Paradigm change for stable coronary disease in chronic coronary syndrome: Novelties in the guidelines of the European Society of Cardiologists from 2019

Bastać, Dušan; Mladenović, Zorica; Čvorović, Vojkan; Joksimović, Zoran; Pavlović, Snežana; Tirmenštajn-Janković, Biserka; Jelenković, Bratimirka; Vasić, Brankica; Adamović, Dragana; Jolić, Aleksandar; Bastać, Mila; Raščanin, Anastasija

doi:10.5937/tmg2001032B

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Timočki medicinski glasnik

2020, vol. 45, br. 1-2, str. 32-67

Promena paradigme za stabilnu koronarnu bolest u hronični koronarni sindromi - novine u vodiču Evropskog udruženja kardiologa iz 2019. godine

Bastać Dušan^a, Mladenović Zorica^b

, Čvorović Vojkan^c, Joksimović Zoran^d, Pavlović Snežana^e, Tirmenštajn-Janković Biserka^f, Jelenković Bratimirka^g, Vasić Brankica^g, Adamović Dragana^h, Jolić Aleksandar^h, Bastać Mila^a, Raščanin Anastasija^a

^aInternistička ordinacija "Dr Bastać", Zaječar
^bVojnomedicinska akademija, Klinika za kardiologiju, Beograd, Srbija
^cPoliklinika Belmedic, Beograd
^dInternistička ordinacija "Joksimović", Bor
^eSpecijalistička ordinacija za internu medicinu "Dr Pavlović-kardiologija", Beograd
^fZdravstveni centar Zaječar (ZCZ), Internistička služba, Nefrološki odsek, Zaječar
^gZCZ, Pedijatrijska služba, Zaječar
^hZCZ, Internistička služba, Odsek invazivne kardiologije, Zaječar

e-adresa: dusan.bastac@gmail.com

Ključne reči: angina pektoris/stabilna; Angina Pektoris/Nestabilna; Mikrovaskularna angina; angina pektoris sa normalnim koronarnim arteriogramom (INOCA); ishemijska bolest srca; koronarna bolest; Akutni koronarni sindrom; Infarkt miokarda; Ishemija miokarda/dijagnoza/prevencija i kontrola/farmakoterapija; Revaskularizacija miokarda/perkutana koronarna intervencija/CABG

