Managing stable angina: How cardiologists can find the right mix of revascularization, therapy and interventions
The management of stable angina is evolving at a rapid rate, according to a new state-of-the-art review published in the Journal of the American College of Cardiology.[1] The one-size-fits-all strategy is becoming a thing of the past, replaced by a patient-centered approach that requires finding the right mix of revascularization, medical therapy and lifestyle interventions.
One of the first steps a heart team must take involves determining whether a patient’s angina is due to coronary artery disease (CAD) or ischemia with nonobstructed coronary arteries (INOCA). Distinguishing between the two can be challenging—the symptoms are often quite similar—but knowing the source of a patient’s angina tells cardiologists how to proceed. An initial assessment including coronary CT angiography (CCTA) and echocardiography is typically how to make this distinction.
“For obstructive CAD, treatment involves a combination of lifestyle modifications promoting a healthy diet and regular physical exercise, cardiovascular (CV) prevention targeting traditional and emerging risk factors, and symptom control; revascularization procedures should be reserved for specific subsets of patients,” wrote first author Rocco A. Montone MD, PhD, a cardiologist with Catholic University of the Sacred Heart in Rome, and colleagues. “In INOCA, the focus shifts toward the management of multiple functional alterations of coronary circulation encompassing both epicardial arteries and microcirculation, along with risk factor control and secondary preventive measures.”
Treating obstructive CAD
Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) have often been viewed as “fundamental” treatments for obstructive CAD, the group wrote, but that approach may not necessarily as be effective as cardiologists once believed.
“Even if myocardial revascularization does improve the prognosis of patients with left main (LM) disease, and CABG demonstrated an improvement in prognosis for diabetic patients with three-vessel disease and in patients with reduced left ventricular ejection fraction (LVEF), the role of PCI in patients with reduced LVEF remains controversial,” the group wrote. “Importantly, data from randomized controlled trials have suggested that a strategy of coronary revascularization plus optimal medical therapy (OMT) might not always confer additional benefits compared with OMT alone in the remaining patients with chronic coronary syndrome.”
Montone et al. reviewed data from several randomized controlled trials and multiple meta-analyses, showing that some studies have found more value in pairing PCI with OMT than others. In fact, the results of some trials suggested a placebo effect could be playing a key role—is it possible patients reporting improved angina symptoms are perceiving significant changes that are not really there?
The ORBITA-2 study, published in The New England Journal of Medicine in November 2023, examined this exact question.[2] Its findings suggest PCI does result in an improved health status when tracking angina symptoms compared to a placebo procedure.
“According to available evidence and clinical guidelines, OMT should represent the initial treatment strategy for patients with stable angina,” the authors wrote. “OMT is often an effective option for these patients, even if revascularization may result in a greater improvement in angina and QoL compared with OMT alone. Myocardial revascularization should be considered as an adjunct to OMT, particularly in patients who remain symptomatic despite guideline-recommended OMT or in whom revascularization has a proven prognostic benefit. Benefits and risks of available therapeutic strategies should be discussed with the patient, because treatment decisions might vary among patients according to treatment expectations, levels of physical activity and quality of life, and willingness to undertake medical therapy intensification.”
When making these decisions with patients, the group emphasized, it is important to remember that “there is no need to rush to revascularization.” PCI does not represent the magic cure-all that some patients may imagine. It will often provide value to begin treatment with OMT alone and then have follow-up appointments every few months.
The risks associated with revascularization should also be discussed at length with patients, the group added. This includes procedural myocardial infarction, for example. In addition, there is an economic angle to consider—OMT alone may be a much more cost-effective approach in parts of the world where PCI is associated with higher healthcare costs.
The document’s authors also provided an in-depth look at what cardiologists need to know about determining which medications should be included in a patient’s care plan. In patients with chronic kidney disease, for example, ranolazine and trimetazidine may not be recommended. That is just one of the many factors care teams will need to consider when developing OMT strategies.
Treating INOCA
Patients presenting with INOCA often face a more rapid decline in quality of life. Evaluating the patient thoroughly with coronary angiography, coronary function testing, intracoronary provocation testing may all be needed to determine the patient’s specific INOCA endotype. Endotypes may be microvascular angina (MVA), vasospastic angina (VSA) or even a mix of the two.
Lifestyle interventions also play a key role in the management of these patients—as they do for anyone suffering from angina, the authors noted.
“Traditional cardiovascular risk factors, including hypertension, dyslipidemia, smoking and diabetes, play a substantial role in the development of both coronary microvascular and vasospastic dysfunction, as well as the structural remodeling of coronary microcirculation,” the group wrote. “Therefore, it is crucial to systematically identify and effectively manage these risk factors to prevent disease progression and alleviate symptoms. The selection of the most appropriate medications should be tailored to the predominant endotype.”
When viewing medication options, there are key recommendations that can go a long way toward getting patients the help they need. Calcium-channel blockers are effective for both MVA and VSA patients, for example. Meanwhile, long-acting nitrates “may reduce anginal episodes in VSA, but they have not shown prognostic benefits and could aggravate symptoms in MVA.”
Montone and colleagues ran down several other key findings related to INOCA treatment, providing a reference so cardiologists can read the original analysis.
“Ranolazine has been demonstrated to be effective in alleviating angina in MVA patients with significantly reduced coronary flow reserve due to an impaired vasodilation,” they wrote. “Ivabradine might improve persistent anginal symptoms in selected MVA patients, but its role is still controversial and barely investigated. Nicorandil could mitigate exercise-induced ischemia in coronary microvascular dysfunction patients, indicating a direct vasodilator effect on coronary microvasculature.”
Cardiologists and any other cardiology professionals can read the full review in the Journal of the American College of Cardiology, an American College of Cardiology journal.
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.