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Table of Contents
Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 3-7

Chronic coronary syndrome: A review of the literature

1 Faculty of Medicine, Royal College of Surgeons In Ireland, Dublin, Ireland
2 Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
3 Department of Cardiology, Sabah Al Ahmed Cardiac Centre, Kuwait City, Kuwait
4 Department of Cardiology, Illinois Masonic Medical Center, Chicago, IL, USA
5 Department of Cardiology, Milton Keynes Hospital, Milton Keynes, England, UK

Date of Submission08-Jul-2020
Date of Decision15-Aug-2020
Date of Acceptance26-Aug-2020
Date of Web Publication15-Sep-2020

Correspondence Address:
Dr. Rajesh Rajan
Department of Cardiology, Sabah Al Ahmed Cardiac Centre, Kuwait City - 13001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ACCJ.ACCJ_21_20

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Chronic coronary syndrome (CCS) is a newly proposed entity by the European Society of Cardiology that replaces stable coronary artery disease (CAD), which is defined as a progressive process of plaque accumulation in coronary circulation with associated functional changes. CCS has replaced stable CAD to raise awareness that despite the clinically silent nature of the disease, there are progressive pathological changes occurring in the coronary arteries. This has allowed clinicians to review the current various diagnostic modalities, methods of risk stratifying patients based on different models and the various management options available, including lifestyle modifications, pharmacological therapies, and revascularization. With the emergence of this new entity, great emphasis has been placed on the consolidation of our comprehension of the dynamic character of the disease and the preventative actions that aim to reduce the cardiovascular disease burden.

Keywords: Chronic coronary syndrome, coronary circulation, revascularization

How to cite this article:
Hussain S, AlRashed M, Rajan R, Al-Jarallah M, Brady PA, Soman B, Dashti R. Chronic coronary syndrome: A review of the literature. Ann Clin Cardiol 2021;3:3-7

How to cite this URL:
Hussain S, AlRashed M, Rajan R, Al-Jarallah M, Brady PA, Soman B, Dashti R. Chronic coronary syndrome: A review of the literature. Ann Clin Cardiol [serial online] 2021 [cited 2023 Mar 26];3:3-7. Available from:

  Introduction Top

Chronic coronary syndrome (CCS) is a newly described classification devised by the European Society of Cardiology (ESC) to replace the term “Stable Coronary Artery Disease (CAD).” The main reason for effecting the change is the term is thought to better describe the disease process and encompass a wider spectrum of clinical, pharmacological, and pathophysiological entities. Using this new lexicon, the disease atherosclerosis manifests as CAD is categorized into Acute Coronary Syndrome (ACS) and CCS.[1] Since this is a relatively new entity, the profile of CCS patients has significantly evolved, challenging clinicians and researchers to have a deeper grasp on the nature of the disease and as a result, develop newer methods of assessing, diagnosing, risk stratifying, and managing patients that fall into the category of CCS.[2],[3]

  Definition of Chronic Coronary Syndrome Top

The main focus of introducing the concept of CCS is on the fact that CAD is a continuous phenomenon involving intravascular plaque aggregation and progression. It has different evolutionary phases.[1],[3]

According to the 2019 ESC guidelines, patients fall into the category of CCS according to the following clinical presentations:[1]

  1. Patient with CAD suspicion and stable angina symptoms with/without dyspnea
  2. New-onset heart failure with or without reduced ejection fraction in patients with suspected CAD
  3. Those with stabilized symptoms, both symptomatic and asymptomatic within a year of ACS or latest revascularization
  4. Patients with or without symptoms more than 1 year after the initial diagnosis or revascularization
  5. Patients with angina and nonobstructive CAD or suspected microvascular/vasospastic disease
  6. Asymptomatic patients where screening detects CAD.

