Chronic coronary syndromes — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 55-year-old man who smokes and has hypertension describes constricting retrosternal chest pain on exertion that settles with rest within 5 minutes. He has no diabetes or dyslipidaemia and no family history of premature CAD. Resting ECG and echocardiogram are normal.^[1]

1. Using the ESC 2024 Risk Factor-weighted Clinical Likelihood (RF-CL) model, calculate his symptom score and number of risk factors, and state his likelihood of obstructive CAD and its category. (3)^[1]
2. Which test does ESC 2024 recommend as the preferred modality to rule out obstructive CAD in him, with its class and level, and why is it suited to this likelihood band? (3)^[1]
3. List the ESC 2024 conditions in which CCTA is not recommended. (2)^[1]
4. His CCTA shows a 60% stenosis in the proximal LAD. Give two ESC 2024 options for establishing its functional significance. (2)^[1]

Model answers — SAQ 1

1. Symptom score 3 points: one each for constricting retrosternal discomfort, aggravation by physical stress, and relief by rest within 5 min.^[1] Two risk factors (smoking and hypertension) out of the five counted: family history, smoking, dyslipidaemia, hypertension and diabetes.^[1] ESC 2024 Figure 4 gives a man aged 50–59 with a symptom score of 3 and 2–3 risk factors an RF-CL of 27%, which is moderate (more than 15% to 50%); ESC 2024 Figure 8 uses this same profile (27%).^[1]
2. To rule out obstructive CAD in individuals with suspected CCS and a low or moderate (more than 5% to 50%) pre-test likelihood, ESC 2024 recommends CCTA as the preferred diagnostic modality (Class I, Level B).^[1] Also creditable: in individuals with suspected CCS and a low or moderate (more than 5% to 50%) pre-test likelihood of obstructive CAD, CCTA is recommended, if available and supported by local expertise, to diagnose obstructive CAD and estimate the risk of MACE (ESC 2024 Class I, Level A); and in symptomatic individuals with suspected CCS whose pre-test likelihood of obstructive CAD by clinical assessment is above 5%, CCTA or non-invasive functional imaging for myocardial ischaemia is recommended as the initial diagnostic test (ESC 2024 Class I, Level B).^[1] Reason: for individuals with suspected CCS, ESC 2024 notes growing support for CCTA as a first-line test in the group with a low or moderate (15%–50%) likelihood of obstructive CAD and, given the low prevalence of CAD in this group of patients and CCTA’s high negative predictive value, calls CCTA the most effective diagnostic method to rule out obstructive CAD; CCTA also shows non-obstructive CAD, which may trigger intensification of preventive measures.^[1]
3. In the initial diagnostic management of individuals with suspected CCS, CCTA is not recommended in patients with severe renal failure (eGFR below 30 mL/min/1.73 m2), decompensated heart failure, extensive coronary calcification, fast irregular heart rate, severe obesity, inability to cooperate with breath-hold commands, or any other condition that can make good image quality unlikely (ESC 2024 Class III, Level C; Recommendation Table 8 is scoped to CCTA if available and supported by local expertise).^[1]
4. In individuals with suspected CCS, functional imaging for myocardial ischaemia is recommended if CCTA has shown CAD of uncertain functional significance or is not diagnostic (ESC 2024 Class I, Level B).^[1] In patients with suspected CCS and a known intermediate coronary artery stenosis (typically around 40%–90% by visual estimate) in a proximal or mid coronary segment on CCTA, CT-based FFR may be considered (ESC 2024 Class IIb, Level B).^[1] Also creditable: in individuals with suspected CCS and an uncertain diagnosis on non-invasive testing, ICA with the availability of invasive functional assessments is recommended to confirm or exclude the diagnosis of obstructive CAD or ANOCA/INOCA (ESC 2024 Class I, Level B); and, during ICA, selective assessment of the functional severity of intermediate diameter stenoses with FFR/iFR (significant at 0.8 or less or 0.89 or less, respectively) is recommended to guide the decision to revascularise (ESC 2024 Class I, Level A).^[1]

SAQ 2 (10 marks)

