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The clinical picture of coronary artery disease has changed considerably in past years. As a consequence, the medical condition was re-defined in 2019 as "chronic coronary syndrome" (CCS). In view of these developments, the primary aim of the ALTHEA study was to gain current insights into the management of patients with CCS and stable angina in German primary care settings.ALTHEA is a national, cross-sectional study that used a structured 10-item-questionaire containing single-choice and multiple-choice questions on diagnosis, symptomatic therapy and quality of life of patients with suspected or confirmed CCS and stable angina. Interviewees were primary care practitioners (PCPs) from Germany.Interviews were conducted between April and September 2021. In total 1,050 PCPs were asked country-wide, aimed at achieving a representative sample. Of the 1,050 PCPs 1,021 replied. The majority of respondents indicated that they would carry out instrument-based diagnostic tests on their own, including a stress electrocardiogram, if CCS was suspected. Regarding treatment goals, the majority of the interviewees gave more relevance to an enhanced quality of life compared to prognostic improvements. In addition, most participants stated that they independently initiate and control symptomatic therapy in patients with suspected CCS and stable angina. Amongst the available antianginal medications, the interviewees showed preferences in terms of efficacy (betablockers), tolerability (ranolazine) and effect on quality of life (ranolazine).The cross-sectional study shows that PCPs currently serve as relevant guides to cardiologists in the care of patients with suspected CCS and stable angina. PCPs provide support in several areas such as diagnosis and symptomatic therapy, in part intersecting with cardiologists' tasks. Hence the study reveals a close link between primary care and cardiology in the management of patients with CCS.Hintergrund: Das Krankheitsbild der chronischen koronaren Herzkrankheit hat sich in den vergangenen Jahren erheblich gewandelt. Davon zeugt nicht zuletzt die Neudefinition der Erkrankung als chronisches Koronarsyndrom (chronic coronary syndrome, CCS) im Jahr 2019. Vor dem Hintergrund dieser Entwicklung war das primäre Ziel der Versorgungsstudie ALTHEA, einen Einblick in die aktuelle Versorgung von Patienten mit CCS und stabiler Angina pectoris (AP) in der hausärztlichen Praxis in Deutschland zu erhalten.ALTHEA ist eine bundesweit durchgeführte Querschnittstudie unter Verwendung eines strukturierten Fragebogens bestehend aus geschlossenen Single- bzw. Multiple-Choice-Fragen. Der Fragebogen umfasste 10 Fragen zu den Bereichen Diagnostik, symptomatische Therapie und Lebensqualität von Patienten mit Verdacht auf bzw. mit diagnostiziertem CCS und stabiler AP. Die Befragung richtete sich an Hausärzte.Ergebnisse: Die Befragung fand von April bis September 2021 statt. Angesprochen wurden bundesweit 1.050 Hausärzte, mit dem Ziel eine möglichst repräsentative Stichprobe zu erhalten. Von diesen haben 1.021 teilgenommen. Die Befragten gaben mehrheitlich an, bei Verdacht auf CCS eine apparative Diagnostik eigenständig durchzuführen, zu einem hohen Anteil einschließlich eines Belastungs-EKGs. Hinsichtlich des Therapieziels gewichtete die Mehrheit der Befragten eine Verbesserung der Lebensqualität höher als eine Prognoseverbesserung. Die überwiegende Mehrheit der befragten Hausärzte gab zudem an, bei symptomatischen Patienten mit Verdacht auf CCS eigenständig eine symptomatische Therapie einzuleiten und deren Erfolg im weiteren Krankheitsverlauf zu kontrollieren. Bei der Bewertung der verfügbaren Antianginosa zeigten sich Präferenzen in Bezug auf Wirksamkeit (Betablocker), Verträglichkeit (Ranolazin) und Einfluss auf die Lebensqualität (Ranolazin).Schlussfolgerungen: Die Versorgungsstudie macht deutlich, dass sich Hausärzte in der gegenwärtigen Versorgung von Patienten mit Verdacht auf CCS und stabiler AP als wichtige Lotsen der Kardiologie verstehen. Sie übernehmen grundlegende Aufgaben in Diagnostik und symptomatischer Therapie, die zum Teil eine deutliche Schnittmenge mit dem Aufgabenbereich der Kardiologen bilden. Demnach zeigt die Studie bei der Versorgung dieser Patienten eine enge Verzahnung von Allgemeinmedizin und Kardiologie.Schlüsselwörter: Angina pectoris, chronisches Koronarsyndrom, koronare Herzkrankheit, Diagnostik, symptomatische Therapie, Lebensqualität, hausärztliche VersorgungEingereicht am 10.1.2022 - Revision akzeptiert am 15.3.2022.

