Esc guidleines on scad

Guidelines on the management
of Stable coronary artery disease
SCAD

Stable coronary artery disease
• Stable coronary artery disease is generally characterized by episodes of
reversible myocardial demand/supply mismatch, related to ischaemia or
hypoxia, which are usually inducible by exercise, emotion or other stress
and reproducible—but, which may also be occurring spontaneously. Such
episodes of ischaemia/hypoxia are commonly associated with transient
chest discomfort (angina pectoris). SCAD also includes the stabilized, often
asymptomatic, phases that follow an ACS.
• Finally SCAD is also comprises the long silent Pre-symptomatic state of
coronary arteriosclerosis
• Angina at rest is caused by coronary vasospasm is regarded within scope
the scope of SCAD

Main features of SCAD
• The various clinical presentations of SCAD are associated with
different underlying mechanisms that mainly include:
• (i) plaque-related obstruction of epicardial arteries;
• (ii) focal or diffuse spasm of normal or plaque-diseased
arteries;
• (iii) microvascular dysfunction and
• (iv) left ventricular dysfunction caused by prior acute
myocardial necrosis and/or hibernation
• Ischaemia cardiomyopathy if present , stable coronary
plaques with or without previous revascularisation may also
be completely clinically silent

Epidemiology
• Angina pectoris is more prevalent in middle
aged women than men , probably due to high
prevalence of functional coronary artery
disease such as Microvascular angina in
women .
• In contrast , angina pectoris is more prevalent
in elderly men

Natural History and Prognosis
• The prognosis in patients with SCAD is relatively benign with
estimates of annual mortality rates in mixed populations
ranging from 1.2 to 2.4 % with an annual incidence of cardiac
death between 0.6to 1.4% .
• In general , the outcome is worse in patients with reduced left
ventricular ejection fraction (LVEF) and heart failure ,a greater
number of diseased vessels , more proximal locations of
coronary stenoses , greater severity of lesions , more
extensive ischemia , more impaired functional capacity , older
age , significant depression and more severe angina

Diagnosis and Assessment
• These investigations may be used to confirm the diagnosis of
ischaemia in patients with suspected SCAD, to identify or
exclude associated conditions or precipitating factors, assist in
stratifying risk associated with the disease and to evaluate the
efficacy of treatment.
• In practice, diagnostic and prognostic assessments are
conducted simultaneously, rather than separately, and many
of the investigations used for diagnosis also offer prognostic
information. However, for the purpose of clarity, the
processes of obtaining diagnostic and prognostic information
are dealt with separately in this text.

Symptoms and signs
• In the majority of cases, it is
possible to make a
confident diagnosis on the
basis of the history alone,
although physical
examination and objective
tests are often necessary to
confirm the diagnosis,
exclude alternative
diagnoses,and assess the
severity of underlying
disease.
Traditional clinical classification of chest pain

The Canadian Cardiovascular Society
Classification
• The Canadian Cardiovascular Society
classification is widely used as a grading
system for stable angina
• Angina pain at rest pain may occur in all
grades as a manifestation of associated and
superimposed coronary vasospasm.
• The class assigned is indicative of the
maximum limitation and that the patient may
do better on other days.

Classification of angina severity
according to the
Canadian Cardiovascular Society

Basic Testing
• This includes standard laboratory biochemical
testing , a resting ECG possibly ambulatory
ECG monitoring (if there is clinical suspicion
that symptoms may be associated with a
paroxysmal arrhythmia) resting
echocardiography and, in selected patients, a
chest X-ray

Blood tests in assessment of patients
with known or suspected SCAD
ACS = acute coronary syndrome; BNP = B-type natriuretic peptide; HbA1c = glycated haemoglobin; LDL = low density lipoprotein; NT-proBNP = N-
terminal pro B-type natriuretic peptide; SCAD = stable coronary artery disease; T2DM = type 2 diabetes mellitus.
a Class of recommendation.
b Level of evidence.
c Reference(s) supporting class I (A + B) and IIa + IIb (A + B) recommendations.
dFor details please refer to dyslipidaemia guidelines.62

Blood tests in assessment of patients
with known or suspected SCAD
SCAD = stable coronary artery disease.

Resting electrocardiogram for initial
diagnostic assessment of SCAD
ECG = electrocardiogram; SCAD = stable coronary artery disease.

Echocardiography
CAD = coronary artery disease; IMD = Intima-media thickness; LVEF = left ventricular
ejection fraction; SCAD = stable coronary artery disease.

