This document discusses the diagnosis and management of chronic coronary syndrome and revascularization. It covers 6 types of chronic coronary syndrome based on symptoms and time since acute coronary syndrome or revascularization. It then discusses the steps in initial diagnosis, including assessing risk, basic testing, probability of coronary artery disease, and appropriate diagnostic testing. Management includes lifestyle changes, pharmacotherapy including different statin trials, and indications for revascularization. It also discusses percutaneous coronary intervention complications, stent thrombosis, in-stent restenosis, and indications for emergency CABG during PCI. Relevant clinical trials are also mentioned.

1. CHRONIC CORONARY SYNDROME &
REVASCULARIZATION
Adelaide Adiwana

2. CCS CLINICAL SCENARIO
• Type 1 : susp. CAD, ‘stable’ anginal symptoms, and/or dyspnea
• Type 2 : new onset HF or LV dysfunction and susp. CAD
• Type 3 : stabilized symptoms <1 year after ACS/with recent revascularization
• Type 4 : >1 year after initial diagnosis/revascularization
• Type 5 : angina and susp. vasospastic/microvascular disease
• Type 6 : asymptomatic CAD detected at screening

3. INITIAL DIAGNOSIS (ANGINA & SUSP. CAD)

4. STEP 1 : ANGINA SYMPTOM

5. STEP 2 : ASSES COMORBID

6. PATIENT CATEGORIES AND ASSOCIATED
CARDIOVASCULAR DISEASE RISK

7. STEP 3 : BASIC TESTING
• Lab
• Resting/ambulatory ECG
• Echo
• CXR

8. STEP 4 : PTP & CLINICAL LIKELIHOOD CAD
• >15% : non-invasive test benefit
• 5-15% : non-invasive test maybe considered after asses clinical likelihood

9. STEP 5 : SELECT APPROPIATE D/ TESTING

14. STEP 6 : ASSESS EVENT RISK

15. STEP 7 : MANAGEMENT – LIFESTYLE
Healthy diet characteristics

17. STEP 7 : MANAGEMENT – PHARMACOTHERAPY
Antithrombotik terapi = ACS

18. Hormone Replacement Therapy
• No prognostic benefit
• Increases risk of CVD in women >60 years

19. TRIAL-TRIAL LIPID
• ALLIANCE
• Atorvastatin dosis tinggi (80 mg) me↓ MACE dan death dibanding dosis biasa
• ASCOT-LLA
• Atorvastatin 10 mg superior dibanding placebo sebagai primary prevention CVD
dengan HT dan faktor resiko
• TNT
• Pada SCAD + hiperlipidemia, Atorvastatin 80 mg me↓ MACE dibanding
Atorvastatin 10 mg
• CARDS
• Atorvastatin 10 mg daily terbukti aman dan efektif me↓ MACE pada DM type 2
tanpa LDL ↑

20. • PRECISE IVUS
• Atorvastatin + Ezetimibeme↓ regresi plak pada post PCI dibanding Atorvastatin
monotherapy yang dilihat dengan IVUS
• PACE
• Atorvastatin + Ezetimibe lebih signifikan me↓ LDL dibandingkan double dose
Atorvastatin/switch ke Rosuvastatin
• FOURIER
• Pada CVD dan LDL >70 walaupun sudah dengan moderate intensity statin,
penambahan Evolocumab (PCSK9 inhibitor) me↓ MACE, tapi tidak death
• ODYSSEY LONG TERM
• Pada high risk pasien, penambahan Alirocumab (PCSK9 inhibitor) pada high
intensity statin me↓ LDL (62%) dan MACE dibanding statin dan placebo

21. MICROVASCULAR ANGINA
• Exercise related angina
• Evidance of ischemia in non-invasive test
• Invasive coronary angiography : non-significant stenosis of epicardial
artery  mild to moderate stenosis (40-60%)
• Exercise/stress test : RWMA rare
• Secondary :
• LVH (HCM, AS, HHD)
• Inflamation (myocarditis, vasculitis)
• Diagnosis :
• Acetylcholine challenge (-) : angina (-), ECG normal
• CFR < 2
• FFR > 0.8
• IMR ≥ 25
• Terapi : lifestyle modification, BB, ACEi, statin

