Epidemiological, Clinical and Angiographic Profile of Chronic Coronary Syndromes in the Catheterization Room. Single-Centre Study Carried Out in the Cardiology Department of the Chu Aristide Le Dantec in Dakar (Senegal)

Background: Ischaemic heart disease is the cause of 7.4 million deaths per year. Their prevention is based on the management of cardiovascular risk factors, but also on the early detection and management of chronic coronary syndromes (CCS), for which few data are available in Africa. The main objective of our study was to determine the factors related to significative coronary artery disease in patients undergoing coronarography for suspected chronic coronary syndrome (CCS). Methodology: We conducted a retrospective descriptive and analytical study over 2 years (from January, 1st, 2018 to December 31st, 2019) in the Cardiology Department of the University Hospital Aristide Le DANTEC in Dakar. All patients admitted for coronary angiography for suspected chronic coronary syndrome were included. Results: One hundred and fifty-two patients were included with a mean age of 60.79 ± 9.73 years, the most represented age group was 60 - 69 years. Advanced age was the most frequent risk factor (77.63%) followed by sedentary lifestyle (56.58%) and hypertension (41.45%). Diabetes was present in 17.1% of cases. A history of angioplasty was found in 1.97% of patients. Typical pain was found in 71.05% of cases, atypical pain in 19.74% and exertional dyspnoea in 2.63%. The pre-test probability was intermediate in 67.1% of cases, low in 25% and high in 7.9%. Significative coronary lesion was found in 52.63% of the patients, while coronary angiography was normal in the remaining cases. Tritroncular status was observed in 37.50%, it was bitroncular in 26.25% and monotroncular in 36.25% of cases. Factors associated with significative coronary artery disease were age (p = 0.0001), diabetes (p = 0.006), previous angioplasty (p = 0.023), previous myocardial infarction (p = 0.018), typical angina (p = 0.001), intermediate pretest probability (p = 0.001). Low pretest probability was significantly correlated with the absence of a coronary lesion with a p = 0.001. Conclusion: Our study shows that screening for chronic coronary disease should be done especially in diabetics, elderly subjects and those with previous angioplasty taking into account symptoms and pretest probability to avoid unnecessary invasive procedures.

ISCHEMIA trial:How to apply the results to clinical practice

During the last years two questions have been continuously asked in chronic coronary syndromes:(1)Do revascularization procedures(coronary artery bypass grafting or percutaneous coronary intervention)really improve symptoms of angina?and(2)Do these techniques improve outcomes,i.e.do they prevent new myocardial infarction events and cardiovascular death?Therefore,there was a need for a large definitive trial.This study was the ISCHEMIA trial,a large,multicentric trial sponsored by the National Heart,Lung,and Blood Institute.The main trial compared coronary revascularization and optimal medical treatment(OMT)vs OMT alone in 5179 patients enrolled after a stress test.During a median 3.2-year follow-up,318 primary outcome events occurred;the adjusted hazard ratio for the invasive strategy as compared with the conservative strategy was 0.93(95%confidence interval 0.80-1.08,P=0.34).The ISCHEMIA trial deeply disrupted many of our prior attitudes regarding management strategies for patients with stable coronary artery disease.The findings underscore the benefits of disease-modifying OMT for stable coronary artery disease patients.The main purposes of ischemia assessment before this trial were:Diagnostic purposes,assessment of outcome,and adding to decision-making processes.Obviously,this changed after the trial results.The results of ISCHEMIA might challenge the current diagnostic approach for stable angina patients recommended in the last European Society of Cardiology guidelines on chronic coronary disease that were based on studies published before the ISCHEMIA trial.In this editorial we propose our approach based on the ISCHEMIA study and the pretest probability for a positive test in patients with chronic coronary syndromes.

Conservative Approach Might Be the Strategy by Default in Stable Angina Patients: A Case Report

Management of stable angina is still a matter of debate. Whether a conservative or invasive approach is better remains unclear. Even though recent large-scale randomized trials depict the conservative strategy as safe and efficient. In this report, we present a case of a 53-year-old male patient with cardiovascular risk factors of hypertension and hypercholesterolemia. He complained about typical chest pain at exertion. The coronary angiogram (CA) revealed severe stenosis of the proximal left anterior descending artery (LAD) ostium. After heart team discussion, coronary artery bypass graft (CABG) was advocated. However, due to a lack of means, the CABG was postponed. Meanwhile, he was managed with guideline-based medical therapy. In addition, he exercised regularly and adopted a healthy diet. Evolution was favorable with excellent symptoms control. A regular follow-up was organized with his cardiologist. A new CA before an eventual CABG six years later showed a significant plaque volume regression of the proximal LAD. We decided to continue conservative management. The stress echocardiogram to assess symptoms and exercise tolerance was normal. Our patient was sent to surgery on top of optimal medical therapy even though angioplasty was a good indication and was feasible. However, while he was struggling to afford the CABG procedure, he adopted a very healthy lifestyle along with medical therapy. Six years later, the result of that approach was without appeal, suggesting and reinforcing the conservative management of stable heart disease over invasive strategy. The recent ISCHEMIA trial is a major argument supporting that approach.