Chronic Coronary Syndrome
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Direct answer
The ISCHEMIA trial reframed how chronic coronary syndrome (the 2019 ESC term replacing "stable coronary artery disease") is managed: among patients with moderate-to-severe ischaemia on non-invasive testing, an initial invasive strategy of catheterisation and revascularisation did not reduce death or myocardial infarction compared with optimal medical therapy, though it relieved angina better. First-line treatment is therefore medical — aspirin, a high-intensity statin, an ACE inhibitor where indicated, and anti-anginals (beta-blocker first, then calcium-channel blocker, long-acting nitrate, nicorandil or ranolazine). Revascularisation is reserved for symptoms refractory to two anti-anginals, or high-risk anatomy: left main disease, three-vessel disease, proximal LAD involvement, or ischaemic burden above 10 per cent of the myocardium.
What you must remember
- Terminology: "stable CAD" is now chronic coronary syndrome — six clinical scenarios from stable angina to asymptomatic post-revascularisation states; the exam still tests the 2019 ESC shift.
- Optimal medical therapy: aspirin 75-100 mg, high-intensity statin regardless of baseline LDL (aim: at least 50 per cent LDL reduction), ACE inhibitor or ARB in hypertension, diabetes or CKD, plus symptom-directed anti-anginals.
- ISCHEMIA (2020): routine invasive strategy gave no reduction in death or MI at median 3.3 years, but better daily angina control — COURAGE (2007) had already shown PCI adds no prognostic benefit over medical therapy in stable disease.
- Prognostic indications for revascularisation: left main stenosis, three-vessel disease (especially with reduced LVEF or diabetes), proximal LAD, large ischaemic territory (>10 per cent) on imaging.
- Diagnostic pathway: pre-test probability first; CT coronary angiography in low-to-intermediate probability (SCOT-HEART: fewer fatal and non-fatal MIs with CTCA-guided management), functional imaging (stress CMR, SPECT, stress echo) in higher probability.
- DAPT after elective PCI: 6 months of aspirin plus clopidogrel (1 month acceptable with high bleeding risk); 12 months after ACS.
- Risk factor targets: blood pressure below 130/80, HbA1c individualised, smoking cessation, cardiac rehabilitation referral — the intervention most reliably skipped in Indian practice.
How to work through a stable chest pain case
Start with the pre-test probability, not the angiogram. A 55-year-old man with typical exertional chest pain has a high probability, so send him straight to functional imaging or invasive angiography; a 45-year-old woman with atypical pain goes to CT coronary angiography first, because her probability of obstructive disease is low and a normal or non-obstructive scan safely ends the ischaemic work-up.
If an intermediate 50-70 per cent stenosis turns up, measure its physiology — FFR at or below 0.80 or iFR at or below 0.89 — before stenting. Once obstructive disease is confirmed, decide whether revascularisation is prognostic (left main, three-vessel, proximal LAD, large ischaemia) or purely symptomatic. In the purely symptomatic case, optimise medical therapy with two anti-anginals before offering PCI, and document why. Every patient leaves on a statin, aspirin where tolerated, and a structured follow-up plan; this is the sequence the examiners want to see articulated, not "cath everyone".
How the exam frames it
The trap is over-reading ISCHEMIA as "PCI is useless in stable disease". The correct statement is narrower: routine invasive management does not reduce death or MI in patients with moderate-to-severe ischaemia but stable symptoms, yet improves quality of life and remains indicated for refractory angina and high-risk anatomy. A favourite vignette contrasts two patients — one with anterior ischaemia over 15 per cent of the myocardium and reduced LVEF (revascularise, prognostic benefit), and one with single-vessel disease controlled on a beta-blocker (medical therapy). The Indian reality adds a second layer: direct-to-angiography pathways in private hospitals make the ISCHEMIA message clinically relevant here, since asymptomatic or mildly symptomatic patients frequently undergo multi-lesion PCI without any physiology measurement or documented anti-anginal trial.
Frequently asked questions
What did the ISCHEMIA trial actually show?
In stable patients with moderate-to-severe inducible ischaemia, an initial invasive strategy did not reduce death or myocardial infarction versus optimal medical therapy, but did improve angina-related quality of life.
When is revascularisation prognostic rather than just symptomatic?
Left main stenosis, three-vessel disease (particularly with diabetes or reduced LVEF), proximal LAD disease, and ischaemia involving more than 10 per cent of the myocardium.
How long should DAPT continue after elective stenting?
Six months of aspirin plus clopidogrel is standard for chronic coronary syndrome, shortened to 1-3 months with high bleeding risk and extended toward 12 months if an ACS intervened.
Which non-invasive test first for suspected chronic coronary syndrome?
CT coronary angiography for low-to-intermediate pre-test probability; functional imaging such as stress CMR or SPECT when probability is higher or CT is unsuitable.
Why did the ESC rename stable coronary artery disease?
To emphasise that atherosclerosis is a dynamic, modifiable disease with fluctuating phases rather than a fixed "stable" state, aligning management with long-term risk control.