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6.6 Treatment of disease complications

Patients with CCS who develop LV dysfunction may experience advanced HF, malignant arrhythmias and secondary valvular heart disease (i.e. mitral and tricuspid regurgitation). Prior MI and ischaemic aetiology are negative prognostic markers in patients with advanced HF,1205 as well as in those with secondary mitral regurgitation.1206 Specific treatments need to be considered in these patients regardless of HF aetiology (i.e. ischaemic).526 Advanced HF treatments include: high diuretic doses; a combination of diuretics and renal replacement therapy to treat congestion; inotropic and vasopressor agents to reduce hypoperfusion; and mechanical circulatory support in selected patients with severe symptoms or exercise intolerance, despite optimal medical therapies, and without right ventricular dysfunction. Heart transplantation is recommended for patients with advanced HF, refractory to medical/device therapy, and who do not have absolute contraindications. Early evaluation for mechanical circulatory supports or heart transplantation is currently suggested also in patients with mild symptoms [i.e. New York Heart Association (NYHA) class II] and high-risk profile (i.e. LVEF of <20%, recurrent HF events, hypotension, intolerance to medical therapy, worsening organ failure, ventricular arrhythmias/ICD shock).526 An ICD is recommended in patients with ischaemic cardiomyopathy and LVEF of <35% or who have recovered from ventricular arrhythmias.526 Frequent, symptomatic ventricular arrhythmias in ICD recipients should be treated medically with either beta-blockers or amiodarone. In patients with CCS who develop ventricular fibrillation or polymorphic ventricular tachycardia, assessment for myocardial ischaemia should be performed without delay. In patients with CAD in whom sustained monomorphic ventricular tachycardia recurs while on amiodarone treatment, catheter ablation is recommended over the escalation of antiarrhythmic drugs.1207 Percutaneous treatment of secondary mitral regurgitation in patients with advanced HF may be considered to improve symptoms.526 Treatment of secondary tricuspid regurgitation in advanced stages of disease was, until recently, supported by limited evidence.1208 Percutaneous tricuspid transcatheter edge-to-edge repair was found to reduce significantly severe tricuspid regurgitation and was associated with improvements in QoL at 1 year.1209

7 Key messages

• Symptoms of myocardial ischaemia due to obstructive atherosclerotic CAD overlap with those of CMD or vasospasm. • Similar guideline-directed cardiovascular preventive therapy is recommended in women and men in spite of the sex differences in the clinical presentation. • Inclusion of risk factors to classic pre-test likelihood models of obstructive atherosclerotic CAD improves the identification of patients with very low (≤5%) pre-test likelihood of obstructive CAD in whom deferral of diagnostic testing should be considered. • CACS is a reliable ‘simple’ test to modify the pre-test likelihood of atherosclerotic obstructive CAD. • First-line diagnostic testing of suspected CCS should be done by noninvasive anatomic or functional imaging. • Selection of the initial non-invasive diagnostic test should be based on the pre-test likelihood of obstructive CAD, other patient characteristics that influence the performance of non-invasive tests, and local expertise and availability. • CCTA is preferred to rule out obstructive CAD and detect nonobstructive CAD. • Functional imaging is preferred to correlate symptoms to myocardial ischaemia, estimate myocardial viability, and guide decisions on coronary revascularization. • PET is preferred for absolute MBF measurements, but CMR perfusion studies may offer an alternative. • Selective second-line cardiac imaging with functional testing in patients with abnormal CCTA and CCTA after abnormal functional testing may improve patient selection for ICA. • ICA is recommended to diagnose obstructive CAD in individuals with a very high pre- or post-test likelihood of disease, severe symptoms refractory to GDMT, angina at a low level of exercise, and/or high event risk. • When ICA is indicated, it is recommended to evaluate the functional severity of ‘intermediate’ stenoses by invasive functional testing (FFR, iFR) before revascularization. • Computed FFR based on the 3D reconstruction of ICA is emerging as a valuable alternative to wire-based coronary pressure to evaluate the functional severity of ‘intermediate’ stenoses. • The use of imaging guidance is now recommended when performing complex PCI. • A single antiplatelet agent, aspirin or clopidogrel, is generally recommended long term in CCS patients with obstructive atherosclerotic CAD. • For high thrombotic-risk CCS patients, long-term therapy with two antithrombotic agents is reasonable, as long as bleeding risk is not high. • For CCS patients with sinus rhythm, DAPT is recommended at the time of PCI and for 1 to 6 month(s), according to high or low bleeding risk, respectively. • For CCS patients requiring OAC and undergoing PCI, OAC and DAPT (aspirin and clopidogrel) for 1 to 4 weeks, followed by OAC and clopidogrel for up to 6 months in patients not at high ischaemic risk and up to 12 months in patients at high ischaemic risk, followed by OAC alone should be considered. • In CCS patients with functionally significant multivessel CAD, current evidence indicates benefit of myocardial revascularization over GDMT alone for symptom improvement, prevention of spontaneous MI, and reduction of cardiovascular mortality at long follow-up. • Among CCS patients with normal LV function and no significant left main or proximal LAD lesions, current evidence indicates that myocardial revascularization over GDMT alone does not prolong overall survival. • Among CCS patients with reduced LV function and ischaemic cardiomyopathy, current evidence indicates that surgical revascularization compared with GDMT alone prolongs overall survival at very long follow-up. • Among patients with complex multivessel CAD without LMCAD, particularly in the presence of diabetes, who are clinically and anatomically suitable for both revascularization modalities, current evidence indicates longer overall survival after CABG than PCI. • Among patients who are clinically and anatomically suitable for both revascularization modalities, a greater need for repeat revascularization after PCI than surgery, independently of multivessel CAD anatomical severity, has been consistently reported with current surgical and stent technology. • Lifestyle and risk-factor modification combined with diseasemodifying and antianginal medications are cornerstones in the management of CCS.

ESC Guidelines                                                                                                                                                                                          3497

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