Ambulatory electrocardiogram
monitoring for initial diagnostic
assessment of SCAD
ECG = electrocardiogram; SCAD = stable coronary artery disease.

CXR for initial diagnostic assessment
of SCAD
CXR = chest X-ray.
c Reference(s) supporting class I (A + B) and IIa
+ IIb (A + B) recommendations.

3-Major steps used for decision making
in patients with Suspected SCAD
• These guidelines recommend a stepwise approach for decision making in
patients with suspected SCAD.
• Step 1 : Determination of pre probability test
• Step 2 : Consist of non-invasive testing to establish the diagnosis of SCAD
or non-obstructive atherosclerosis
• Step 3 : consist of stratifying for risk of subsequent event usually on the
basis of available non-invasive tests in patients at intermediate PTP
• Usually optimal medical therapy will be instituted between steps 2 and 3
• In patients with severe symptoms who have high intermediate or high pre
test probability early invasive coronary angiography (ICA) may be
performed with appropriate invasive confirmation of the significance of a
stenosis (FFR) and subsequent revascularization, bypassing non-invasive
testing in Steps 2 and 3.

Principles of Diagnostic testing
• Non-invasive, imaging-based diagnostic methods for CAD have typical
sensitivities and specificities of approximately 85% . Hence, 15% of all
diagnostic results will be false and, as a consequence, performing no test
at all will provide fewer incorrect diagnoses in patients with a PTP below
15% (assuming all patients to be healthy) or a PTP above 85% (assuming
all patients to be diseased).
• This is the reason why this Task Force recommends no testing in patients
with (i) a low PTP <15% and (ii) a high PTP >85%. In such patients, it is safe
to assume that they have (i) no obstructive CAD or (ii) obstructive CAD.

Characteristics of tests commonly
used to diagnose the presence of CAD
CAD = coronary artery disease; CTA = computed tomography angiography; ECG = electrocardiogram; MRI =
magnetic resonance imaging; PET = positron emission tomography; SPECT = single photon emission computed
tomography.
a Results without/with minimal referral bias.
b Results obtained in populations with medium-to-high prevalence of disease without compensation for
referral bias.
c Results obtained in populations with low-to-medium prevalence of disease.

Clinical pre-test probabilities in
patients with SCAD
ECG = electrocardiogram; PTP = pre-test probability; SCAD = stable coronary artery disease.
a Probabilities of obstructive coronary disease shown reflect the estimates for patients aged 35, 45, 55, 65, 75
and 85 years.
• Groups in white boxes have a PTP <15% and hence can be managed without further testing.
• Groups in blue boxes have a PTP of 15–65%. They could have an exercise ECG if feasible as the initial test.
However, if local expertise and availability permit a non-invasive imaging based test for ischaemia this would be
preferable given the superior diagnostic capabilities of such tests. In young patients radiation issues should be
considered.
• Groups in light red boxes have PTPs between 66–85% and hence should have a non-invasive imaging
functional test for making a diagnosis of SCAD.
• In groups in dark red boxes the PTP is >85% and one can assume that SCAD is present. They need risk
stratification only.

Initial diagnostic management of patients with suspected SCAD
CAD = coronary artery disease; CTA = computed tomography
angiography; CXR = chest X-ray; ECG = electrocardiogram; ICA =
invasive coronary angiography; LVEF = left ventricular ejection fraction;
PTP = pre-test probability; SCAD = stable coronary artery disease.

Non-invasive testing in patients with suspected SCAD and an intermediate pre-test
probability.

Stress testing for diagnosing
ischaemia
• The main value of exercise ECG testing is in
patients with normal resting ECGs .
• Inconclusive exercise ECGs are common in
these patients an alternative non-invasive
imaging test often with pharmacological stress
should be selected .
• In patients at a low intermediate pre-test
probability , coronary CTA is another option

Performing an exercise ECG for initial
Diagnostic assessment of Angina

Stress Imaging
• With this technique , exercise is the test of choice when
feasible as compared to testing with pharmacological agents .
• Pharmacological testing is preferred when viability
assessment is necessary or if patient is unable to exercise
adequately .
• Dobutamine is the pharmacological agent of choice .
• Contrast agent must be used when two or more continuous
segments are not visualized at rest

Myocardial perfusion Scintigraphy
(SPECT /PET )
• 99mTC radiopharmaceuticals are the most commonly used
tracers and symptoms-limited exercise testing is preferred .
• Pharmacological testing has the same indications as for stress
echocardiography
• Perfusion imaging using PET is superior to SPECT imaging and
may be used if available

