Chronic coronary disease, previously known as stable ischemic heart disease, is a spectrum of coronary artery disease characterized by obstructive or nonobstructive atherosclerotic plaque accumulation in the coronary arteries. Functional noninvasive tests used to diagnose obstructive coronary artery disease can detect myocardial ischemia through electrocardiographic changes, wall motion abnormalities, or cardiac perfusion changes. These tests include stress echocardiography, stress cardiac magnetic resonance imaging, or stress single-photon emission computed tomography. The goals when treating chronic coronary disease are to improve patients’ quality of life and extend their lifespan. Management includes lifestyle and risk factor optimization through diet and exercise; control of hyperlipidemia, blood pressure, and diabetes; long-term beta-blocker therapy; antianginal treatment; and antiplatelet therapy. Treatments should aim to reduce cardiac death, nonfatal ischemic events, and progression of atherosclerosis, using guideline-directed medical therapy. Clinicians should assess the socioeconomic status of patients who have chronic coronary disease and provide resources to community-based health workers when available.
Case 3. BP is a 71-year-old patient who experienced a myocardial infarction 6 years ago. He is receiving appropriate therapy to manage his contributing risk factors and was able to stop smoking successfully. He is interested in taking a trip to visit his grandchildren next year but is concerned about overdoing it. He wants to know if there is anything he can do to improve his exercise capacity without damaging his heart.
Definitions and Epidemiology
Chronic coronary disease (CCD), previously known as stable ischemic heart disease, results from structural or functional alterations of the coronary arteries and micro-circulation, leading to a mismatch between transient myocardial demand and blood supply.1 Conditions under the umbrella of CCD include obstructive and nonobstructive coronary artery disease, with and without previous revascularization or known myocardial infarction (MI), as well as chronic angina. Patients with ischemic heart disease diagnosed through noninvasive testing are also considered to have CCD.2
Approximately 20.1 million people in the United States live with coronary heart disease, and 8.8 million have had a previous MI.2 About 11.1 million US adults have chronic stable angina pectoris.2 Despite a relative decline in mortality from coronary heart disease compared with 10 years earlier, it remains the most common cause of death from cardiovascular disease (CVD) in the United States, leading to more than 40% of cardiovascular-related deaths in 2019.3 Patients with CCD are at risk for major adverse cardiovascular events (MACE), a term with several definitions. In many studies, MACE is the composite of all-cause death (or cardiovascular death), acute MI, stroke, hospitalization due to heart failure, and revascularization, including percutaneous coronary intervention (PCI) and coronary artery bypass grafting.4
Testing
Evaluation is warranted in patients who have known CCD and experience a decline in functional capacity or develop new symptoms, such as chest pain or dyspnea. The tests of choice are stress myocardial perfusion imaging with either stress single-photon emission computed tomography or stress positron emission tomography imaging, stress cardiac magnetic resonance imaging, or stress echocardiography.2 Any of these modalities can identify ischemia and provide additional information for estimating the future risk of MACE.2 For patients specifically seeking alleviation of symptoms from stable angina, invasive coronary angiography is considered a first-line option because it provides therapeutic intervention and diagnostic imaging.2
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