Chronic coronary syndrome medical therapy — viva

Stem

Practice viva. The examiner describes a patient with stable angina and obstructive coronary disease seen in clinic, and works through antianginal drug choice, event prevention, lifestyle and vaccination, the place of revascularisation, and follow-up.

Branch A — Aims and first drugs

Examiner: What are you trying to achieve with medical therapy, and what do you start?^[1]

Strong answer:

• ESC 2024 says clinicians should clearly explain that certain treatments can alleviate symptoms, while others can reduce the likelihood of ischaemic events.^[1]
• Short-acting nitrates are recommended for immediate relief of angina (ESC 2024, Class I, Level B); AHA/ACC 2023 recommends sublingual nitroglycerin or nitroglycerin spray for immediate short-term relief (COR 1, LOE B-NR).^[1][2]
• ESC 2024 recommends initial treatment with beta-blockers and/or CCBs to control heart rate and symptoms for most patients (Class I, Level B), tailored to haemodynamic profile, comorbidities, interacting drugs and preferences.^[1]
• AHA/ACC 2023 recommends a beta blocker, CCB or long-acting nitrate for relief of angina (COR 1, LOE B-R).^[2]

Follow-up: Which antianginal drug improves outcomes?^[1]

• ESC 2024 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]

Branch B — Escalation and pitfalls

Examiner: Angina persists on a beta-blocker. What next, and what must you avoid?^[1]

Strong answer:

• ESC 2024: if angina is not controlled by a beta-blocker alone, a beta-blocker plus a dihydropyridine CCB should be considered, unless contraindicated (Class IIa, Level B).^[1]
• ESC 2024: long-acting nitrates or ranolazine should be considered as add-on therapy (Class IIa, Level B), with a nitrate-free or low-nitrate interval to reduce tolerance (Class IIa, Level B); nicorandil or trimetazidine may be considered (Class IIb, Level B).^[1]
• AHA/ACC 2023: add a second antianginal agent from a different class (COR 1, LOE B-R); ranolazine is recommended if symptoms persist despite beta blockers, CCB or long-acting nitrates (COR 1, LOE B-R).^[2]
• Avoid ivabradine as add-on with LVEF >40% and no clinical heart failure (ESC 2024, Class III), ivabradine with non-DHP-CCBs or strong CYP3A4 inhibitors (Class III), and nitrates with phosphodiesterase inhibitors or in hypertrophic cardiomyopathy (Class III).^[1]

Follow-up: Why be careful adding verapamil to a beta blocker?^[2]

• AHA/ACC 2023 says non-dihydropyridine CCBs should be used with caution in patients on beta blockers because of the potential for synergistic induction or exacerbation of bradycardia and LV dysfunction.^[2]
• It adds that verapamil and diltiazem should not be used in CCD with significant LV dysfunction.^[2]

Branch C — Event prevention

Examiner: Which drugs prevent events in this patient?^[1]

Strong answer:

• ESC 2024, with no clear indication for oral anticoagulation: with significant obstructive CAD and no prior MI or revascularisation, aspirin 75–100 mg daily is recommended lifelong (Class I, Level B); after prior MI or remote PCI, aspirin 75–100 mg daily lifelong after an initial period of DAPT (Class I, Level A) or clopidogrel 75 mg daily as a safe and effective alternative to aspirin monotherapy (Class I, Level A).^[1]
• ESC 2024: an LDL-C goal of <1.4 mmol/L with ≥50% reduction (Class I, Level A), a high-intensity statin to the highest tolerated dose (Class I, Level A), then ezetimibe (Class I, Level B), then a PCSK9 inhibitor (Class I, Level A).^[1]
• ESC 2024: ACE inhibitors (or ARBs) with specific comorbidities such as hypertension, diabetes or heart failure (Class I, Level A); SGLT2 inhibitors or GLP-1 receptor agonists with proven benefit in type 2 diabetes (Class I, Level A); colchicine 0.5 mg daily should be considered with atherosclerotic CAD (Class IIa, Level A).^[1]

Follow-up: Where do ESC and AHA/ACC differ on colchicine?^[1][2]

• ESC 2024 says low-dose colchicine (0.5 mg daily) should be considered in CCS with atherosclerotic CAD (Class IIa, Level A); AHA/ACC 2023 says colchicine for secondary prevention may be considered (COR 2b, LOE B-R); NHFA/CSANZ 2025 gives a weak recommendation after ACS.^[1][2][6]

Branch D — Lifestyle and vaccination

Examiner: What lifestyle advice and vaccines do you give?^[1]

Strong answer:

• ESC 2024: aerobic activity of at least 150–300 min per week of moderate intensity or 75–150 min per week of vigorous intensity, with less sedentary time (Class I, Level B).^[1]
• ESC 2026 cardiac rehabilitation guideline: cardiac rehabilitation is recommended after ACS or with CCS, with or without PCI or CABG, to reduce cardiovascular mortality and MI (Class I, Level A).^[3]
• AHA/ACC 2023: assess tobacco use at every visit and advise patients who regularly smoke to quit at every visit; for them, behavioural interventions plus pharmacotherapy are recommended (each COR 1, LOE A).^[2]
• AHA/ACC 2023: annual influenza vaccination (COR 1, LOE A), COVID-19 vaccination per public health guidelines (COR 1, LOE C-EO) and pneumococcal vaccine (COR 2a, LOE B-NR).^[2]

Branch E — Revascularisation and follow-up

Examiner: Does PCI improve prognosis in stable disease, and how do you follow him up?^[7]

Strong answer:

• ISCHEMIA randomised 5179 patients with moderate or severe ischaemia; over a median of 3.2 years there was no evidence that an initial invasive strategy reduced ischaemic cardiovascular events or death from any cause.^[7]
• ESC 2024 reports lower spontaneous MI and better angina-related health status with the invasive strategy; ISCHEMIA-EXTEND, up to 7 years, showed a significant 2.2% absolute decrease in cardiovascular mortality favouring it, offset by a significant 1.2% absolute increase in non-cardiac mortality, with no significant difference in all-cause mortality.^[1]
• ESC 2024 recommends revascularisation of functionally significant obstructive CAD for persistent angina despite guideline-directed medical treatment (Class I, Level A).^[1]
• For follow-up, ESC 2024 recommends periodic visits (e.g. annual) regardless of symptoms (Class I, Level C); AHA/ACC 2023 says routine periodic CT coronary angiography or stress testing is not recommended to guide therapy without a change in clinical or functional status on optimised GDMT (COR 3: No benefit).^[1][2]