Sažetak

Iako je engleski lekar Heberden opisao anginu pektoris (AP) još pre 2 i po veka, naše razumevanje ovog sindroma, kako uzroka, optimalnog dijagnostičkog pristupa tako i lečenja, nastavlja da se razvija. Novi vodič Evropskog udruženja kardiologa iz 2019 godine donosi pre svega promenu paradigme za stabilnu koronarnu bolest (SKB) u sveobuhvatni termin hronični koronarni sindromi (HKS), koja suštinski znači da hronična koronarna bolest (HKB) ili ishemična bolest srca (IBS) ima kompleksne kliničke scenarije i može imati periode nestabilnosti u bilo kojoj evolucionoj fazi. Rezultati esencijalne COURAGE studije te najnovijih studija: ISHEMIA, ORBITA i metanaliza o HKS kao i ključne poruke Evropskog Vodiča za dijagnostiku i lečenje hroničnih koronarnih sindroma (HKS) bacaju svetlo na problematiku koronarne bolesti, bolesti koja još uvek prednjači u svetskom mortalitetu. Koronarna bolest (KB) ima duge stabilne perode ali zbog akutnih aterotrombotskih događaja, erozije ili rupture aterosklerotskog plaka može preći u neki od akutnih koronarnih sindroma (AKS). Bolest je hronična, najčešće progresivna i zato ozbiljna čak i u asimptomatskim fazama. Dinamična priroda KB ispoljava se u različitim kliničkim prezentacijama, koje kategorizujemo u bilo akutne, bilo hronične koronarne sindrome. Promena paradigme naglašava činjenicu da dinamički procesi akumulacije u aterosklerotske plakove i funkcionalne alteracije koronarne cirkulacije, mogu biti modifikovani promenom životnih navika, farmakološkom terapijom i revaskularizacijom miokarda (RM), koje dovode do stabilizacije ili regresije bolesti ali nažalost ne i do potpunog izlečenja. Od kardinalnog značaja je pažljiva evaluacija anamneze, karakterizacija anginoznih i drugih simptoma i evaluacija rizik faktora i manifestacija predhodnih kardiovaskularnih bolesti (KVB), kao i procena adekvatnosti fizičke aktivnosti i tolerancije napora. U sadašnjem vodiču za HKS je prepoznato 6 vodećih i najčešćih kliničkih sindroma-scenarija : 1. Pacijenti sa suspektnom KB i stabilnom anginom pektoris i/ili dispnejom na napor; 2. Pacijenti sa novonastalom srčanom insuficijencijom (SI) ili disfunkcijom leve komore (DLK) i suspektnom KB; 3. Asimptomatski i simptomatski bolesnici sa stabilizovanim simptomima koji traju manje od jedne 1 godine posle AKS ili skorašnje revaskularizacije miokarda (KRM); 4. Asimptomatski i simptomatski pacijenti više od 1 godine protekle posle AKS ili RM; 5. Pacijenti sa anginom pektoris i suspektnom vazospastičnom ili mikrovaskularnom bolešću; 6. Asimptomatske osobe u kojih je KB otkrivena na skriningu. Svaki od ovih scenarija je klasifikovan kao HKS i posledice su različitih evolucionih faza hronične KB, te imaju različit rizik za buduće neželjene kardiovaskularne (KV) događaje. Pretest verovatnoća (PTP) koronarne bolesti, bazirana na starosti, polu i kvalitetima simptoma, podvrgnuta je reviziji i izmenjena u odnosu na predhodni vodič iz 2013. godine. Uveden je i novi termin: Klinička verovatnoća KB (KPKB) koji uključuje kako PTP tako i razne rizik faktore aterosklerotske KB i služi da isključi ili potvrdi sumnju na KB. Opšti metodološki pristup za inicijalnu dijagnozu za pacijente sa AP i suspektnom opstruktivnom KB uključuje 6 koraka. KORAK 1-Procena simptoma i znakova za identifikaciju pacijenata sa mogućom nestabilnom AP i drugim formama AKS; KORAK 2 je procena opšteg stanja i kvaliteta života koji odlučuju o planiranju lečenja; KORAK 3 uključuje osnovne dijagnostičke procedure i procenu funkcije leve komore (LK) srca; KORAK 4 čini odredivanje Pre-test i Kliničke verovatnoće opstruktivne KB; KORAK 5 je izbor