Patients that present with unstable angina symptoms would be classified as part of the ACS category and follow a different clinical assessment route. Since the disease is dynamic, there is substantial overlap between low-risk unstable angina patients and CCS patients. In addition, many CCS patients may experience episodes of unstable angina, thus proving a challenge to many clinicians in practice.[1]

Since CCS is a newly proposed entity that involves a wider spectrum of CAD patients, literature is lacking regarding different aspects of this entity, representing a potential area of future clinical research focus. However, the majority of the data and evidence can be extrapolated from studies and clinical trials previously done on stable CAD patients and re-assed for implications involving patients with CCS.

  Initial Assessment and Diagnosis Top

A thorough history is essential to both establishing a diagnosis of CAD and differentiating between chronic or stable and acute or unstable symptoms consistent with angina. A major group of patients with CAD do not present with the classical anginal symptoms or chest pain, while only 10%–15% of patients have typical anginal symptoms.[4] Comorbidities and risk factors, which include dyslipidemia, hypertension, family history of cardiovascular disease, obesity, lifestyle factors (lack of exercise and unhealthy eating habits), and smoking, should all be addressed. Every patient with a suspicion of CAD should undergo basic laboratory testing (full blood count, thyroid hormone levels, lipid profile, and fasting plasma glucose), resting electrocardiogram (ECG), and resting echocardiography.[1] The utilization of further non-invasive (anatomical or functional) or invasive evaluation (i.e., invasive coronary angiogram) is based on the findings of the initial assessment.[1]

The most commonly used functional non-invasive tests include: ECG, stress cardiac magnetic resonance (CMR), stress echocardiography, and positron emission topography (PET).

Anatomical noninvasive tests include coronary computed tomography angiography (CCTA).

The decision to proceed with specialized imaging depends on the risk stratification of patients using the pretest probability (PTP) model that takes into account age, gender, anginal symptoms, and the available hospital facilities.[5] This model has been revised in the current guidelines and re-evaluated data from previous PTP models used in older guidelines.[5],[6],[7] This model recommends that patients in high-risk groups (>85%) undergo invasive diagnostic modalities, whereas, in low-risk patients (<15%), no routine testing is recommended. For patients in the intermediate-risk group (15%–85%), noninvasive testing is recommended, although no specific imaging modality is preferred.[1],[8] This is in large part due to the wide availability of some techniques (CCTA or stress echocardiography) or the low technical demands (stress ECG), whereas other modalities are limited by their technical requirements and the lack of availability (CMR or PET).[8],[9]

  Management of Chronic Coronary Syndrome Top

Lifestyle changes

A key element of CCS patient management is to emphasize the importance of risk factor control (smoking, hypertension, diabetes, dyslipidemia, and lifestyle factors), reduce symptoms, and improve overall prognosis,[1],[10] Smoking cessation significantly reduces mortality and improves prognosis.[11] Evidence suggests that the most effective method to achieve this is a combination of behavioral and pharmacological approaches.[12]

Robust epidemiological evidence exists to support that regular exercise significantly reduces cardiovascular risk factors, including blood pressure, glucose intolerance, and blood lipids.[13] A meta-analysis demonstrated the superiority of non-drug approaches as compared to drug-based approaches in diabetes prevention, with no major increase in overall cardiovascular mortality or myocardial infarction (MI).[14],[15] Furthermore, several studies have shown that obesity is linked to higher cardiovascular events risk. Thus, bodyweight reduction and adoption of a healthy eating habit are associated with fewer unfavorable clinical outcomes and a decrease in overall cardiovascular events and mortality.[16],[17],[18]

Pharmacological therapy

Pharmacological therapies aim to relieve symptoms and control the main cardiovascular risk factors such as hyperlipidemia, diabetes mellitus, and hypertension.[1]