Practice scenario. A 70-year-old woman with CCS, LVEF 60% and no heart failure has exertional angina (Canadian Cardiovascular Society class II) despite a beta-blocker. She asks about other tablets and about having a stent.^[1]

1. State the ESC 2024 general strategy for choosing antianginal drugs, with its class. (2)^[1]
2. List three ESC 2024 add-on options for her persistent angina, each with its class and level. (3)^[1]
3. Name two antianginal drugs or combinations that ESC 2024 does not recommend, stating the setting for each. (2)^[1]
4. When does ESC 2024 recommend revascularisation to improve symptoms, and what did ORBITA-2 show? (3)^[1][8]

Model answers — SAQ 2

1. For patients with CCS, ESC 2024 recommends tailoring the selection of antianginal drugs to the patient’s characteristics, comorbidities, concomitant medications, treatment tolerability and underlying pathophysiology of angina, also considering local drug availability and cost (Class I, Level C).^[1]
2. In patients with CCS whose anginal symptoms are not successfully controlled by initial treatment with a beta-blocker or a CCB alone, the combination of a beta-blocker and a DHP-CCB should be considered, unless contraindicated (ESC 2024 Class IIa, Level B).^[1] In patients with CCS, long-acting nitrates or ranolazine should be considered as add-on therapy when symptoms are inadequately controlled on beta-blockers and/or CCBs (ESC 2024 Class IIa, Level B); when long-acting nitrates are prescribed, a nitrate-free or low-nitrate interval should be considered to reduce tolerance (ESC 2024 Class IIa, Level B).^[1] In patients with CCS and inadequate control of symptoms on beta-blockers and/or CCBs, nicorandil or trimetazidine may be considered as add-on therapy (ESC 2024 Class IIb, Level B).^[1] Also creditable (AHA/ACC 2023): in patients with CCD and angina who remain symptomatic after initial treatment, addition of a second antianginal agent from a different therapeutic class (beta blockers, CCB, long-acting nitrates) is recommended for relief of angina or equivalent symptoms (COR 1, LOE B-R); and in patients with CCD who remain symptomatic despite treatment with beta blockers, CCB or long-acting nitrate therapies, ranolazine is recommended (COR 1, LOE B-R).^[2]
3. Ivabradine: not recommended as add-on therapy in patients with CCS, LVEF above 40% and no clinical heart failure (ESC 2024 Class III, Level B); this applies to her (LVEF 60%, no heart failure).^[1] In patients with CCS, combination of ivabradine with a non-DHP-CCB or other strong CYP3A4 inhibitors is not recommended (ESC 2024 Class III, Level B).^[1] In patients with CCS, nitrates are not recommended in those with hypertrophic cardiomyopathy or in co-administration with phosphodiesterase inhibitors (ESC 2024 Class III, Level B).^[1]
4. In CCS patients with persistent angina or anginal equivalent despite guideline-directed medical treatment, ESC 2024 recommends myocardial revascularisation of functionally significant obstructive CAD to improve symptoms (Class I, Level A).^[1] ESC 2024 adds that, for patients with obstructive CAD and refractory symptoms despite optimised GDMT, a referral for ICA may be considered to improve symptoms through revascularisation, and that optimisation of medical therapy by combining two or more antianginal drugs can safely be obtained over 6 weeks in almost all patients and should be awaited before such a referral.^[1] ORBITA-2 (double-blind, placebo-controlled): 301 patients with stable angina and objective evidence of ischaemia stopped all antianginal medications and, after a 2-week symptom assessment phase, were randomised 1:1 to PCI or a placebo procedure; the primary end point was the angina symptom score (0 to 79, higher scores worse); at 12 weeks the mean angina symptom score was 2.9 with PCI vs 5.6 with placebo (OR 2.21; 95% CI 1.41 to 3.47; P below 0.001).^[8] The investigators concluded that, among patients with stable angina who were receiving little or no antianginal medication and had objective evidence of ischaemia, PCI resulted in a lower angina symptom score than a placebo procedure, indicating a better health status with respect to angina.^[8] Also creditable (AHA/ACC 2023): in patients with CCD and lifestyle-limiting angina despite GDMT and with significant coronary artery stenoses amenable to revascularisation, revascularisation is recommended to improve symptoms (COR 1, LOE A).^[2]