Chronic Coronary Syndrome (CCS), also referred to as Chronic Coronary Disease (CCD) is a term used to describe the chronic, stable phase of coronary artery disease (CAD).
It encompasses a heterogeneous group of conditions, including obstructive and nonobstructive CAD, with or without a history of myocardial infarction (MI).
CCS focuses on long-term management to prevent events like heart attacks, improve quality of life, and extend life expectancy. 0 10
The hallmark symptom of CCS is angina pectoris, which presents as chest pain or discomfort due to myocardial ischemia.
This can occur during exertion or stress and may radiate to the arms, neck, jaw, or back.
Other symptoms include shortness of breath, fatigue, or nausea, particularly in women or older adults.
Angina with no or nonobstructive coronary arteries (ANOCA/INOCA), can mimic traditional CCS but requires different diagnostic approaches.
Key risk factors include advanced age, male sex, smoking, hypertension, diabetes, dyslipidemia, obesity, family history of premature CAD, and chronic kidney disease.
Non-invasive testing like stress testing or coronary CT angiography is often sufficient.
Echocardiography assesses left ventricular function, and invasive angiography is reserved for high-risk cases or when revascularization is planned.
Diagnostic goals confirm ischemia, quantify stenosis, and rule out acute syndromes.
Management of CCS aims to relieve symptoms, prevent progression, and reduce cardiovascular events.
Key strategies include:
Lifestyle Modifications: Smoking cessation, regular physical activity (at least 150 minutes/week of moderate aerobic exercise), heart-healthy diet (Mediterranean-style), weight management, and stress reduction.
Pharmacotherapy: Anti-anginal/anti-ischemic drugs: Beta-blockers (first-line for post-MI), calcium channel blockers, long-acting nitrates, or ivabradine for symptom relief.
Event prevention: High-intensity statins for lipid control (LDL <55 mg/dL target), antiplatelet therapy (e.g., aspirin 75-100 mg daily), ACE inhibitors/ARBs for hypertension or diabetes, and SGLT2 inhibitors/GLP-1 agonists for high-risk patients.
Recent evidence questions routine aspirin use in patients on oral anticoagulation, suggesting de-escalation in select high-risk groups to reduce bleeding without increasing events.
Among patients with chronic coronary syndrome and high thrombotic risk who were receiving oral anticoagulant, the addition of aspirin led to higher risk of cardiovascular death, myocardial infarction, stroke, systemic, embolism, coronary revascularization, or acutely ischemia, then placebo, as well as high risk of death from any cause and major bleeding (AQUATIC trial investigators).
Percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is indicated for significant left main disease, proximal LAD stenosis, or refractory symptoms despite optimal medical therapy.
For refractory angina, options include enhanced external counterpulsation or spinal cord stimulation.