Anti-ischemic drugs

Many anti-ischemic drugs that improved anginal symptoms had little or no impact on preventing adverse cardiovascular events. In the REACH Registry, a retrospective study of 21860 patients reported that in patients with CAD, beta-blockers (BB) did not decrease cardiovascular death.[19] While the use of Calcium Channel Blockers (CCBs) has not been proven to minimize mortality, they may be useful as a first-line treatment option in managing a subset of CAD patients.[20] Patients with left ventricular systolic dysfunction or patients undergoing Coronary Artery Bypass Graft (CABG) who use BB are less likely to experience adverse cardiovascular events and exhibit reduced long-term mortality.[21] Angiotensin-converting Enzyme (ACE) inhibitors are favored in those with hypertension, diabetes, heart failure, and in high-risk patients.[1] However, the use of ACE inhibitors in stable CAD patients without heart failure was not associated with an incremental benefit when compared to active controls.[22]

Anti-thrombotic therapy

Antithrombotic therapy is important in CCS patients who are at elevated risk of ischemic events or with previous MI. The current recommendation for anti-thrombotic therapy is the combination of aspirin and an oral P2Y12 inhibitor, dual antiplatelet therapy (DAPT).[1] While there are no studies that evaluate the optimal length of DAPT use in CCS patients undergoing percutaneous coronary intervention (PCI), recommendations are based on data from subgroups of patients in relevant randomized controlled trials. Six months of DAPT therapy establishes the balance of significant benefit in secondary prevention and reduction in stent thrombosis without a significant increase in bleeding events.[23] Further studies might be needed in CCS patients to establish the optimal length of treatment.


Patients with CCS should be considered for statin treatment irrespective of their low density lipoprotein (LDL) levels.[1] Newer lipid reducing agents such as proprotein convertase subtilisin/Kexin type 9 inhibitors have demonstrated impressive results in various clinical trials in reducing cholesterol, particularly LDL levels, thereby reducing the risk of cardiovascular events significantly.[24] While short-term safety is established, long-term safety is unknown to this date, which has limited their use in practice.[25]

Revascularization versus optimal medical therapy

The ideal approach toward patients with CCS continues to prove controversial in regard to the use of PCI and optimal medical therapy as compared to only optimal medical therapy.[26] Various studies have reported a more favorable outcome with the incorporation of PCI, particularly fractional flow reserve (FFR)-guided PCI. FFR is a pressure wire-based index that is undergone to determine the probability of stenosis to produce an infarction using coronary angiography.[27],[28] However, patients with non-ischemic stenosis did not receive added benefit compared to optimal medical therapy alone. Similar observations were made in the FAME 2 clinical trial.[29]

Data from the COURAGE and ISCHEMIA trials suggested that despite improvement in anginal symptoms with revascularization through PCI, the risk of cardiovascular death or MI did not reduce significantly when compared with optimal medical therapy. The role of invasive therapy in CCS patients needs to be reconsidered.[30],[31]

  Discussion Top

The primary purpose in adopting the term CCS is to better reflect the dynamic process of CAD and to distinguish from ACSs allowing for more targeted research and clinical approaches.

The current method for risk stratifying patients with CCS is the PTP model.[1] Numerous sources of data suggest that PTP could greatly overestimate the actual prevalence of the disease.[32] Data obtained from the PROMISE trial showed that 50% of patients classified as intermediate risk, were reclassified to a PTP < 15%.[8]

Incorporating the cardiovascular risk factors like the coronary calcium score into the basic PTP model would make it more robust and risk stratification more reliable.[33] Coronary artery calcium score provides robust prognostic information and accurately predicts the presence of CAD.[34] There is some evidence based on data derived from the CONFIRM registry on the use of a machine learning model that utilizes the various clinical factors in addition to the calcium score to accurately estimate CAD on CCTA.[35]

A newer model based on biomarkers (ABC model) which utilizes A (age), B (biomarkers that include pro-B-type natriuretic peptide, high sensitivity cardiac troponin T and LDL) and C (clinical variables including diabetes, peripheral arterial disease, and smoking) has been shown to be very effective in predicting cardiovascular death in stable CAD patients.[36] This can be especially important in patients with the long-standing diagnosis of CCS. Further research is needed to verify whether this model can be implemented clinically.

