Management of Chronic Coronary Syndromes (2025)

Learning Objectives:

• Understand the Pathophysiology and Risk Stratification of Chronic Coronary Syndromes Explain the pathophysiology of chronic coronary syndromes, including the role of atherosclerosis, endothelial dysfunction, and myocardial oxygen supply-demand imbalance. Identify key clinical features that differentiate chronic stable angina from acute coronary syndromes (ACS). Utilize risk stratification tools such as the Duke Treadmill Score, coronary artery calcium (CAC) scoring, and stress testing to assess the severity of coronary artery disease (CAD) and guide management.
• Implement Evidence-Based Pharmacologic and Non-Pharmacologic Therapies Apply first-line pharmacologic therapies for CCS, including beta-blockers, calcium channel blockers, nitrates, statins, antiplatelet agents (aspirin, P2Y12 inhibitors), and renin-angiotensin system blockers. Recognize indications for advanced anti-anginal therapies, such as ranolazine in refractory angina. Recommend non-pharmacologic interventions, including smoking cessation, dietary modifications (Mediterranean diet), regular exercise, and cardiac rehabilitation to optimize cardiovascular health.
• Determine When to Pursue Revascularization in CCS Differentiate the indications for percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG) in stable ischemic heart disease. Recognize high-risk coronary anatomy, such as left main disease, proximal LAD stenosis, or multi-vessel disease in diabetics, that warrants CABG for survival benefit. Understand the role of ischemia-guided vs. anatomy-guided revascularization and the importance of fractional flow reserve (FFR) in guiding PCI decisions.