Evolving Management Paradigm for Stable Ischemic Heart Disease Patients: JACC Review Topic of the Week

Area of Science:

• Cardiology
• Internal Medicine

Background:

• Current management of stable coronary artery disease (CAD) primarily targets flow-limiting atherosclerotic obstructions, assuming they are the main cause of angina and ischemia.
• Revascularization benefits for long-term cardiac events are largely confined to specific high-risk patient groups (e.g., left main disease, diabetes with 3-vessel disease, low ejection fraction).

Purpose of the Study:

• To challenge the singular focus on epicardial CAD as the cause of angina and ischemia.
• To advocate for a more inclusive diagnostic and management paradigm for angina and ischemia.
• To highlight the prevalence and importance of nonepicardial coronary causes.

Main Methods:

• Review of mounting evidence on causes of angina and ischemia.
• Analysis of the limitations of current diagnostic and treatment strategies for coronary artery disease.
• Conceptual framework development for a revised management paradigm.

Main Results:

• Nonepicardial coronary causes, such as coronary microvascular dysfunction and vasospastic disorders, are increasingly recognized as prevalent.
• Flow-limiting stenoses may not be the sole or primary driver of symptoms in many patients.
• Current diagnostic approaches may overlook significant contributors to angina and ischemia.

Conclusions:

• A paradigm shift is needed to decouple the association between epicardial CAD and revascularization.
• Diagnostic strategies should broaden to identify diverse causes of angina and ischemia.
• Tailoring treatment to underlying mechanisms beyond epicardial stenosis is crucial for contemporary clinical practice.