is the use of the risk factor-weighted clinical likelihood model to estimate the pre-test likelihood of obstructive coronary artery disease. With this new prediction model, around half of individuals assessed for chest pain have a very low likelihood of large artery blockage (</=5%), and in these patients further testing should be deferred, whereas with the ESC 2019 model, only 19% were identified as having a very low likelihood. This prediction model has been developed and validated in Western countries (northern EU, UK, and US). The results may vary depending on region, race, cultural differences, and healthcare system organisations.
For individuals with symptoms suggestive of chronic coronary syndrome who have a low to moderate (>5%–50%) likelihood of obstructive coronary artery disease based on symptoms, age, sex and risk factors, coronary computed tomography angiography (CCTA) is very effective in ruling out coronary atherosclerosis, or at the other extreme, in estimating the risk of major adverse cardiovascular events based on disease anatomy.
"Rarely, however, is a single non-invasive test sufficient to diagnose obstructive disease of the epicardial coronary arteries and a sequential approach is required. When CCTA reveals coronary blockages of intermediate severity, additional tests like stress echocardiography, stress positron emission tomography or stress cardiac magnetic resonance perfusion imaging, if available, are recommended to evaluate the functional significance of the blockages. These additional exams also help to diagnose ANOCA/INOCA when CCTA does not reveal any blockages," explains Professor Vrints.
"In patients with large coronary artery blockages, surgical or percutaneous revascularization is recommended for specific anatomical and/or clinical groups of patients in whom revascularization over medical therapy alone has been shown to prolong survival and to reduce deaths from cardiovascular causes, as well as spontaneous myocardial infarctions and symptoms caused by cardiac ischemia," says guidelines co-chair Professor Felicita Andreotti, Fondazione Policlinico Universitario Gemelli IRCCS and Catholic University Medical School, Rome, Italy.
Prof. Andreotti adds that representatives of the European Association for Cardio-Thoracic Surgery (EACTS) and representatives of the Patient Forum were included in the 28-member task force and that the Guidelines have been endorsed by the EACTS.
The indications for coronary revascularization in the 2024 Guidelines are largely similar to those of 2018: namely, symptoms related to ischemia that are refractory to medical therapy alone, and/or significant disease of the left main stem, of the proximal left anterior descending artery, or of multiple large epicardial arteries.
The Guidelines state/recommend that the most appropriate revascularization modality should be selected based on the patient's profile, coronary anatomy, procedural factors, patient preferences and outcome expectations. Surgery, if possible, is preferred over percutaneous coronary intervention in patients with extensive disease, especially those with diabetes or reduced left ventricular ejection fraction.
When performing revascularization via percutaneous coronary intervention, intracoronary imaging, in addition to pressure measurements, is helpful to guide interventions and enhance immediate and long-term results, especially in complex anatomical scenarios such as left main disease, bifurcations, or long lesions.
"Percutaneous coronary intervention using modern thin-strut stents allows patients who are not at high ischemic risk and/or who are at high bleeding risk to safely shorten the duration of dual antiplatelet therapy. In all or in certain subgroups of patients with chronic coronary syndromes, new lipid-lowering, metabolic and anti-inflammatory medical strategies have the potential to lower the risk of adverse cardiovascular events," adds Professor Andreotti.
"Patient education and involvement in decision-making and self-care, along with mobile-health interventions and simplified medication regimens, have the potential to improve adherence to healthy lifestyles and to medical therapy, and to enhance long-term patient monitoring for disease complications and side effects of treatment," explains Professor Vrints.
The Guidelines co-chairs conclude, "Chronic coronary syndromes are a global health concern because transient or long-lasting damage of the heart caused by diseases of the coronary circulation can cause ineffective heart pump function or malignant arrhythmias that can be fatal. Coronary syndromes remain the single largest cause of death in the adult population worldwide, resulting in millions dying every year. Therefore, the new guidelines stress the importance of early detection, appropriate treatment, and careful long-term follow-up."
More information: 2024 ESC Guidelines for the Management of Chronic Coronary Syndromes, European Heart Journal (2024). DOI: 10.1093/eurheartj/ehae177
Citation: New chronic coronary syndrome guidelines expand diagnostic tools and ways to prevent major adverse events (2024, August 30) retrieved 12 September 2024 from https://medicalxpress.Com/news/2024-08-chronic-coronary-syndrome-guidelines-diagnostic.Html
This document is subject to copyright. Apart from any fair dealing for the purpose of private study or research, no part may be reproduced without the written permission. The content is provided for information purposes only.
Comments
Post a Comment