Chronic coronary syndrome medical therapy — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 68-year-old man with chronic coronary syndrome and obstructive coronary disease on CT coronary angiography has exertional angina several times a week. His resting heart rate is 78 beats per minute, blood pressure 150/90 mmHg and LVEF 60%, with no clinical heart failure. He takes aspirin and atorvastatin.^[1]

1. State the two aims of medical therapy in CCS that ESC 2024 asks clinicians to explain, and the one antianginal outcome exception it names. (2)^[1]
2. Give the ESC 2024 recommendations for immediate relief and for initial treatment, with class and level, and the resting heart-rate aim for a beta-blocker used for angina. (3)^[1]
3. Angina persists on a beta-blocker at the highest tolerated dose. Give the ESC 2024 next step and its class. (1)^[1]
4. Give two add-on options with their ESC 2024 class, and the ESC 2024 and AHA/ACC 2023 positions on ivabradine for him. (3)^[1][2]
5. What does AHA/ACC 2023 say about ranolazine when symptoms persist on beta blockers, CCB or long-acting nitrates? (1)^[2]

Model answers — SAQ 1

1. ESC 2024 says clinicians should clearly explain that certain treatments can alleviate symptoms, while others can reduce the likelihood of ischaemic events (1 mark).^[1] It says there is no evidence that any antianginal medication may improve long-term cardiovascular outcomes, except beta-blockers if administered within 1 year after an acute MI (1 mark).^[1]
2. Short-acting nitrates are recommended for immediate relief of angina (Class I, Level B) (1 mark).^[1] Initial treatment with beta-blockers and/or CCBs to control heart rate and symptoms is recommended for most patients with CCS (Class I, Level B) (1 mark).^[1] If a beta-blocker is used for angina, the aim should be a resting heart rate of 55–60 beats per minute (1 mark).^[1]
3. If angina is not controlled by a beta-blocker alone, the combination of a beta-blocker and a dihydropyridine CCB should be considered, unless contraindicated (Class IIa, Level B) (1 mark).^[1]
4. Long-acting nitrates or ranolazine should be considered as add-on therapy (Class IIa, Level B); nicorandil or trimetazidine may be considered as add-on therapy (Class IIb, Level B) (2 marks: 1 each for any two options with correct class).^[1] With LVEF >40% and no clinical heart failure, ESC 2024 does not recommend ivabradine as add-on therapy (Class III, Level B), and AHA/ACC 2023 says adding it to standard therapy with normal LV function is potentially harmful (COR 3: Harm) (1 mark).^[1][2]
5. AHA/ACC 2023 recommends ranolazine in CCD patients who remain symptomatic despite beta blockers, CCB or long-acting nitrate therapies (COR 1, LOE B-R) (1 mark).^[2]

SAQ 2 (10 marks)

Practice scenario. A 60-year-old woman had PCI for an MI 3 years ago and has completed DAPT. She now has chronic coronary syndrome without angina, type 2 diabetes on metformin (HbA1c 6.9%), hypertension, LVEF 55% and BMI 29 kg/m². Her LDL-C is 1.9 mmol/L on the highest tolerated dose of a high-intensity statin. She has no indication for oral anticoagulation and smokes 10 cigarettes a day.^[1]

1. Give the ESC 2024 long-term antiplatelet recommendation for her and its alternative, with class and level. (2)^[1]
2. Give the ESC 2024 LDL-C goal and the next lipid step, with class and level. (2)^[1]
3. Which ESC 2024 row applies to her diabetes, and why does her HbA1c not change it? (2)^[1]
4. Give the ESC 2024 rows on an ACE inhibitor and on colchicine for her, with class and level. (2)^[1]
5. Give the AHA/ACC 2023 tobacco rows that apply at every visit, and its influenza vaccination row. (2)^[2]

Model answers — SAQ 2

1. With no clear indication for oral anticoagulation and a prior MI or remote PCI, aspirin 75–100 mg daily is recommended lifelong after an initial period of DAPT (Class I, Level A) (1 mark).^[1] Clopidogrel 75 mg daily is recommended as a safe and effective alternative to aspirin monotherapy in the same group (Class I, Level A) (1 mark).^[1]
2. Lipid-lowering treatment with an LDL-C goal of <1.4 mmol/L (55 mg/dL) and a ≥50% reduction from baseline is recommended (Class I, Level A) (1 mark).^[1] Her goal is not achieved on the maximum tolerated statin, so combination with ezetimibe is recommended (Class I, Level B) (1 mark).^[1]
3. SGLT2 inhibitors and GLP-1 receptor agonists with proven cardiovascular benefit are recommended in type 2 diabetes and CCS to reduce cardiovascular events (each Class I, Level A) (1 mark).^[1] The rows apply independent of baseline or target HbA1c and of concomitant glucose-lowering medication (1 mark).^[1]
4. ACE inhibitors (or ARBs) are recommended in CCS with specific comorbidities such as hypertension, diabetes or heart failure (Class I, Level A) (1 mark).^[1] Low-dose colchicine (0.5 mg daily) should be considered in CCS with atherosclerotic CAD to reduce MI, stroke and need for revascularisation (Class IIa, Level A) (1 mark).^[1]
5. Tobacco use should be assessed at every health care visit, and patients who regularly smoke should be advised to quit at every visit (each COR 1, LOE A); for those who regularly smoke, behavioural interventions combined with pharmacotherapy are recommended to maximise cessation rates (COR 1, LOE A) (1 mark).^[2] Annual influenza vaccination is recommended to reduce cardiovascular morbidity, cardiovascular death and all-cause death (COR 1, LOE A) (1 mark).^[2]