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2019 ESC Guidelines for Diagnosis and Management of Chronic Coronary Syndromes
Debabrata Mukherjee, MD, FACC

The following are key points to remember from the 2019 European Society of Cardiology (ESC) guidelines for the diagnosis and management of chronic coronary syndromes (CCS):

  1. 1. Coronary artery disease (CAD) can have long, stable periods, but can also become unstable at any time, typically due to an acute atherothrombotic event caused by plaque rupture or erosion. The disease is chronic, most often progressive, and hence serious, even in clinically apparently silent periods.
  2. 2. The dynamic nature of the CAD process results in various clinical presentations, which can be conveniently categorized as either acute coronary syndromes (ACS) or chronic coronary syndromes (CCS). These guidelines have been revised to focus on CCS instead of stable CAD.
  3. 3. This change emphasizes the fact that the clinical presentations of CAD can be categorized as either ACS or CCS. CAD is a dynamic process of atherosclerotic plaque accumulation and functional alterations of coronary circulation that can be modified by lifestyle, pharmacological therapies, and revascularization, which result in disease stabilization or regression.
  4. 4. In the current guidelines on CCS, six clinical scenarios most frequently encountered in patients are identified: (i) patients with suspected CAD and “stable” anginal symptoms, and/or dyspnea; (ii) patients with new onset of heart failure (HF) or left ventricular (LV) dysfunction and suspected CAD; (iii) asymptomatic and symptomatic patients with stabilized symptoms <1 year after an ACS or patients with recent revascularization; (iv) asymptomatic and symptomatic patients >1 year after initial diagnosis or revascularization; (v) patients with angina and suspected vasospastic or microvascular disease; (vi) asymptomatic subjects in whom CAD is detected at screening.
  5. 5. The pretest probability of CAD based on age, gender, and nature of symptoms have undergone major revisions. In addition, these guidelines introduced a new phrase “Clinical likelihood of CAD” that utilizes also various risk factors of CAD as pretest probability modifiers. The application of various diagnostic tests in different patient groups to rule-in or rule-out CAD have been updated.
  6. 6. The general approach for the initial diagnostic management of patients with angina and suspected obstructive CAD includes six steps. The first step is to assess the symptoms and signs, to identify patients with possible unstable angina or other forms of ACS (step 1). In patients without unstable angina or other ACS, the next step is to evaluate the patient’s general condition and quality of life (step 2). Comorbidities that could potentially influence therapeutic decisions are assessed and other potential causes of the symptoms are considered. Step 3 includes basic testing and assessment of LV function. Thereafter, the clinical likelihood of obstructive CAD is estimated (step 4) and, on this basis, diagnostic testing is offered to selected patients to establish the diagnosis of CAD (step 5). Once a diagnosis of obstructive CAD has been confirmed, the patient’s event risk will be determined (step 6), as it has a major impact on the subsequent therapeutic decisions.
  7. 7. Careful evaluation of patient history, including the characterization of anginal symptoms, and evaluation of risk factors and manifestations of cardiovascular disease, as well as proper physical examination and basic testing, are crucial for the diagnosis and management of CCS.
  8. 8. Unless obstructive CAD can be excluded based on clinical evaluation alone, either noninvasive functional imaging or anatomical imaging using coronary computed tomography angiography may be used as the initial test to rule-out or establish the diagnosis of CCS. Selection of the initial noninvasive diagnostic test is based on the pretest probability, the test’s performance in ruling-in or ruling-out obstructive CAD, patient characteristics, local expertise, and the availability of the test.
  9. 9. For revascularization decisions, both anatomy and functional evaluation are to be considered. Either noninvasive or invasive functional evaluation is required for the assessment of myocardial ischemia associated with angiographic stenosis, unless very high grade (>90% diameter stenosis). Assessment of risk serves to identify CCS patients at high event risk who are projected to derive prognostic benefit from revascularization. Risk stratification includes the assessment of LV function. In general, patients at high event risk should undergo invasive investigation for consideration of revascularization, even if they have mild or no symptoms.
  10. 10. Implementation of healthy lifestyle behaviors decreases the risk of subsequent CV events and mortality, and is additional to appropriate secondary prevention therapy. Clinicians should advise on and encourage necessary lifestyle changes in every clinical encounter. Cognitive behavioral interventions such as supporting patients to set realistic goals, self-monitor, plan how to implement changes and deal with difficult situations, set environmental cues, and engage social support are effective interventions for behavior change. Multidisciplinary teams can provide patients with support to make healthy lifestyle changes, and address challenging aspects of behavior and risk.
  11. 11. Anti-ischemic treatment must be adapted to the individual patient based on comorbidities, co-administered therapies, expected tolerance and adherence, and patient preferences. The choice of anti-ischemic drugs to treat CCS should be adapted to the patient’s heart rate, blood pressure, and LV function.
  12. 12. Beta-blockers and/or calcium channel blockers remain the first-line drugs in patients with CCS. Beta-blockers are recommended in patients with LV dysfunction or HF with reduced ejection fraction. Long-acting nitrates provoke tolerance with loss of efficacy. This requires prescription of a daily nitrate-free or nitrate-low interval of approximately 10–14 hours.
  13. 13. Antithrombotic therapy is a key part of secondary prevention in patients with CCS and warrants careful consideration. Patients with a previous myocardial infarction, who are at high risk of ischemic events and low risk of fatal bleeding, should be considered for long-term dual antiplatelet therapy with aspirin and either a P2Y12 inhibitor or very low-dose rivaroxaban, unless they have an indication for an oral anticoagulation such as atrial fibrillation.
  14. 14. Statins are recommended in all patients with CCS. Angiotensin-converting enzyme inhibitors (or angiotensin-receptor blockers) are recommended in the presence of HF, diabetes, or hypertension and should be considered in high-risk patients. Proton pump inhibitors are recommended in patients receiving aspirin or combination antithrombotic therapy who are at high risk of gastrointestinal bleeding.
  15. 15. Efforts should be made to explain to patients the importance of evidence-based prescriptions to increase adherence to treatment, and repeated therapeutic education is essential in every clinical encounter. Patients with a long-standing diagnosis of CCS should undergo periodic visits to assess potential changes in risk status, adherence to treatment targets, and the development of comorbidities. Repeat stress imaging or invasive coronary angiography with functional testing is recommended in the presence of worsening symptoms and/or increased risk status. Contact us by

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