dijagnostičkog testa fizičkim ili farmakološkim opterećenjem putem EKG i vizuelizacionih (slikovnih, imidžing) metoda uključujući MSCT (MDCT) koronarnu angiografiju (CTKA, CTA) za ustanovljavanje diagnoze KB. Na kraju, KORAK 6 je procena rizika od neželjenih KV događaja, posebno mortaliteta i na bazi toga donošenje definitivne terapijske odluka uz invazivnu koronarografiju (ICA) i eventualnu RM. Ako opstruktivna KB ne može biti isključena kliničkom evaluacijom, radi se bilo neinvazivni funkcionalni imidžing test bilo anatomski imidžing putem CTKA kao inicijalni test za isključenje ili potvrdu dijagnoze KB. Za odluku o RM treba razmotriti i anatomsku i funkcionalnu procenu, izuzev kod teških koronarnih stenoza >90%. Visok rizik neželjenih KV događaja identifikuje pacijente koji bi imali veliku prognostičku korist od RM, čak i ako su asiptomatski. Uloga revaskularizacije miokarda (RM) je stavljena u kontekst novijih dokaza koji se odnose na prognostičku ulogu perkutanih koronarnih intervencija (PCI) ili koronarnog arterijskog premošćavanja graftom (CABG) u ovoj niskorizičnoj populaciji. RM je rezervisana za pacijente gde postoje jaki dokazi da bi se njom poboljšala prognoza na bazi dokaza regionalne ishemije perfuzionim imidžingom. Pacijenti sa visokim rizikom -mortalitetom od 3% godišnje i više podvrgavaju se frakcionoj rezervi koronarnog protoka (FFR) ili koronarnoj rezervi protoka (CFR) zbog RM čak i ako nemaju simptome. Primena zdravog načina života smanjuje rizik od naknadnih neželjenih KV događaja i spada u adekvatnu terapiju sekundarne prevencije. Neophodna je redovna vakcinacija protiv gripa kod svih sa HKS. Optimalnoj medikalnoj terapiji (OMT): nefarmakološkoj i farmakološkoj terapiji HKS poklanja se ogromna pažnja kao glavnoj vrsti lečenja HKS, a ne RM. Istaknuta je savremena uloga anti-ishemijskih (antianginalnih lekova): Prve linijebetablokatori (BB) i antagonisti kalcijuma (CCB) uz sublingvalni nitroglicerin, i Druge linijedugodelujući nitrati (LAN), uz novije opcije: ivabradin, nikorandil, trimetazidine, ranolazine, alopuronol i drugo. Lekovi koji poboljšavaju prognozu HKS jesu statini i acetilsalicilna kiselina (ASA) i drugi antitrombocitni lekovi i od skora male doze rivaroksabana a dodatno inhibitori angiotensin konvertaze (ACEI) i ponovo BB u specifičnim indikacijama. Anti-ishemijski tretman mora se prilagoditi pojedinačnom pacijentu na osnovu komorbiditeta, druge konkomitantne terapije, očekivane tolerancije i pridržavanja i sklonosti pacijenta. Izbor anti-ishemijskih lekova za lečenje HKS-a treba da bude prilagođen srčanom ritmu, krvnom pritisku i funkciji srca. BB i ACEI se preporučuju pacijentima sa DLK ili SI sa smanjenom ejekcionom frakcijom leve komore (HFrEF). Antitrombotska terapija je ključni deo sekundarne prevencije kod pacijenata sa HKS-om. Pacijente sa prethodnim infarktom miokarda, koji su pod visokim rizikom od ishemijskih događaja i niskim rizikom od smrtnog krvarenja, trebalo bi razmotriti dugoročnu dvostruku antiagregacionu terapiju aspirinom i bilo inhibitorom P2Y12 receptora ili rivaroksabanom sa vrlo malim dozama, osim ako nemaju indikacija za oralnu antikoagulaciju kao što je atrijalna fibrilacija (AF). Inhibitori protonske pumpe preporučuju se kod pacijenata koji primaju i samo aspirin ili kombinaciju antitrombotske terapije koji su pod rizikom od gastrointestinalnog krvarenja. Statini se preporučuju svim pacijentima sa HKS-om bez obzira na nivo LDL. ACEI (ili blokatori receptora angiotenzina-ARB) preporučuju se u prisustvu SI, dijabetesa i hipertenzije i treba ih razmotriti kod pacijenata sa visokim rizikom za neželjene događaje.

