Medical Management for Chronic Coronary Syndrome

Core Pharmacological Therapy

• The European Society of Cardiology recommends comprehensive medical therapy targeting multiple pathways, including antiplatelet agents, statins with aggressive LDL-lowering, ACE inhibitors, beta-blockers if post-MI, blood pressure control, diabetes management with SGLT2 inhibitors or GLP-1 agonists, and intensive lifestyle modification, for all patients with chronic coronary syndrome 1, 2, 3
• Aspirin 75-100 mg daily is the foundation for all patients with chronic coronary syndrome unless contraindicated, as recommended by the European Heart Journal 4, 3
• Clopidogrel 75 mg daily serves as an alternative in patients with aspirin intolerance, according to the European Heart Journal 4, 3
• Following coronary stenting, dual antiplatelet therapy is required for 6 months, though shorter duration may be indicated if life-threatening bleeding risk exists, as stated in the European Heart Journal 4, 3
• A proton pump inhibitor should be added when prescribing aspirin monotherapy, dual antiplatelet therapy, or oral anticoagulation in patients at high gastrointestinal bleeding risk, as recommended by the European Heart Journal 4, 3
• Statins are mandatory in all patients with chronic coronary syndrome, with a target LDL-cholesterol <70 mg/dL for very high-risk patients, according to the European Heart Journal 4, 3, 1, 6, 7
• If maximum tolerated statin dose fails to achieve goals, ezetimibe should be added, as recommended by the European Heart Journal 4, 3
• For patients at very high risk not reaching goals on statin plus ezetimibe, a PCSK9 inhibitor should be added, according to the European Heart Journal 4, 3
• ACE inhibitors or ARBs are recommended in the presence of hypertension, diabetes, heart failure, or post-MI, as stated in the European Heart Journal 4, 3, 7
• Beta-blockers are essential in patients with prior MI to reduce morbidity and mortality, according to the European Heart Journal 3, 5
• SGLT2 inhibitors and GLP-1 receptor agonists are recommended in patients with diabetes and cardiovascular disease, as recommended by the European Heart Journal 6, 7

Antianginal Symptom Management

• Sublingual nitroglycerin is recommended for acute symptom relief, with symptoms resolving within 1-5 minutes, according to the European Heart Journal 1
• If angina persists despite optimal antianginal therapy, myocardial revascularization is recommended, as stated in the European Heart Journal 3

Risk Factor Modification

• Quantitative assessment of tobacco use is mandatory at every visit, as recommended by the European Heart Journal 1
• Office blood pressure control to systolic 120-130 mmHg is recommended, according to the European Heart Journal 6, 7
• Aggressive LDL-lowering with statins is recommended as first-line therapy, with sequential addition of ezetimibe and PCSK9 inhibitors if goals are not met, as stated in the European Heart Journal 4, 3

Team-Based Care and Patient Education

• A team-based approach is mandatory to improve health outcomes, facilitate ASCVD risk factor modification, and improve health service utilization, according to Circulation 2
• Patients require ongoing individualized education on symptom management, lifestyle changes, and medication adherence, as recommended by Circulation 2

Follow-Up and Monitoring

• Regular cardiovascular healthcare visits are recommended to reassess risk status, lifestyle modifications, adherence to risk factor targets, and development of comorbidities, according to the European Heart Journal 3
• Periodic resting ECG is recommended in asymptomatic diabetic patients for detection of conduction abnormalities, atrial fibrillation, and silent MI, as stated in the European Heart Journal 6, 7

Critical Pitfalls to Avoid

• Ticagrelor or prasugrel should not be used as part of triple antithrombotic therapy with aspirin and oral anticoagulation, as recommended by the European Heart Journal 4, 3
• ACE inhibitors should not be combined with ARBs, according to the European Heart Journal 6, 7
• Proton pump inhibitor should not be neglected in patients on antiplatelet or anticoagulant therapy at high GI bleeding risk, as stated in the European Heart Journal 4, 3