2024 ESC Guidelines for Management of Chronic Coronary Syndromes: Key Points

2024 European Society of Cardiology  Guidelines for Management of Chronic Coronary Syndromes: Key Points European Heart Journal, ehae177, https://doi.org/10.1093/eurheartj/ehae177  The key points to remember from the 2024 European Society of Cardiology (ESC) guidelines for the management of chronic coronary syndromes (CCS) are:  · The term chronic coronary syndromes describes the clinical presentations of coronary artery disease (CAD) during stable periods, particularly those preceding or following an acute coronary syndrome (ACS). Of note, symptoms of myocardial ischemia due to obstructive atherosclerotic CAD overlap with those of coronary microvascular disease or vasospasm. Characterization of endotypes is important to guide appropriate medical therapy for angina with nonobstructive coronary arteries (ANOCA)/ischemia with nonobstructive coronary arteries (INOCA) patients. · Managing individuals with suspected CCS involves four steps: The first step is a general clinical evaluation that focuses on assessing symptoms and signs of chronic coronary syndromes, differentiating noncardiac causes of chest pain and ruling out acute coronary syndrome. This initial clinical evaluation requires recording a 12-lead resting electrocardiogram, basic blood tests, and in selected individuals, chest X-ray imaging and pulmonary function testing. This evaluation can be done by the general practitioner. The second step is a further cardiac examination, including echocardiography at rest to rule out left ventricular (LV) dysfunction and valvular heart disease. After that, it is recommended to estimate the clinical likelihood of obstructive CAD to guide deferral or referral to further noninvasive and invasive testing. The third step involves diagnostic testing to establish the diagnosis of CCS and determine the patient’s risk of future events. The final step includes lifestyle and risk factor modification combined with disease-modifying medications. A combination of antianginal medications is frequently needed, and coronary revascularization is considered if symptoms are refractory to medical treatment or if high-risk CAD is present. If symptoms persist after obstructive CAD is ruled out, coronary microvascular disease and vasospasm should be considered. · The inclusion of risk factors to classic pretest likelihood models of obstructive atherosclerotic CAD improves the identification of patients with very low (≤5 %) pretest likelihood of obstructive CAD in whom deferral of diagnostic testing should be considered. · First-line diagnostic testing of suspected CCS should be done by noninvasive anatomic or functional imaging. Selection of the initial noninvasive diagnostic test should be based on the pretest likelihood of obstructive CAD, other patient characteristics that influence the performance of noninvasive tests, and local expertise and availability. · Coronary computed tomography angiography (CCTA) is preferred to rule out obstructive CAD and detect nonobstructive CAD. Functional imaging is preferred to correlate symptoms to myocardial ischemia, estimate myocardial viability, and guide decisions on coronary revascularization. Positron emission tomography is preferred for absolute myocardial blood flow measurements, but cardiac magnetic resonance perfusion studies may offer an alternative. Selective second-line cardiac imaging with functional testing in patients with abnormal CCTA and CCTA after abnormal functional testing may improve patient selection for invasive coronary angiography (ICA). · Invasive coronary angiography is recommended to diagnose obstructive CAD in individuals with a very high pre- or post-test likelihood of disease, severe symptoms refractory to guideline-directed medical therapy (GDMT), angina at a low level of exercise, and/or high event risk. When ICA is indicated, it is recommended to evaluate the functional severity of ‘intermediate’ stenoses by invasive functional testing (fractional flow reserve, instantaneous wave-free ratioi) before revascularization. · A single antiplatelet agent, aspirin or clopidogrel, is generally recommended long term in CCS patients with obstructive atherosclerotic CAD. For high-thrombotic-risk CCS patients, long-term therapy with two antithrombotic agents is reasonable, as long as bleeding risk is not high. · Among CCS patients with normal LV function and no significant left main or proximal left anterior descending lesions, current evidence indicates that myocardial revascularization over GDMT alone does not prolong overall survival. · Among patients with complex multivessel CAD without left main CAD, particularly in the presence of diabetes, who are clinically and anatomically suitable for both revascularization modalities, current evidence indicates longer overall survival after coronary artery bypass grafting than percutaneous coronary intervention. · Lifestyle and risk factor modification combined with disease-modifying and antianginal medications are cornerstones in the management of CCS. Furthermore, shared decision making between patients and health care professionals, based on patient-centered care, is paramount in defining the appropriate therapeutic pathway for CCS patients. Patient education is key to improve risk factor control in the long term.