Stable angina

Patients with stable angina are at a high risk for future cardiovascular event.
The goal of management for patients with a stable angina is: to improve mortality and to achieve resolution or reasonable control of symptoms, such  that functional status is optimized
Two treatment modalities for a stable angina exist.
Invasive approach-requires coronary angiography that often leads to percutaneous coronary intervention with the stent or coronary artery bypass grafting.
The second approach is aggressive medical therapy with stabilizing and, partially reversing the atherosclerotic plaque.
Relief from angina is the primary reason patients with stable, coronary artery disease undergo PCI.
Large, multicenter studies have found it long-term treatment with intensive medical therapy results in the same cardiovascular end points as does percutaneous coronary
intervention (COURAGE trial).
In the COURAGE  trial patients were randomized to PCI plus intensive medical therapy or intensive medical therapy alone for severe coronary artery disease and stable angina: stenting did not reduce the risk of death, myocardial infarction, or other major cardiovascular events compared with medical therapy, nor were there significant differences in the change of anginal symptoms between groups.
In the ORBITA trial stenting did not increase exercise tolerance more than the medically treated patients on placebo.
ISCHEMIA trial demonstrated no significant differences in ischemic cardiovascular events with mortality between treatment groups over a median of 3.2 years.
Partial reversal of atherosclerosis has been demonstrated by intravascular ultrasound for the control of major cardiovascular risk factors, including smoking, hypertension, diabetes, and dyslipidemia.
Aggressive lowering of LDL cholesterol stabilizes atherosclerotic plaque that can occur within 30 days of beginning antilipidemic therapy.
The initial plaque reversal can be demonstrated within one or two years thereafter.
Atherosclerotic plaque reversal is based on removal of cholesterol from the plaque in elimination elimination of inflammatory cytokines that lead to plaque rupture.
The reason that stenting  does not necessarily reduce cardiovascular events is that the obstructive plaque is often not the same plaque that ruptures to cause myocardial infarction.
Among patients who undergo a coronary angiogram and then suffer a subsequent myocardial infarction with  repeat coronary angiogram, in only 34% did the infarction occur as a result of the occlusion of the artery that previously contained the most severe stenosis: that’s why stenting does not necessarily reduce cardiovascular disease events.

B-blockers first-line therapy.

Aspirin is the mainstay of antiplatelet treatment and should be started at diagnosis and continued indefinitely.

Patients with stable coronary artery disease treated conservatively and medically as opposed to invasive stent placement or a bypass surgery showed similar risk for cardiovascular death, myocardial infarction heart failure, and cardiac arrest or hospitalization (ISCHEMIA trial).
Approximately 60% of patients with stable chest pain referred for angiography have no hemodynamically significant coronary artery stenosis.
Defining the anatomy does not necessarily provide useful information about the hemodynamic importance of a lesion unless such definition is accompanied by some demonstration of impaired perfusion.
Coronary CT tomographic angiography (CCTA) is a sensitive, specific, and positive predictive evaluator, and negative predictive evaluator for identifying obstructive coronary artery lesions.
CCTA has become the preferred imaging approach for assessing patients with stable chest pain especially  those with intermediate pretest probabilities of obstructive coronary artery disease.
DISCHARGE trial found no material difference between CCTA as compared with angiography in the incidence of primary composite outcome of cardiovascular death, nonfatal myocardial infarction, or non-fatal stroke during 3.5 years of follow up: it is probably a consequence of the lack of effective revascularization on cardiovascular events among most patients with stable angina in the limited number of those with high risk anatomy who would benefit from revascularization.
Among patients with stable angina, who were receiving little or no antianginal medication and had objective evidence of ischemia, PCI resulted in lower angina symptoms score than a placebo procedure, indicating a better health status with respect to angina (ORBITA-2 investigators).
In a randomized, double blind, placebo controlled trial, PCI was shown as an effective antianginal treatment in patients with stable angina, who had objective evidence of ischemia (ORBITA-2).

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