The utilization of CCTA rule out anatomical CAD because of its high negative predictive value[8] has resulted in a decrease in the need for invasive coronary angiography in most clinical scenarios.[37] However, CCTA only provides information on the presence or absence of CAD along with the degree of stenosis but does not provide information on the significance of the stenosis and extent of ischemia. Impairment in the microcirculation also has the potential to induce ischemia, or result in MI, even without significant stenosis.[1],[38],[39] Thus, the clinical relevance of stenosis highly depends on the ischemia burden of the coronary microcirculation, which can be assessed by the perfusion and viability studies using noninvasive imaging modalities such as stress CMR and PET.[8],[38] Incorporation of stress CMR into clinical decision pathways was shown to exhibit a lower incidence of PCI as compared to FFR-guided angiography without an increase in non-favorable clinical outcomes.[40] This information will influence the way CCS patients are assessed and guide the decision of whether or not a more aggressive management option is necessary.

The combination of revascularization (PCI or CABG) and optimal medical therapy has always played a central role in managing stable CAD patients.[1] Data drawn from the FAME-2 trial revealed that with the use of FFR-guided PCI, there was a decrease in the utilization of antianginal medication and as a result, a reduction in the associated side effects, along with an increase in the quality of life, with the exception of patients with non-ischemic stenosis.[41] However, other studies, including meta-analyses, have reported no[31],[42],[43],[44] or only minimal incremental benefit[45] of the combination of PCI with optimal medical therapy when compared to only optimal medical therapy.

However, recent evidence from published data suggest that in patients with stable CAD, patients with left main or multivessel disease, who underwent CABG for revascularization, had lower cardiovascular and MI risk when compared with those on optimal medical therapy alone. Similarly, those in whom, the left main or multivessel disease was excluded and had PCI with the newer generation drug-eluting stents (DES) had a lower risk of MI when compared with those on optimal medical therapy alone, a risk reduction which was not evident with the earlier generation DES.[46]

Since it is well established that dysfunction in the microcirculation also have the potential to result in ischemia, and that epicardial vessel stenosis or obstructions are not the sole cause of ischemia, directing treatment to epicardial disease alone is not ideal in treating CCS patients.[39] This could potentially change the algorithm of CCS management, where revascularization may be reserved for patients who fail to improve and continue to be symptomatic with optimal medical therapy, and subsequently have a lower quality of life. The method of revascularization could also be tailored to the specific subset of patients, in which there is the maximal benefit and least possible complications.

There is little evidence regarding long-term outcomes in those with a long-established CCS. The CLARIFY registry, a prospective observational study that addressed this issue, reported that previous MI and anginal symptoms were major factors contributing to the worse prognosis. History of previous MI with or without angina had poor prognosis when compared with those without previous MI. However, among those with anginal symptoms, poor outcome was limited only to those with previous MI.[2] Another study demonstrated that silent ischemia alone is not associated with adverse cardiovascular outcomes, and as a result, management should not be based on anti-ischemic treatment alone.[47]

There is a knowledge gap regarding the use of risk stratification scores to critically assess different CCS patients and the follow-up time intervals, which are yet to be determined.[1]

The combination of CCB and BB has not demonstrated superiority over monotherapy in stable CAD patients.[48] The combination of anti-ischemic drugs most effective in the varying clinical scenario is debatable. In addition, it is also unclear whether the combination of CCBs and BB provide better relief of anginal symptoms as compared to the use of long-acting nitrates with either CCB or BB. The current guidelines state that the recommendations are only potential combinations and not formal recommendations.[1] This highlights a large gap in evidence, and further research is encouraged to study the various potential drug combinations.

