in cardiovascular medicine
Updated ESC guidelines on the management of stable coronary artery disease
2013 ESC guidelines on the management of stable coronary artery disease
The Task Force on the management of stable coronary artery disease of the European Society of Cardiology, Montalescot G, Sechtem U, Achenbach S, et al., ESC Committee for Practice Guidelines (CPG)
Eur Heart J 2013 34: 2949-3003
The concept of stable coronary artery disease (SCAD) has evolved since the release of guidelines addressing the management and treatment of stable angina pectoris in 2006. SCAD is now considered to refer to all different evolutionary phases of CAD. SCAD thus encompasses those having stable angina pectoris or other symptoms felt to be related to coronary artery disease, such as dyspnoea; those previously symptomatic with known obstructive or non-obstructive CAD who have become asymptomatic with treatment and need regular follow-up; and those who report symptoms for the first time and are judged to be already in a chronic stable condition. Situations in which coronary artery thrombosis dominates clinical presentation (acute coronary syndromes) are excluded.
The changing views on SCAD called for updated guidelines on its management. The present guidelines focus both on diagnostic testing and on prognostic assessment, as many tests nowadays provide this prognostic information in addition to diagnostic information.
The role of coronary revascularisation is extensively discussed and put into the context of recent evidence questioning the prognostic role of percutaneous coronary intervention or coronary artery bypass grafting in this low risk patient population.
The estimation of pre-test probability of SCAD has been updated according to recent evidence and is now strongly influencing the choice of diagnostic tests. The application of the revised diagnostic and prognostic algorithms streamline clinical decision-making, as discussed in the guidelines.
The importance of physiological assessment of CAD in the catheterisation laboratory is also discussed. Practical algorithms for diagnostic and therapeutic purposes are given. The new diagnostic and prognostic algorithms now also consider microvascular dysfunction and coronary vasospasm, in addition to atherosclerotic narrowings.
Lifestyle and pharmacological management options are thoroughly discussed. In particular, cardiac rehabilitation, influenza vaccination and hormone replacement therapy are addressed along with the current role of several pharmacological options.
Special attention is paid to specifically complex patient sub-groups, such as those with SCAD and low arterial pressure or with low heart rate. Moreover, women, diabetic patients, those with chronic kidney disease, elderly patients and those who have previously undergone coronary revascularisation received in-depth attention.
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Although increased risk of MACE was seen at high Lp(a) levels, marked heterogeneity is seen across studies. Especially if LDL-c is well-controlled, value of Lp(a) is limited.
CRP levels are more strongly associated with fatal, than with nonfatal CV events
2-10-2013 • van Wijk DF, Boekholdt SM, Wareham NJ et al.
Analysis of EPIC-Norfolk cohort shows independent association of CRP levels with future CAD events, as well as PAD in apparently healthy individuals.
AQUARIUS: Aliskiren does not significantly reduce atheromavolume, but shows fewer MACE
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First epigenetic modification of HDL-c levels with an oral agent that stimulates Apo A-I production, does not give the reduction of atheroma volume that was hoped for.
Combination therapy consisting of statin, aspirin and >1 BP-lowering agent reduces CV-risk
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Using three components is more effective at reducing CV events and mortality than taking one or two components of combination therapy, in patients with established CAD.
Protective effects of HDL-C challenged in CABG
7-6-2013 • Angeloni E, Paneni F, Landmesser U et al.
Directing all efforts to increasing HDL-C levels to reduce CV risk might not be the way to go, since evidence suggests that the normal protective HDL-C is lost in CAD.
Asymptomatic CAD predicts major vascular events after ischemic stroke
28-5-2013 • Amarenco P, Lavallée PC, Labreuche J, et al.
Risk of future vascular events increases with severity of stenosis and number of arteries involved.
Atypical chest pain in women revisited
15-4-2013 • Kreatsoulas C, Shannon HS, Giacomini M, et al.
Women and men are more alike than previously thought in presentation of CAD, and both are most likely to experience chest pain, pressure, and tightness
Coronary artery disease alters downstream effects of HDL
13-3-2013 • Riwanto M, Rohrer L, Roschitzki B, et al.
Functional study in mice show that HDL obtained from CAD stimulates endothelial proapoptotic pathways, instead of antiapoptotic in the case of healthy HDL
Cardioprotective effect of Beta-blockers questioned
16-10-2012 • Bangalore S, Steg G, Deedwania P, et al; REACH Registry Investigators, JAMA. 2012;
JAMA, Oct 2012.
Beta blockers may not improve outcomes in patients with CAD.
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