Understanding Chronic Coronary Syndrome: A Guide for Patients
10 min read | for healthy hearts
A health guide: How to prevent Heart Attacks?
Digital Health Clinic
21 May 2024
Background
Chronic coronary syndrome (CCS), also known as stable coronary artery disease, is a common heart condition affecting millions worldwide, including many in Singapore. As a leading cause of heart-related deaths, CCS requires careful management to improve quality of life and prevent serious complications like heart attacks or strokes. This article breaks down the essentials of CCS, its management, and practical steps you can take to live well with this condition. Whether you're newly diagnosed or supporting a loved one, this guide offers clear, actionable advice based on the latest medical guidance from Singapore’s Agency for Care Effectiveness (ACE), published in March 2025.
What is Chronic Coronary Syndrome?
Chronic coronary syndrome refers to a long-term heart condition caused by narrowed or blocked coronary arteries, which supply blood to the heart. Unlike acute coronary syndrome (a sudden heart attack), CCS develops gradually and includes symptoms like chest pain (angina), shortness of breath, or fatigue, especially during physical activity. According to the ACE Clinical Guidance, CCS affects people with stable angina, those who’ve had a heart attack but stabilized, or those with no symptoms but confirmed artery blockages through tests.In Singapore, heart disease is a major health concern, responsible for about one in five deaths in 2021. CCS often occurs alongside other conditions like high blood pressure, high cholesterol, diabetes, or stroke, making comprehensive management critical.
Why Managing CCS Matters
The primary goals of managing CCS are to relieve symptoms, improve daily life, and prevent serious heart events. Without proper care, CCS can lead to heart attacks, heart failure, or other complications. The good news? With the right combination of medications, lifestyle changes, and regular check-ups, you can manage CCS effectively and live a full, active life. The ACE Clinical Guidance emphasizes a two-pronged approach: pharmacological treatments (medications) and non-pharmacological interventions (lifestyle changes). This guide will walk you through both, focusing on what you can do to take control of your heart health.
What is Chronic Coronary Syndrome?
Chronic coronary syndrome refers to a long-term heart condition caused by narrowed or blocked coronary arteries, which supply blood to the heart. Unlike acute coronary syndrome (a sudden heart attack), CCS develops gradually and includes symptoms like chest pain (angina), shortness of breath, or fatigue, especially during physical activity. According to the ACE Clinical Guidance, CCS affects people with stable angina, those who’ve had a heart attack but stabilized, or those with no symptoms but confirmed artery blockages through tests.
In Singapore, heart disease is a major health concern, responsible for about one in five deaths in 2021. CCS often occurs alongside other conditions like high blood pressure, high cholesterol, diabetes, or stroke, making comprehensive management critical.
Medications for Chronic Coronary Syndrome
Medications are the cornerstone of CCS management, particularly antiplatelet therapy, which prevents blood clots that can cause heart attacks or strokes. Here’s a breakdown of the key recommendations:
1. Antiplatelet Therapy: Aspirin or Clopidogrel
- Low-dose aspirin (75-100 mg daily) is the go-to medication for most people with CCS. It reduces the risk of heart attacks, strokes, and other cardiovascular events. It’s safe for long-term use and has minimal bleeding risks, though some may need stomach-protecting drugs (like proton pump inhibitors) to prevent gastrointestinal issues.
- Clopidogrel is an alternative for those who can’t tolerate aspirin due to allergies or side effects. It’s equally effective but may require temporary switching to aspirin before certain surgeries to reduce bleeding risks. If you’ve had a recent stent, stopping clopidogrel too early can be dangerous, so always consult your doctor.
2. Dual Antiplatelet Therapy (DAPT) After Stent Placement
- If you’ve had a procedure called percutaneous coronary intervention (PCI) to place a stent in your artery, you’ll likely need dual antiplatelet therapy (DAPT), combining aspirin with clopidogrel or ticagrelor. DAPT is highly effective but increases bleeding risk, so it’s used for a specific duration (often 1-12 months), depending on your case. Your cardiologist will set this timeline, but your primary care doctor should confirm it during follow-ups. If the duration is unclear, reach out to your cardiologist to avoid complications.
3. Anticoagulants for Atrial Fibrillation (AF)
- Some people with CCS develop atrial fibrillation (AF), an irregular heartbeat that raises stroke risk. If you have AF but no recent stent (within 12 months), your doctor may prescribe an oral anticoagulant (OAC) like a direct oral anticoagulant (DOAC) instead of warfarin. This decision is based on your CHA2DS2VASc score, which assesses stroke risk, along with factors like bleeding risk and other health conditions. If you have a recent stent and develop AF, your cardiologist will adjust your medications to balance clot prevention and bleeding risks.
Tip: Always discuss new symptoms like irregular heartbeats with your doctor, as they may signal AF or other issues requiring treatment changes.
- Some people with CCS develop atrial fibrillation (AF), an irregular heartbeat that raises stroke risk. If you have AF but no recent stent (within 12 months), your doctor may prescribe an oral anticoagulant (OAC) like a direct oral anticoagulant (DOAC) instead of warfarin. This decision is based on your CHA2DS2VASc score, which assesses stroke risk, along with factors like bleeding risk and other health conditions. If you have a recent stent and develop AF, your cardiologist will adjust your medications to balance clot prevention and bleeding risks.
