Management of stable anginaBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2789 (Published 17 July 2009) Cite this as: BMJ 2009;339:b2789
- Salim Yusuf, professor of medicine, director1,
- Madhu Natarajan, associate professor of medicine1,
- Ganesan Karthikeyan, CIHR Canada-HOPE scholar1,
- David Taggart, professor of cardiovascular surgery2
- 1Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada, L8L 2X2
- 2John Radcliffe Hospital, Oxford OX3 9DU
The management of patients with stable coronary artery disease (especially chronic stable angina) has been extensively debated as pathophysiological concepts, drug treatments, and interventional strategies have evolved. From an initial focus on alleviating symptoms, efforts have moved to managing discrete coronary stenoses with invasive procedures, and more recently to improving survival and reducing myocardial infarction.
It is now well recognised that even a single coronary stenosis indicates generalised atherosclerosis of the coronary and non-coronary vasculature. Mortality, myocardial infarction, and strokes are more closely correlated with the extent of generalised atherosclerosis and the composition of plaques, rather than the severity of specific coronary stenoses. Thus, a patient with extensive “minor” stenosis may carry a higher risk of future myocardial infarction than one with a greater degree of stenosis apparent at only a single site.1 The initial response to atherosclerosis is a compensatory dilatation of the coronary artery. Therefore, angiography underestimates the degree of generalised atherosclerosis.
We have a robust evidence base to inform our concepts and clinical decisions.2 The foundation of management of everyone with coronary artery disease should be vigorous lifestyle modification (a healthy diet, smoking cessation, and regular activity) supplemented with drugs (statins, angiotensin converting enzyme inhibitors, β blockers, and antiplatelet agents) to delay or reverse the progression of atherosclerosis and to stabilise plaques to reduce the …