One important new aspect of these guidelines is that functional coronary disease plays a much larger role than in the previous version of the guidelines from 2006. Filippo Crea outlined that microvascular disease was a prevalent cause of angina. The diagnosis is made by demonstrating the reduced flow reserve associated with the disease, for instance by PET or external Doppler of the left anterior descending artery after adenosine challenge. Treatment starts with betablockers and may – in case these do not provide sufficient relief – be supplemented by calcium antagonists of the dipyridine type. A new drug with promise for this condition is ranolazine.
Coronary vasospasm is another functional disease of the coronaries causing angina. If spasm is focal, ST-elevation may ensue with potentially deleterious consequences. Thus, high dose calcium antagonist treatment is important. In refractory cases this may potentially be supplemented by focal stenting at the site of spasm. Details can be found on the web, where the guidelines can be viewed
Stephan Achenbach explained the basic philosophy of the guidelines. There are three steps in this disease. First, the pre-test probability needs to be determined based on the type of symptoms and the age and sex of the patient. Second, the optimal test is selected for the particular patient, based on patient profile, and local availability and expertise with the techniques. Third, the risk of events is stratified and a decision on how to proceed is made based on this information. If angina is very severe, all steps can be bypassed and invasive coronary angiography can be performed without priori non-invasive testing, but it may need to be complemented by determination of fractional flow reserve (FFR). The role coronary CT angiography is to exclude significant disease in those patients who have pretest probabilities in the low - intermediate range, and are suitable candidates for a CT scan.
Jean-Sebastien Hulot described the optimal medical treatment of patients focussing on antianginal drugs and drugs that improve prognosis. Whereas the first line antianginal drugs have not changed since the last guidelines, new second line drugs such as ivabradine and ranolazine have become available and should be used if first line drugs fail.
Finally, Bernard Gersh summarised the recommendations on revascularisation. This intervention should be reserved for patients in whom evidence is strong that prognosis can be improved. Typical constellations are patients with large areas of ischemia corresponding to left main stenosis and multivessel disease, including the proximal left anterior descending. Especially for complex coronary anatomy, in patients with a low surgical risk, bypass surgery is the method of choice for revascularisation.