4. Medications for Angina Relief
- Angina (chest pain) is a common CCS symptom. For immediate relief, sublingual glyceryl trinitrate (a fast-acting nitrate) is recommended. It works within minutes to ease chest pain. For long-term prevention, your doctor may prescribe:Beta blockers (e.g., atenolol, bisoprolol) to reduce heart strain.Calcium channel blockers (e.g., amlodipine, diltiazem) if beta blockers aren’t suitable.
Other options like long-acting nitrates, ivabradine, ranolazine, or trimetazidine for additional symptom control.
Your doctor will choose medications based on your blood pressure, heart rate, and other health conditions to ensure they’re safe and effective.
- Angina (chest pain) is a common CCS symptom. For immediate relief, sublingual glyceryl trinitrate (a fast-acting nitrate) is recommended. It works within minutes to ease chest pain. For long-term prevention, your doctor may prescribe:Beta blockers (e.g., atenolol, bisoprolol) to reduce heart strain.Calcium channel blockers (e.g., amlodipine, diltiazem) if beta blockers aren’t suitable.
Managing Related Health Conditions
CCS often comes with other health issues like high cholesterol, high blood pressure, diabetes, kidney disease, or heart failure. Managing these comorbid conditions is crucial to reduce your overall heart risk. Here’s how:
- Diabetes: Aim for an HbA1c level of 7% or less. Medications like SGLT2 inhibitors or GLP-1 receptor agonists can improve blood sugar and protect your heart and kidneys.
- High Blood Pressure: Keep blood pressure below 130/80 mmHg using ACE inhibitors, ARBs, or calcium channel blockers. Older adults may have less strict targets.
- High Cholesterol: Lower LDL cholesterol to below 1.8 mmol/L (or 1.4 mmol/L if you’re at high risk) with statins, ezetimibe, or PCSK9 inhibitors.
- Kidney Disease: Use ACE inhibitors or ARBs and consider SGLT2 inhibitors to slow disease progression.
- Heart Failure: Join a multidisciplinary heart failure program for tailored care, including medications to improve heart function and reduce hospitalization risk.
Tip: Work with your doctor to create a personalized plan that addresses all your health conditions, not just CCS.
Lifestyle Changes for Heart Health
Lifestyle changes are just as important as medications for managing CCS. The ACE guidance recommends sustained lifestyle interventions to boost your heart health and overall well-being. Here’s what you can do:
1. Stay Physically Active
- Aerobic exercise: At least 150 minutes of moderate activity (e.g., brisk walking, cycling) or 75 minutes of vigorous activity weekly, spread over 3-7 days.
- Resistance training: 2 days a week, targeting major muscle groups.
- Safety first: Avoid exercise if you have unstable conditions like uncontrolled blood pressure or recent angina. Check with your doctor if you’re unsure.
2. Quit Smoking
- Smoking is a major risk factor for heart events. Quitting can cut your risk of heart attack by 32% and death by 36%. Ask your doctor about smoking cessation programs or medications to help you quit.
3. Eat a Heart-Healthy Diet
- Adopt a diet rich in whole grains, fruits, vegetables, legumes, and fish, like the Mediterranean or DASH diet. Limit alcohol to reduce heart risks, and aim for a healthy weight (BMI below 23 kg/m²).
4. Manage Stress and Mental Health
- Stress, anxiety, and depression can worsen CCS. Practice relaxation techniques, seek counseling, or consider medications if needed. Avoid stressful situations when possible.
5. Stay Safe with Sexual Activity
- Sexual activity is generally safe if your CCS is stable. However, avoid nitrate medications with PDE-5 inhibitors (e.g., sildenafil) to prevent dangerous blood pressure drops.
Regular Follow-Ups: Staying on Track
Regular check-ups are vital for managing CCS, even if you feel fine. Follow-up frequency depends on your condition’s severity, recent procedures, and other health issues. Newly diagnosed patients or those post-PCI may need visits every 1-3 months initially. Always report changes in symptoms or daily function to your doctor. Your doctor will:
- Monitor symptoms and medication side effects.
- Check adherence to medications and lifestyle changes.
- Assess heart risk factors, especially if you have diabetes or high cholesterol.
- Recommend vaccinations (e.g., flu, pneumococcal) to protect your health.
Patient Education and Support
Understanding CCS empowers you to manage it better. Use resources like the ACE patient education aids on coronary heart disease and antiplatelet therapy myths to learn more. These tools explain your condition, debunk misconceptions, and highlight lifestyle changes to reduce risks.
Conclusion: Taking Control of Your Heart Health
Chronic coronary syndrome is a manageable condition with the right care. By following your doctor’s advice on medications, adopting a heart-healthy lifestyle, and attending regular check-ups, you can reduce symptoms, prevent complications, and enjoy a better quality of life. In Singapore, where heart disease is a leading health challenge, resources like the ACE Clinical Guidance provide clear, evidence-based recommendations to guide you and your healthcare team. Stay proactive: talk to your doctor about any concerns, stick to your treatment plan, and make small, sustainable changes to your daily habits. Your heart will thank you.
