Holistic management of chest pain: Consensus Statement

Expert group recommendation 1: Definition

• The terminology of stable angina/stable CAD has been replaced with chronic coronary syndromes (CCS).
• Coronary syndromes are categorized into CCS and acute coronary syndrome (ACS).
• ACS is further classified as ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), or unstable angina.
• CCS is further classified as:
• Stable angina
• New heart failure (HF) and suspected CAD
• Stabilized symptoms for less than a year post ACS or PCI
• Stabilized symptoms for more than a year post initial diagnosis
• Patients with angina and suspected microvascular disease
• Asymptomatic CAD detected at screening

Expert group recommendation 2: Diagnosis

• Microvascular angina and vasospastic angina are diagnosis of exclusion.
• If ischemia is present on resting electrocardiogram (ECG) and echocardiogram (ECHO) as ischemia is present on resting.

Heart Rate

• Pharmacotherapy
• Additional therapies
• Counselling, ACE inhibitors, anxiolytics, control of lipids and anemia are equally important in the management of CSA.
• Statins have shown to prevent secondary events as well as improve the chest pain in non-obstructive angina.
• Both aspirin and statins are indicted for microvascular dysfunction and show the most benefits.
• In certain individuals, anxiolytics have demonstrated to relieve chest pain
• Revascularization
• Angina management in special population

Angina in Hypotension and Bradycardia Patients

• Approximately 10% of patients develop hypotension and bradycardia, which leads to negative outcome
• Prescribing nitrates or beta blockers to elderly patients can lead to hypotension/bradycardia
• To manage hypotension, adjust the doses of the prescribed antianginal drugs and assess if there is deterioration of left ventricular function
• Trimetazidine and ranolazine can be prescribed as it does not alter the blood pressure.

Angina in Diabetes Patients

· Almost 50% of angina patients are diagnosed with diabetes.

· In patients with DM who have systolic heart failure, if angina persists after beta blockers or nitrates or calcium channel blockers, trimetazidine or ranolazine are preferred.

· Ranolazine is preferred in diabetes patients as it significantly reduces glycated haemoglobin levels.

· In patients with newly diagnosed diabetes, intense diabetes control decreases both micro as well as macrovascular complications.

Newer Therapies

· Preference should be given to newer emerging antianginal therapies especially trimetazidine

· Agents such as allopurinol, coronary sinus reducer, enhanced external counter pulsation, neuromodulation are being investigated for management of CSA.

Reference:

"Consensus Statement on Holistic Management of Angina," is published in the JAPI: Journal of the Association of Physicians of India. 

DOI: https://japi.org/x294a454/consensus-statement-on-holistic-management-of-angina