Optimizing Management of Stable Angina: A Patient-Centered Approach Integrating Revascularization, Medical Therapy, and Lifestyle Interventions (JACC August 2024-2)-Article: Optimizing Management of Stable Angina: A Patient-Centered Approach Integrating Revascularization, Medical Therapy, and Lifestyle Interventions

Article: Optimizing Management of Stable Angina: A Patient-Centered Approach Integrating Revascularization, Medical Therapy, and Lifestyle Interventions

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The comprehensive review by Montone et al. on optimizing the management of stable angina emphasizes a patient-centered approach integrating revascularization, medical therapy, and lifestyle interventions. Angina pectoris, a symptom of ischemic heart disease (IHD), can originate from obstructive coronary artery disease (CAD) or in the absence of significant CAD, termed ischemia with nonobstructed coronary arteries (INOCA).<br /><br />For patients with obstructive CAD, therapeutic goals include reducing cardiovascular events and alleviating symptoms. Revascularization, through procedures like coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI), is typically reserved for specific subsets of patients, as it may not always confer additional benefits over optimal medical therapy (OMT) alone. Evidence from randomized controlled trials, such as COURAGE, BARI 2D, FAME 2, and ISCHEMIA, supports the strategic combination of OMT and selective revascularization for angina management.<br /><br />In cases of INOCA, a precise endotype diagnosis is crucial to tailor therapy toward the specific pathogenic mechanisms affecting the coronary microcirculation. Treatments target both traditional risk factors and functional coronary alterations. A personalized medical approach, including the use of coronary angiography and functional tests, helps allocate the most effective pharmacologic therapy based on the specific INOCA endotype.<br /><br />The review also highlights the ongoing shift from a generalized treatment strategy to individualized care, stressing the importance of comprehensive risk factor management, patient education, and adherence to therapy. It underscores a dynamic use of OMT involving first-line agents like beta-blockers and calcium-channel blockers, supplemented by newer evidence-based medications such as ranolazine or ivabradine, tailored to patient-specific profiles.<br /><br />In conclusion, the optimal management of stable angina requires an integrated approach that combines revascularization, tailored pharmacologic therapy, and lifestyle interventions, aiming to improve patient outcomes through personalized care strategies. Future directions highlight the need for further research and innovation in diagnostics and treatment personalization.

Keywords

stable angina

patient-centered approach

revascularization

medical therapy

lifestyle interventions

obstructive coronary artery disease

ischemia with nonobstructed coronary arteries

personalized medical approach

optimal medical therapy

randomized controlled trials