  Conclusion Top

The classification of CCS is a welcome addition that better describes a wide range of related conditions under a single category. This has the potential to benefit research and clinical practice through improved recognition of patients that require earlier and more intensive treatment versus those patients with milder disease that could benefit from more conservative management options. By summarizing and collating the current evidence, we are able to identify gaps where further research needs to be focused.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC). Europ Heart J 2019;41:407-77.  Back to cited text no. 1
Sorbets E, Fox KM, Elbez Y, Danchin N, Dorian P, Ferrari R, et al. Long-term outcomes of chronic coronary syndrome worldwide: Insights from the international CLARIFY registry. Eur Heart J 2020;41:347-56.  Back to cited text no. 2
Lüscher TF. Chronic coronary syndromes: Expanding the spectrum and natural history of ischaemic heart disease. Eur Heart J 2020;41:333-6.  Back to cited text no. 3
Diamond GA. A clinically relevant classification of chest discomfort. J Am Coll Cardiol 1983;1:574-5.  Back to cited text no. 4
Genders TS, Steyerberg EW, Alkadhi H, Leschka S, Desbiolles L, Nieman K, et al. A clinical prediction rule for the diagnosis of coronary artery disease: Validation, updating, and extension. Eur Heart J 2011;32:1316-30.  Back to cited text no. 5
Foldyna B, Udelson JE, Karády J, Banerji D, Lu MT, Mayrhofer T, et al. Pretest probability for patients with suspected obstructive coronary artery disease: Re-evaluating Diamond-Forrester for the contemporary era and clinical implications: Insights from the PROMISE trial. Eur Heart J Cardiovasc Imaging 2019;20:574-81.  Back to cited text no. 6
Task Force Members, Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, et al. 2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013;34:2949-3003.  Back to cited text no. 7
Knuuti J, Ballo H, Juarez-Orozco LE, Saraste A, Kolh P, Rutjes AWS, et al. The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: A meta-analysis focused on post-test disease probability. Eur Heart J 2018;39:3322-30.  Back to cited text no. 8
Nakazato R, Berman DS, Alexanderson E, Slomka P. Myocardial perfusion imaging with PET. Imaging Med 2013;5:35-46.  Back to cited text no. 9
Chow CK, Jolly S, Rao-Melacini P, Fox KA, Anand SS, Yusuf S. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation 2010;121:750-8.  Back to cited text no. 10
Critchley JA, Capewell S. Mortality risk reduction associated with smoking cessation in patients with coronary heart disease a systematic review. JAMA 2003;290:86-97.  Back to cited text no. 11
Prochaska JJ, Benowitz NL. The past, present, and future of nicotine addiction therapy. Annu Rev Med 2016;67:467-86.  Back to cited text no. 12
Bruning RS, Sturek M. Benefits of exercise training on coronary blood flow in coronary artery disease patients. Prog Cardiovasc Dis 2015;57:443-53.  Back to cited text no. 13
Fiuza-Luces C, Garatachea N, Berger NA, Lucia A. Exercise is the real polypill. Physiology (Bethesda) 2013;28:330-58.  Back to cited text no. 14
Hopper IK, Billah B, Skiba MA, Krum H. Abstract 15435: Prevention of diabetes and reduction in major cardiovascular events in studies of subjects with impaired glucose tolerance: Meta-analysis of randomized controlled clinical trials. Circulation 2010;122 Suppl 21:A15435-A.  Back to cited text no. 15
Pack QR, Rodriguez-Escudero JP, Thomas RJ, Ades PA, West CP, Somers VK, et al. The prognostic importance of weight loss in coronary artery disease: A systematic review and meta-analysis. Mayo Clin Proc 2014;89:1368-77.  Back to cited text no. 16
Freeman AM, Morris PB, Barnard N, Esselstyn CB, Ros E, Agatston A, et al. Trending cardiovascular nutrition controversies. J Am Coll Cardiol 2017;69:1172-87.  Back to cited text no. 17
