Chronic coronary syndrome

Chronic ischaemic heart disease is referred to as chronic coronary syndrome (CCS) or stable ischaemic heart disease. These are chronic disorders caused by constant or recurring ischaemia of the heart, almost always due to coronary artery atherosclerosis.

CCS includes the following disorders:

• Effort angina/stable angina
• CCS with “anginal equivalent”
• Vasospastic angina/Prinzmetal angina
• Silent ischaemia

Knowing the types of chest pain is important in the evaluation of CCS.

Effort angina

Effort angina, also called stable angina, is the classical manifestation of CCS. It’s characterised by anginal pain which occurs predictably and reproducibly at a certain level of exertion and is relieved with rest or nitroglycerine. It occurs when the atherosclerotic stenosis reaches > 70% of the coronary artery lumen.

Anginal equivalents

Not all patients with CCS experience the typical anginal chest pain. Some experience so-called “anginal equivalents”, dyspnoea, nausea, sweating, or fatigue.

Vasospastic angina

Some patients with CCS experience spontaneous and transient symptoms (angina or anginal equivalent) in rest. This is called vasospastic angina or Prinzmetal angina and is due to coronary artery vasospasm, with or without underlying coronary artery disease.

ST elevation or depression is present during the pain episode. This may make it difficult to distinguish from ACS. Patients where ACS can’t be ruled out should be managed as ACS. Vasospasm can be diagnosed on angiography, and angiography is usually required to rule out ACS in these patients.

Silent ischaemia

Some patients with CCS never experience symptoms, called silent ischaemia. This is often due to diabetic neuropathy, but not always.