24. VASOSPASTIC ANGINA
• Angina dominant saat istirahat
• Sering saat malam/subuh (sesuai circadian pattern)
• Younger, risk factor -/sedikit
• Diagnosis :
• ECG changes during angina (Prinzmetal angina  transien ST elevasi)
• Holter ECG : ECG changes but HR normal
• Provocation test saat angiografi
• Hyperventilation, cold pressor test, intracoronary Acetylcholine/Ergonovine)
• Positif : angina (+), ECG changes, vasoconstriction of epicardial vessel
• Terapi :
• Lifestyle and control CV risk factor
• CCB (Nifedipine)
• Long-acting Nitrat

25. TRIAL-TRIAL YANG BERHUBUNGAN
Evidance-based FFR-guided PCI:
• DEFER
• Tidak PCI klo FFR ≥ 0.75
• FAME
• FFR-guided PCI superior daripada PCI berdasarkan angio aja
• FAME-2
• FFR-guided PCI + OMT menurunkan urgent revascularisasi VS OMT aja (me↓
kematian + MI)

26. REVASCULARIZATION

28. INDIKASI REVASKULARISASI PADA CAD
STABIL / SILENT ISCHEMIA

29. Hitung juga :
• SYNTAX SCORE (assess anatomy
complexity)
• STS (30 d in-hospital mortality &
morbidity after CABG)
• EuroSCORE II (in-hospital mortality
after CABG)

31. CABG

32. INDIKATOR KEBERHASILAN PCI (VERSI AHA)
• Angiografi
• TIMI 3
• Residual stenosis <10%
• Tidak ada diseksi, thrombus, side branch loss
• Prosedur
• Tidak ada komplikasi mayor in-hospital (death, MI, stroke, urgent CABG)
• Klinis
• Pain free
• Angio & procedural success (>9 bulan  keberhasilan jangka panjang)

33. KOMPLIKASI PCI
• Mayor
• Death, MI, CVA, life-threatening aritmia
• Others
• Diseksi, CHF, reaksi kontras (anafilaksis, CIN), perdarahan, infeksi, tamponade
Versi AHA (SPIDI)
• Slow flow
• Perforation
• In stent thrombosis
• Diseksi
• In stent restenosis

34. STENT THROMBOSIS
• Definisi
• Oklusi tiba-tiba pada stent koroner akibat thrombus
• Lebih akut dari ISR
• Diagnosis berdasarkan waktu:
• Akut : 0 - 24 jam
• Subakut : 24 jam – 30 hari
• Late : 30 hari – 1 tahun
• Very late: > 1 tahun
• Faktor risiko:
• Faktor pasien : DM, post ACS, DAPT tidak disiplin, low EF, CKD
• Faktor lesi : bifurcatio, stent panjang, residual diseksi, diameter stent
kecil, malposisi stent

35. KLASIFIKASI STENT THROMBOSIS

36. IN STENT RESTENOSIS
• Diagnosis berdasarkan waktu:
• Early : < 1 tahun
• Late : 1-3 tahun
• Very late : > 3 tahun
• Mehran System
(≤ 10 mm)
(> 10 mm)

37. INDIKASI EMERGENCY CABG SAAT PCI
• Failed PCI + ongoing ischemia/oklusi
• Failed PCI  stent fracture pada lokasi crusial
• Failed PCI + hemodinamik incompromise
Tidak memandang konsekuensi pasien masih on DAPT (bleeding risk ↑
perioperatif)
Urgent CABG : 48-72 jam

38. TRIAL-TRIAL YANG BERHUBUNGAN
• TOTAL
• Manual thrombectomy prior PCI pada STEMI tidak mempengaruhi outcome,
tapi me↑ stroke dalam 30 hari dibanding PCI saja
• TASTE
• Thrombus aspiration prior PCI pada STEMI tidak berbeda dalam hal kematian
30 hari
• IABP-SHOCK II
• IABP pada cardiogenic shock + acute MI tidak me↓ kematian dalam 30 hari

39. ISCHEMIA TRIAL
• Jadi, pada CCS, OMT/GDMT dulu,
kalau masih bergejala, baru
ditindaki
• Non-culprit stabil plaknya. Kalau
diutak-atik  inflamasi  ruptur
ESC : OMT (Optimal Medical Therapy)
ACC/AHA : GDMT (Guideline Directed Medical Therapy)

40. SYARAT BISA OMT (VERSI AHA)
• Treatment satisfactory reduced symptoms
• Prevent cardiac event
• Minimal side effect
• Max. patients adherance/good compliance

41. THANK YOU