The Present and Future
JACC State-of-the-Art Review
Evaluation and Management of Patients With Stable Angina: Beyond the Ischemia Paradigm: JACC State-of-the-Art Review

https://doi.org/10.1016/j.jacc.2020.08.078Get rights and content
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Highlights

  • Results from large clinical trials support medical therapy rather than revascularization as an initial management strategy for most patients with stable ischemic heart disease.

  • Available data support revascularization only for specific patient subgroups, in contrast to prevalent practice patterns.

  • Further efforts are needed to align incentives, resource allocation, and patient expectations with evidence to promote application of medical management and preventive care as the initial strategy for patients with stable CHD.

Abstract

Coronary heart disease is a chronic, systemic disease with a wide range of associated symptoms, clinical outcomes, and health care expenditure. Adverse events from coronary heart disease can be mitigated or avoided with lifestyle and risk factor modifications, and medical therapy. These measures are effective in slowing the progression of atherosclerotic disease and in reducing the risk of thrombosis in the setting of plaque disruptions. With increasing effectiveness of prevention and medical therapy, the role of coronary artery revascularization has decreased and is largely confined to subgroups of patients with unacceptable angina, severe left ventricular systolic dysfunction, or high-risk coronary anatomy. There is a compelling need to allocate resources appropriately to improve prevention. Herein, we review the scientific evidence in support of medical therapy and revascularization for the management of patients with stable coronary heart disease and discuss implications for the evaluation of patients with stable angina and public policy.

Key Words

atherosclerosis
coronary artery disease
coronary heart disease
ischemic syndrome
stable ischemic heart disease

Abbreviations and Acronyms

ACS
acute coronary syndrome
CABG
coronary artery bypass grafting
CCS
Canadian Cardiovascular Society
CHD
coronary heart disease
CT
computed tomography
CVD
cardiovascular disease
DAPT
dual antiplatelet therapy
FFR
fractional flow reserve
LDL
low-density lipoprotein
MACE
major adverse cardiovascular event
MRI
magnetic resonance imaging
NCDR
National Cardiovascular Data Registry
OMT
optimal medical therapy
PCI
percutaneous coronary intervention
PCSK-9
proprotein convertase subtilisin/kexin type 9
SAQ
Seattle Angina Questionnaire

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The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC author instructions page.

Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.

Drs. Ferraro and Latina contributed equally to this work.