Abstract

Although the English physician Heberden described angina pectoris (AP) two and a half centuries ago, our understanding of this syndrome, as a cause, an optimal diagnostic approach and treatment, continues to develop. The new guidelines of the European Society of Cardiology(ESC) from year 2019 brings, first of all, a paradigm shift for stable coronary artery disease (SCAD) to the comprehensive term chronic coronary syndromes (CCS), which essentially means that chronic coronary artery disease (CAD) has complex clinical scenarios and may have periods of instability, at any evolutionary stage. The results of the essential COURAGE study and the latest studies: ISCHEMIA, ORBITA and metha-analysis on CCS as well as the key messages of the European Guidelines for Diagnosis and Treatment of Chronic Coronary Syndromes (CCS) shed light on the issue of coronary heart disease. Chronic coronary artery disease (CCAD) has long stable periods but due to acute atherothrombotic events, erosion or rupture of atherosclerotic plaque can progress to some of the acute coronary syndromes (ACS). The disease is chronic, usually progressive and therefore serious even in asymptomatic stages. The dynamic nature of CAD is manifested in various clinical presentations, which we categorize into either acute or chronic coronary syndromes. The paradigm shift emphasizes the fact that the dynamic processes of accumulation in atherosclerotic plaques and functional alterations of the coronary circulation can be modified by lifestyle changes, pharmacological therapy and myocardial revascularization (MR), which lead to stabilization or regression of the disease but unfortunately not complete cure. Careful evaluation of the anamnesis, characterization of anginal and other symptoms and evaluation of risk factors and manifestations of previous cardiovascular diseases (CVD), as well as assessment of the adequacy of physical activity and exercise tolerance, are of cardinal importance. The current guide to CCS identifies 6 leading and most common clinical syndromes: 1. Patients with suspected CCS and stable angina pectoris and / or dyspnea on exertion; 2. Patients with newly developed heart failure (HF) or left ventricular dysfunction (LVD) and suspected CAD; 3. Asymptomatic and symptomatic patients with stabilized symptoms lasting less than one 1 year after ACS or recent myocardial revascularization (MR); 4. Asymptomatic and symptomatic patients more than 1 year after ACS or Mr; 5. Patients with AP and suspected vasospastic or microvascular disease; 6. Asymptomatic individuals in whom CAD was detected at screening. Each of these scenarios is classified as CCS and is a consequence of different evolutionary phases of chronic CAD, and has a different risk for future adverse cardiovascular (CV) events. Pre-test probability (PTP) of CAD, based on age, sex and quality of symptoms, has been revised and changed from the previous guide from year 2013. A new term has been introduced: Clinical probability of obstructive coronary artery disease (CPCAD) which includes both PTP and various risks factors of atherosclerotic CAD and serves to exclude or confirm the suspicion of CAD. The general methodological approach for initial diagnosis for patients with AP and suspected obstructive CAD involves 6 steps. STEP 1-Assessment of symptoms and signs to identify patients with possible unstable AP and other forms of ACS; STEP 2 is an assessment of the general condition and quality of life that decide on treatment planning; STEP 3 includes basic diagnostic procedures and assessment of left ventricular (LV) function of the heart; STEP 4 makes the determination of Pre-test and Clinical probability of obstructive CAD; STEP 5 is the selection of a diagnostic test by physical or pharmacological stress via ECG and imaging methods including MSCT coronary angiography (CTA) to establish the diagnosis of CAD. Finally, STEP 6 is the assessment of the risk of adverse CV events, especially mortality, and based on that, make definitive therapeutic decisions with invasive coronary angiography (ICA) and possible Mr. If obstructive CAD cannot be ruled out by clinical evaluation, either a noninvasive functional imaging test or anatomical imaging by CTA is performed as an initial test to exclude or confirm the diagnosis of CAD. Anatomical and functional assessment should be considered for a decision on RM, except in severe coronary stenosis> 90%. A high risk of adverse CV events identifies patients who would have great prognostic benefit from Mr, even if asymptomatic. The role of myocardial revascularization (MR) has been placed in the context of recent evidence relating to the prognostic role of percutaneous coronary interventions (PCI) or coronary artery bypass graft (CABG) in this low-risk population. Mr is reserved for patients where there is strong evidence to improve prognosis based on evidence of regional ischemia by perfusion imaging. Patients at high risk of mortality of 3% per year or more undergo coronary flow fractional reserve (FFR) or coronary flow reserve (CFR) due to perform Mr even if they have no symptoms. The application of a healthy lifestyle reduces the risk of subsequent adverse CV events and is part of adequate secondary prevention therapy. Regular vaccination against influenza is necessary for everyone with CCS. Optimal medical therapy (OMT): nonpharmacological and pharmacological therapy of CCS is given great attention as the main type of treatment of CCS, not Mr. The modern role of anti-ischemic (antianginal) drugs is emphasized: First lines - beta-blockers (BB) and calcium antagonists (CCB) with sublingual nitroglycerin, and Second lines - longacting nitrates (LAN), with newer options: ivabradine, nicorandil, trimethazidine, allopuronol, etc. Drugs that improve the prognosis of CCS are statins and acetylsalicylic acid (ASA) and other antiplatelet drugs and recently low dose rivaroxaban and additionally angiotensin converting enzyme inhibitors (ACEI) and again BB in specific indications. Anti-ischemic treatment must be tailored to the individual patient based on comorbidities, other concomitant therapies, expected tolerances and adherence, and patient preferences. The choice of anti-ischemic drugs for the treatment of CCS should be adjusted to the heart rhythm, blood pressure and heart function. BB and ACEI are recommended for patients with LVD or HF with reduced left ventricular ejection fraction (HFrEF). Antithrombotic therapy is a key part of secondary prevention in patients with CCS. Patients with previous acute myocardial infarction (AMI), who are at high risk of ischemic events and low risk of fatal bleeding, should consider long-term dual antiplatelet therapy with aspirin and either P2Y12 receptor inhibitor or a very low-dose rivaroxaban, unless there is an indication for oral anticoagulation, is atrial fibrillation (AF). Proton pump inhibitors are recommended in patients receiving only aspirin or a combination of antithrombotic therapy who are at risk of gastrointestinal bleeding. Statins are recommended for all patients with CCS, regardless of LDL level. ACEIs (or angiotensin receptor blockers, ARBs) are recommended in the presence of SI, diabetes, and hypertension and should be considered in patients at high risk for adverse events.

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O članku

jezik rada: srpski, engleski
vrsta rada: prikaz
DOI: 10.5937/tmg2001032B
objavljen u SCIndeksu: 26.07.2020.

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