2024 ESC Clinical Practice Guidelines for the Management of Chronic Coronary Syndromes
01 Sep 2024
Banner-Guidelines_CCS-Name-1500x1000.jpg As explained by Professor Christiaan Vrints (University of Antwerp - Antwerp, Belgium) and Professor Felicita Andreotti (Fondazione Policlinico Universitario Gemelli IRCCS and Catholic University Medical School - Rome, Italy), Chairs of the Guidelines Task Force, the first main change to the ESC Guidelines on chronic coronary syndromes (CCS) is its definition.1
The guidelines were developed by 28 task force members, including 26 experts and 2 patients. Patients’ input contributed greatly by keeping the focus on patient perspectives and on clear, understandable content. Additionally, involving patients aims to empower them to participate in decision-making and, as a result, to stimulate adherence to healthy lifestyles and appropriate therapies.
“The term CCS was first introduced in the 2019 guidelines but, based on expanded pathophysiological concepts, a new more comprehensive definition has been developed,” explains Prof. Vrints, continuing: “There is a shift in our understanding away from the simple concept of inducible myocardial ischaemia caused by fixed, focal, flow-limiting atherosclerotic stenosis of a large or medium coronary artery. Today’s more complex and dynamic model embraces structural and functional abnormalities in both the macro- and microvascular compartments of the coronary tree, which may be focal or diffuse.”
A stepwise approach to managing suspected CCS is advocated in the 2024 guidelines, beginning with STEP 1, a general clinical evaluation to differentiate the patient’s signs and symptoms from non-cardiac causes of chest pain and rule out acute coronary syndrome. STEP 2 is a cardiac specialist examination, including an echocardiography at rest to rule out left ventricular dysfunction and valvular heart disease. A new Class I recommendation endorses estimating the pre-test likelihood of obstructive epicardial coronary artery disease (CAD) using the Risk Factor-weighted Clinical Likelihood model.
STEP 3 involves testing to establish the CCS diagnosis and determine the patient's risk of future events. It is now recommended that coronary computed tomography angiography is used to diagnose obstructive CAD and to estimate the risk of major adverse cardiovascular events (MACE) in individuals with suspected CCS and low or moderate (>5%–50%) pre-test likelihood of obstructive CAD. In those with moderate or high (>15%–85%) pre-test likelihood of obstructive CAD, there are new Class I recommendations regarding the use of stress echocardiography, positron emission tomography and cardiac magnetic resonance perfusion imaging, if available.
Invasive coronary angiography (ICA) is recommended to diagnose obstructive CAD in individuals with a high pre- or post-test likelihood of disease, severe symptoms refractory to medical therapy, angina at a low level of exercise, and/or high event risk. When ICA is indicated, it is recommended that the functional severity of ‘intermediate’ stenoses is evaluated by invasive functional testing (fractional flow reserve and instantaneous wave-free ratio) before revascularisation.
STEP 4 includes lifestyle and risk-factor modification combined with disease-modifying medications, with coronary revascularisation if symptoms are refractory to medical treatment or if high-risk CAD is present. “Shared decision-making between patients and healthcare professionals, based on patient-centred care, is paramount in defining the appropriate therapeutic pathway for CCS patients,” states Prof. Andreotti. “And where needed, the most appropriate revascularisation modality should be selected based on the patient’s profile, coronary anatomy, procedural factors, patient preference and outcome expectations.” The 2024 guidelines confirm the findings of the 2022 ESC/EACTS Task Force that coronary artery bypass grafting (CABG) is recommended as the overall preferred revascularisation mode over percutaneous coronary intervention (PCI) for left main CAD in low-risk surgical patients given the lower risk of spontaneous myocardial infarction and repeat revascularisation. It is also acknowledged that in patients with significant left main CAD of low complexity (SYNTAX score ≤22), in whom PCI can provide equivalent completeness of revascularisation to that of CABG, PCI is recommended as an alternative to CABG.
The high prevalence of angina with nonobstructive coronary arteries (ANOCA) and ischaemia with nonobstructive coronary arteries (INOCA) and its associated MACE rate is noted in the guidelines. It is recommended that symptomatic patients with suspected ANOCA/INOCA who do not respond to guideline-derived medical therapy should undergo invasive coronary functional testing to determine underlying endotypes to guide appropriate medical therapy.
The final section concerns long-term follow-up and care, with new recommendations on the use of simplified medication regimens, along with mobile health interventions to improve adherence to healthy lifestyles and medical therapy.
Want to know more about what’s new? 2024 ESC Guidelines are now published in the European Heart Journal and are available on the ESC Pocket Guidelines app.
References
- Vrints C, et al. 2024 ESC Guidelines on the management of chronic coronary syndromes. Eur Heart J. 2024. doi:10.1093/eurheartj/ehae177.