Khan SS, Ning H, Wilkins JT, Allen N, Carnethon M, Berry JD, et al. Association of body mass index with lifetime risk of cardiovascular disease and compression of morbidity. JAMA Cardiol 2018;3:280-7.  Back to cited text no. 18
Stamm O, Latscha U, Janecek P, Campana A. Development of a special electrode for continuous subcutaneous pH measurement in the infant scalp. Am J Obstet Gynecol 1976;124:193-5.  Back to cited text no. 19
Cooper-DeHoff RM, Chang SW, Pepine CJ. Calcium antagonists in the treatment of coronary artery disease. Curr Opin Pharmacol 2013;13:301-8.  Back to cited text no. 20
Zhang H, Yuan X, Zhang H, Chen S, Zhao Y, Hua K, et al. Efficacy of long-term β-blocker therapy for secondary prevention of long-term outcomes after coronary artery bypass grafting surgery. Circulation 2015;131:2194-201.  Back to cited text no. 21
Bangalore S, Fakheri R, Wandel S, Toklu B, Wandel J, Messerli FH. Renin angiotensin system inhibitors for patients with stable coronary artery disease without heart failure: Systematic review and meta-analysis of randomized trials. BMJ 2017;356:j4.  Back to cited text no. 22
Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018;39:213-60.  Back to cited text no. 23
Schmidt AF, Pearce LS, Wilkins JT, Overington JP, Hingorani AD, Casas JP. PCSK9 monoclonal antibodies for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2017;4:CD011748.  Back to cited text no. 24
Robinson JG, Rosenson RS, Farnier M, Chaudhari U, Sasiela WJ, Merlet L, et al. Safety of very low low-density lipoprotein cholesterol levels with alirocumab: pooled data from randomized trials. J Am Coll Cardiol 2017;69:471-82.  Back to cited text no. 25
Fearon WF, Nishi T, De Bruyne B, Boothroyd DB, Barbato E, Tonino P, et al. Clinical outcomes and cost-effectiveness of fractional flow reserve-guided percutaneous coronary intervention in patients with stable coronary artery disease: Three-year follow-up of the FAME 2 trial (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation). Circulation 2018;137:480-7.  Back to cited text no. 26
De Bruyne B, Pijls NH, Kalesan B, Barbato E, Tonino PA, Piroth Z, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 2012;367:991-1001.  Back to cited text no. 27
De Bruyne B, Fearon WF, Pijls NH, Barbato E, Tonino P, Piroth Z, et al. Fractional flow reserve-guided PCI for stable coronary artery disease. N Engl J Med 2014;371:1208-17.  Back to cited text no. 28
Corrigendum to: 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019;40:3096.  Back to cited text no. 29
Maron DJ, Boden WE, O'Rourke RA, Hartigan PM, Calfas KJ, Mancini GBJ, et al. Intensive multifactorial intervention for stable coronary artery disease: Optimal medical therapy in the COURAGE (Clinical Outcomes Utilizing Revascularisation and Aggressive Drug Evaluation) Trial. J Am College Cardiol 2010;55:1348-58.  Back to cited text no. 30
ISCHEMIA Trial Research Group, Maron DJ, Hochman JS, O'Brien SM, Reynolds HR, Boden WE, et al. International study of comparative health effectiveness with medical and invasive approaches (ISCHEMIA) trial: Rationale and design. Am Heart J 2018;201:124-35.  Back to cited text no. 31
Cheng VY, Berman DS, Rozanski A, Dunning AM, Achenbach S, Al-Mallah M, et al. Performance of the traditional age, sex, and angina typicality-based approach for estimating pretest probability of angiographically significant coronary artery disease in patients undergoing coronary computed tomographic angiography: Results from the multinational coronary CT angiography evaluation for clinical outcomes: An international multicenter registry (CONFIRM). Circulation 2011;124:2423-32, 1-8.  Back to cited text no. 32
