Management of Chronic Coronary Syndromes (2026 IMCU)

Learning Objectives:

• Educational Objectives for a Module on Stable Ischemic Heart Disease (SIHD) and Chronic Coronary Disease Management Based on the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease, these objectives are designed for medical students, residents, or healthcare professionals. 

By the end of this module, learners will be able to: 

• Describe the key pathophysiological principles of SIHD, including the balance of myocardial oxygen supply and demand, the Law of Laplace, and the ischemic cascade, using diagrams and examples from clinical guidelines. 
• Identify at least five major take-home messages from the 2023 guidelines on chronic coronary disease, such as the emphasis on nonpharmacologic therapies like diet, exercise, and cardiac rehabilitation, and explain their role in reducing morbidity and mortality. 
• Compare the Class of Recommendation (COR) and Level of Evidence (LOE) for diagnostic evaluations in patients with chronic coronary disease, including when to use stress imaging (e.g., PET/SPECT MPI) versus invasive coronary angiography for guiding treatment in symptomatic patients despite guideline-directed medical therapy (GDMT).
• Apply risk stratification tools to classify patients with chronic coronary disease as low, intermediate, or high risk for major adverse cardiovascular events (MACE), incorporating noninvasive testing results and validated scores to inform treatment decisions. 
• Evaluate the potential adverse cardiovascular effects of substances with abuse potential (e.g., alcohol, cocaine, opioids, marijuana) in patients with chronic coronary disease, and recommend strategies to mitigate risks based on guideline evidence. 
• Recommend appropriate lipid management strategies for patients with chronic coronary disease, including high-intensity statin therapy aiming for ≥50% LDL-C reduction, and adjunctive therapies like ezetimibe or PCSK9 inhibitors in select high-risk populations, while assessing adherence through periodic lipid measurements. 
• Develop a blood pressure management plan for patients with chronic coronary disease and hypertension, targeting <130/80 mm Hg using nonpharmacologic strategies first and GDMT agents like ACE inhibitors, ARBs, or beta blockers as primary pharmacologic options. 
• Select SGLT2 inhibitors or GLP-1 receptor agonists for patients with chronic coronary disease and comorbidities such as type 2 diabetes, chronic kidney disease (CKD), or heart failure with LVEF ≤40%, justifying their use based on evidence for reducing MACE and improving quality of life. 
• Differentiate between antiplatelet therapy regimens for patients with chronic coronary disease, including low-dose aspirin for primary prevention and dual antiplatelet therapy (DAPT) post-PCI, while considering shorter durations to balance ischemic and bleeding risks. 
• Analyze the indications for revascularization in patients with chronic coronary disease, such as CABG over PCI in those with diabetes and multivessel disease or left main involvement, using trial data (e.g., FREEDOM trial) to support decisions on improving survival and reducing repeat procedures.