Understanding and treating chronic ischemic heart disease. Why do we need a new approach?

INTRODUCTION
Angina pectoris is a clinical diagnosis and is considered the most frequent presentation of chronic ischemic heart disease disease (1). The traditional understanding of chronic heart disease is that of a condition closely associated with narrowings of ≥50% in the left main coronary artery and/or of ≥70% in one or several of the major coronary arteries (1). Based on these conceptions, removal of “critical” atherosclerotic obstructions by means of percutaneous coronary interventions (PCI) with angioplasty and stenting or by means of coronary artery bypass grafting (CABG) is expected to eliminatesymptoms and improve prognosis. Unfortunately, available data do not confirm these expectations. Large clinical trials report limited and transient symptomatic benefit after elective revascularization procedures and no prognostic impact. Moreover, many patients continue to present with a positive stress test and persistent symptoms after “angiographically successful” procedures (Table 1) (2). Recent studies suggest that the prevalence of persistent angina after revascularization may be as high as 25-35% (3). Given these numbers and the negative impact of angina on quality of life and on prognosis (4), identification and treatment of this patient population is of increasing relevance.

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