Genders TS, Steyerberg EW, Hunink MG, Nieman K, Galema TW, Mollet NR, et al. Prediction model to estimate presence of coronary artery disease: Retrospective pooled analysis of existing cohorts. BMJ 2012;344:e3485.  Back to cited text no. 33
Sengupta PP, Shrestha S, Zeb I. Solving coronary risk: Time to feed machines some calcium (score) supplements. Eur Heart J 2020;41:368-70.  Back to cited text no. 34
Al'Aref SJ, Maliakal G, Singh G, van Rosendael AR, Ma X, Xu Z, et al. Machine learning of clinical variables and coronary artery calcium scoring for the prediction of obstructive coronary artery disease on coronary computed tomography angiography: Analysis from the CONFIRM registry. Eur Heart J 2020;41:359-67.  Back to cited text no. 35
Lindholm D, Lindbäck J, Armstrong PW, Budaj A, Cannon CP, Granger CB, et al. Biomarker-Based Risk Model to Predict Cardiovascular Mortality in Patients With Stable Coronary Disease. J Am Coll Cardiol 2017;70:813-26.  Back to cited text no. 36
Chang HJ, Lin FY, Gebow D, An HY, Andreini D, Bathina R, et al. Selective referral using CCTA versus direct referral for individuals referred to invasive coronary angiography for suspected CAD: A randomized, controlled, open-label trial. JACC Cardiovasc Imaging 2019;12:1303-12.  Back to cited text no. 37
Figulla HR, Maier LS, Sechtem U, Silber S, Thiele H. Percutaneous coronary intervention in stable coronary heart disease-is less more? Arztebl Int 2020;117:137-44.  Back to cited text no. 38
César LAM, Mioto BM. How and when to revascularize patients with chronic coronary syndrome. Int J Cardiol 2020;308:26-7.  Back to cited text no. 39
Nagel E, Greenwood JP, McCann GP, Bettencourt N, Shah AM, Hussain ST, et al. Magnetic resonance perfusion or fractional flow reserve in coronary disease. N Engl J Med 2019;380:2418-28.  Back to cited text no. 40
Xaplanteris P, Fournier S, Pijls NH, Fearon WF, Barbato E, Tonino PA, et al. Five-year outcomes with PCI guided by fractional flow reserve. N Engl J Med 2018;379:250-9.  Back to cited text no. 41
Trikalinos TA, Alsheikh-Ali AA, Tatsioni A, Nallamothu BK, Kent DM. Percutaneous coronary interventions for non-acute coronary artery disease: A quantitative 20-year synopsis and a network meta-analysis. Lancet 2009;373:911-8.  Back to cited text no. 42
Stergiopoulos K, Brown DL. Initial coronary stent implantation with medical therapy vs. medical therapy alone for stable coronary artery disease: Meta-analysis of randomized controlled trials. Arch Intern Med 2012;172:312-9.  Back to cited text no. 43
Maron DJ, Hochman JS, Reynolds HR, Bangalore S, O'Brien SM, Boden WE, et al. Initial invasive or conservative strategy for stable coronary disease. New England J Med 2020;382:1395-1407.  Back to cited text no. 44
Bangalore S, Pursnani S, Kumar S, Bagos PG. Percutaneous coronary intervention versus optimal medical therapy for prevention of spontaneous myocardial infarction in subjects with stable ischemic heart disease. Circulation 2013;127:769-81.  Back to cited text no. 45
Taglieri N, Bruno AG, Bacchi Reggiani ML, D'Angelo EC, Ghetti G, Bruno M, et al. Impact of coronary bypass or stenting on mortality and myocardial infarction in stable coronary artery disease. Int J Cardiol 2020;309:63-9.  Back to cited text no. 46
Steg PG, Greenlaw N, Tendera M, Tardif JC, Ferrari R, Al-Zaibag M, et al. Prevalence of anginal symptoms and myocardial ischemia and their effect on clinical outcomes in outpatients with stable coronary artery disease: Data from the International Observational CLARIFY Registry. JAMA Intern Med 2014;174:1651-9.  Back to cited text no. 47
Kenneth Pehrsson S, Ringqvist I, Ekdahl S, Karlson BW, Ulvenstam G, Persson S. Monotherapy with amlodipine or atenolol versus their combination in stable angina pectoris. Clin Cardiol 2000;23:763-70.  Back to cited text no. 48


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