An invasive measurement of the fractional flow reserve (FFR) allows the valuation of the individual risk for ischemic events in patients with coronary artery disease. Therefore, FFR has become a valuable tool to guide coronary revascularisations. The cut-off value ≤ 0.80 has been validated in many different subsets of patients. However, FFR values describe a risk continuum with an inverse correlation between FFR value and the risk of events. So FFR should always be interpreted regarding the patient's clinical context, especially in patients with a high risk for rapid disease progression. As such, patients with diabetes mellitus and deferred revascularisation based on FFR 0.80 had worse clinical outcomes compared to patients without diabetes. In addition, FFR shows methodical deficiencies concerning the quantification of serial stenoses as well as the valuation of residual ischemia of the culprit vessel early after myocardial infarction. This article highlights both the strengths and the pitfalls in the use and interpretation of FFR.

Current therapy for stable angina includes surgical and percutaneous revascularization, which has been improved tremendously over the last decades. Smoking cessation and regular exercise are the cornerstone for prevention of further cerebrovascular events. Medical treatment includes treatment of cardiovascular risk factors and antithrombotic management, which can be a challenge in some patients. Owing to the fact the coronary revascularization is readily accessible these days in many industrialized countries, the importance of antianginal therapy has decreased over the past years. This article presents a contemporary overview of the management of patients with stable angina in the year 2015.

The updated 2014 ESC guidelines on myocardial revascularization did indeed impact on current practice. Some of the most important changes are summarized in this review. Importantly, the recommendation for dual antiplatelet therapy after stenting in stable patients was reduced to 6 months. Also, a more liberal use of PCI in left main stem disease was proposed by the ESC guideline committee.

The European Society of Cardiology (ESC) guidelines on the management of stable coronary artery disease published in 2013 give practical recommendations for diagnostics and therapy. The approach depends on the clinical picture and symptoms of the patient, the severity and extent of ischemia, the degree and location of coronary stenoses, additional cardiac findings and finally on non-cardiac comorbidities. The selection of suitable diagnostic tools is based on the tabulated pretest probability for the presence of coronary artery disease which plays an important and central role in the diagnostic algorithm. An invasive approach is recommended only in patients with severe angina, i.e. a Canadian Cardiovascular Society (CCS) angina grading scale of ≥ CCS3 or in patients who are at high risk for death or myocardial infarction based on the results of the test used for detection of ischemia. Detailed therapeutic recommendations are given for medicinal and interventional or surgical therapy. Medicinal therapy includes drugs both for relief of symptoms and prevention of cardiovascular events. Recommendations are also given for the use of new antianginal drugs. A PCI is only indicated in vessels causing ischemia which can be verified by using fractional flow reserve measurements. The indications for PCI now also include patients with a low SYNTAX score and multivessel disease or left main stenosis; however, the optimal strategy should be individually determined in heart team discussions.

Early detection of prognostically significant coronary artery disease (CAD) using ischemic tests, including noninvasive cardiac imaging, are fundamental approaches of optimized patient treatment guidelines to lower morbidity and mortality of these patients. Current international guidelines and the national standard of care guidelines from 2006 and 2011 as well as the third universal definition of myocardial infarction stress the increasing role of echocardiography as a favorable noninvasive imaging test. Echocardiography at rest, ergometric and pharmacologic stress echocardiography are established and readily available diagnostic tools with the potential to evaluate global and regional left ventricular function at rest and during exercise combined with information regarding regional perfusion. Especially new data on perfusion analysis allow further extension of the indications spectrum of reperfusion analysis and sensitivity increases in chest pain unit settings. The noninvasive detection of significant and prognostic stenosis burden in CAD without radiation is possible with high sensitivity and good specificity and encompasses functional cardiovascular parameters as well as extension of the ischemic area.The likelihood of future cardiac events can be assessed with high negative predictive accuracy, giving a high safety aspect in the treatment options of patients. The diagnostic potential of stress echocardiography is best in patients with intermediate and higher pretest probabilities. In patients under concurrent antiischemic medication identification of high risk patients seems feasible. Stress echocardiography has an excellent specificity and prognostic value for either indications for revascularization or survival prediction as well as survival benefits after revascularization in test positive patients.The detection of pathologic findings is not impaired by gender differences. New technical approaches include 2-D and 3-D speckle analysis of the myocardial wall and contrast-enhanced improvements in myocardial border delineation and perfusion. A new European multicenter study published in 2013 could demonstrate comparable to improved sensitivities in intermediate to severe coronary stenosis from 50% to 70% and in highly obstructive proximal stenoses compared to a reference electrocardiogram (ECG)-gated single photon emission computed tomography (SPECT).