Stress Cardiac Magnetic resonance
• This can only be used in conjunction with pharmacological stress . This
technique has a good diagnostic accuracy as compared with nuclear
perfusion imaging

Technique Advantage Disadvantage
Echocardiography Wide access
Portability
No radiation
Low cost
Echo contrast needed in patients with
poor ultrasound windows
Dependent on operator skills
SPECT Wide access
Expensive date
Radiation
PET Flow quantitation Radiation
Limited access
High cost
CMR High soft tissue contrast including
precise imaging of myocardial scar
No radiation
Limited access in cardiology
Contrindiactions
Functional analysis Limited in
arrhythmias
Limited 3D quantification of ischemia
High cost
Coronary CTA High NPV in patients with Low
intermediate PTP
Limited availability
Radiation
Assessment Limited with extensive
coronary calcification or previous
stent implantation
Image quality Limited with arrhythmias
and high heart rates that cannot be
lowered below 60-65/min
Low NPV in patients with high PTP

Non-invasive techniques to assess
coronary anatomy
• Computed tomography
• Calcium scoring
• Coronary computed tomography angiography
• Magnetic resonance coronary angiography

Use of Coronary CTA for the diagnosis
of SCAD
CTA = computed tomography angiography; ECG = electrocardiogram; PTP = pre-test
probability; SCAD = stable coronary artery disease.

Invasive coronary angiography
• The main role of ICA is in patients in whom either symptoms
or a high risk of adverse events suggest a clear benefit of
revascularization .
• However in patients who cannot undergo stress imaging
techniques , patients with reduced LEVF<50% and typical
angina or in patients with special professions such as pilots
due to regulatory issues ICA may be useful for sole purpose of
establishing or excluding the diagnosis of SCAD

Stratification for Risk of events
• These guidelines provide a uniform definition of risk of
adverse events based on commonly used non invasive test
and ICA
• an annual mortality >3% are defined as high event risk
patients. It is in such patients that revascularization has the
potential effect
• low event risk patients are those with an annual mortality
<1% per year, similar to the definition chosen in the previous
edition.
• The intermediate event risk group has an annual mortality of
≥1% but ≤3% per year

Definitions of risk for various test
modalities
CAD = coronary artery disease; CMR = cardiac magnetic resonance; CTA = computed
tomography angiography; CV = cardiovascular; ECG = electrocardiogram; ICA =
invasive coronary angiography; LM = left main; PTP = pre-test probability; SPECT =
single photon emission computed tomography.

Stratification for risk of events
• Clinical information can provide important prognostic clues and is used to
modulate decisions made on the basis of pre-test probability and non
invasive ischemia / anatomy evaluation of prognosis .
• The strongest predictor of long term survival is LV function and Patients
with LVEF <50% are already at high risk for events ( annual mortality >3% )
• Especially in patients with tolerable symptoms ICA and revascularization
should be reserved for those patients found to be at high risk on the basis
of non invasive stress testing .
• Patients with high pre test probability who do not need diagnostic testing
should nevertheless undergo stress testing for event risk stratification
purpose .

Management based on risk determination for prognosis in patients with chest pain and
suspected SCAD

Risk stratification by resting
Echocardiography Quantification of
Ventricular function of SCAD
LV = left ventricular; SCAD = stable coronary artery
disease.

Risk Stratification using Ischemia
testing
ECG = electrocardiogram; LBBB = left bundle branch block; SCAD = stable coronary
artery disease; SPECT = single photon emission computed tomography.

Risk stratification by invasive or non-
invasive coronary arteriography in
patients with SCAD

Diagnostic aspect in symptomatic
individual without known CAD
• The use of tests in asymptomatic adults should be restricted to the indications
listed below

Management aspects in patients with
known CAD
• The clinical course of patients with known SCAD may continue
to be stable or be complicated by phases of instability, MI and
heart failure. Revascularization(s) may become necessary in
the course of the disease.
• No evidence based recommendation can be made for what
time interval prognostic testing should be repeated in stable
asymptomatic patient with known CAD
• Thus, clinical judgement is required for determining the need
for repeated stress testing, which should be performed using
the same stress and imaging technique

Reassessment in patients with SCAD

Special diagnostic considerations :
Angina with Normal coronary arteries
• The identification of patients who have normal coronary arteries despite
suffering from typical angina or angina at rest only without non invasive or
invasive coronary angiography is notoriously difficult .
• Patients with Microvascular angina have angina which is mostly typical
features although the duration of symptoms may be prolonged and
relation to exercise is somewhat inconsistent .
• Often , these patients have abnormal results of stress test .
• In patients who have typical features of Angina in terms of location and
duration but where angina occurs predominantly at rest , coronary
vasospasm should be considered

Investigation in patients with suspected
coronary Microvascular disease
FFR = fractional flow reserve; LAD = left anterior descending.

Vasospastic Angina
• The diagnosis of vasopsastic angina can be
made when resting ECGs are taken during an
anginal attack and when patient is pain free .
As the prevalence of coronary vasospasm is
still underestimated by clinicans it may be
prudent to perform spasm test in those
patients in whom invasive coronary
angiography is anyway performed to exclude
epicardial stenoses

Diagnostic test in suspected
vasospastic Angina

Life style and Pharmacological
management
• The aim of the management of SCAD is to reduce symptoms
and improve prognosis. The management of CAD patients
encompasses lifestyle modification, control of CAD risk
factors, evidence-based pharmacological therapy and patient
education
• Life style recommendations include
• Smoking Cessation
• Healthy Diet
• Regular physical activity
• Weight and lipid mangement
• BP and Glucose control

Blood pressure thresholds for definition of
hypertension with different types of blood
pressure measurement (adapted from
Umpierrez et al. 2012
BP= blood pressure; DPB= diastolic blood pressure; SBP= systolic blood pressure.

Pharmacological management of SCAD
patients
• The two aims of the pharmacological
management of stable CAD patients are to
obtain relief of symptoms and to prevent CV
events.
• Table 27 indicates the main side-effects,
contra-indications and major drug–drug
interactions for each drug class.
• Table 28 presents the recommendations for
drug therapy.

Major side-effects, contra-indications, drug–drug interactions (DDI) and precautions of
anti-ischaemic drugs.

Medical management of patients with stable coronary artery disease.

Pharmacological treatments in
SCAD Patients

Treatment in patients with
microvascular angina
ACE = angiotensin converting enzyme.

Stenting and peri-procedural
antiplatelet strategies in SCAD
DATP = Dual antiplatelet therapy; SCAD = stable coronary artery disease.

Optical coherence tomography
• When non-invasive stress imaging is contra-indicated, non-
diagnostic, or unavailable, the measurement of FFR during
adenosine infusion is particularly helpful in identify
haemodynamically or functionally significant stenosis,
inducing ischaemia, justifying revascularization
• The use of inta vascular ultrasound ( IVUS) has been broadly
investigated in SCAD with many different subsets of lesions
and more recently , optical coherence tomography (OCT) has
been developed as a new intracoronary imaging tool with
superior resolution

Use of fractional flow reserve /
Intravascular
FFR = fractional flow reserve; IVUS = intravascular ultrasound; OCT = optical coherence
tomography; SCAD = stable coronary artery disease.

Global strategy of intervention in stable coronary artery disease (SCAD) patients with
demonstrated ischaemia.

Revascularization of SCAD Patients of
OMT

Characteristics of Seven more recent
randomized trials

Percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG) in
stable coronary artery disease without left main coronary artery involvement.
Task Force Members et al. Eur Heart J
2013;eurheartj.eht296
© The European Society of Cardiology 2013. All rights reserved. For permissions please email:
journals.permissions@oup.com

PCI or CABG in SCAD patients without
left coronary arm involvement
• >50% stenosis and proof of ischaemia, >90% stenosis in two
angiographic views, or FFR = 0.80.bCABG is the preferred
option in most patients unless patients co-morbidities or
specificities deserve discussion by the heart team. According
to local practice (time constraints, workload) direct transfer to
CABG may be allowed in these low risk patients, when formal
discussion in a multidisciplinary team is not required (adapted
from ESC/EACTS Guidelines on Myocardial Revascularization
2010).

Percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG) in
stable coronary artery disease with left main coronary artery involvement.
Task Force Members et al. Eur Heart J
2013;eurheartj.eht296
© The European Society of Cardiology 2013. All rights reserved. For permissions please email:
journals.permissions@oup.com

PCI or CABG in SCAD with Coronary
arm involvement
• >50% stenosis and proof of ischaemia, >70%
stenosis in two angiographic views, or
fractional low reserve = 0.80.bPreferred option
in general. According to local practice (time
constraints, workload) direct decision may be
taken without formal multidisciplinary
discussion, but preferably with locally agreed
protocols

Follow-up of revascularized stable coronary
artery disease patients

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