2019 ESC guidelines on chronic coronary syndromes

30 Oct 2019

The new European Society of Cardiology (ESC) guidelines for the diagnosis and management of chronic coronary syndromes (CCS) were presented at the ESC congress 2019 in Paris, France. These new guidelines, which updated those published in 2013, have been revised to focus on CCS instead of stable coronary artery disease (CAD) and are newly published in European Heart Journal guidelines.1

The new guidelines emphasize that CAD can have long and stable periods, but can also become unstable at any time, typically due to an acute atherothrombotic event caused by the plaque rupture or erosion. In addition, these guidelines introduced a new phrase “Clinical likelihood of CAD” meaning that various risk factors of CAD can be utilized as the pretest probability modifiers. The application of various diagnostic tests in different patient groups to rule-in or rule-out CAD have been updated as well.2

Careful evaluation of patient history including the characterization of anginal symptoms, risk factors and manifestations of cardiovascular (CV) disease, as well as proper physical examination and basic testing, are crucial for the diagnosis and management of CCS.

Unless obstructive CAD can be excluded based on the clinical evaluation alone, either non-invasive functional imaging or anatomical imaging using coronary computed tomography angiography could be used as the initial test to rule-out or establish the diagnosis of CCS. The selection of initial non-invasive diagnostic test is based on the pretest probability, the test performance in ruling-in or ruling-out obstructive CAD, patient characteristics, local expertise, and the availability of the test. For revascularization decisions, the evaluation of both anatomy and functional should be considered.2

Also, the implementation of healthy lifestyle behaviors could decrease 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 the effective interventions for behavior change as well. Besides, the multidisciplinary teams can provide patients with support to make healthy lifestyle changes, and address challenging aspects of behavior and risk.2

Regarding the therapeutic options, anti-ischemic treatment must be adapted to the individual patient based on comorbidities, co-administered therapies, expected tolerance and adherence, and patient preferences. Beta-blockers and/or calcium channel blockers remain the first-line drugs in patients with CCS. Antithrombotic therapy is a key part of secondary prevention in patients with CCS and warrants careful consideration. 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.2

Efforts should be made to explain to patients the importance of evidence-based prescriptions to increase the treatment adherence, and repeated therapeutic education is essential in every clinical encounter. On the other hand, patients with a long-standing diagnosis of CCS should undergo periodic visits to assess the 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.1,2

  1. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. In: Eur Heart J. 2019 Aug 31. pii: ehz425.
  2. Mukherjee D. 2019 ESC Guidelines for Diagnosis and Management of Chronic Coronary Syndromes. American College of Cardiology. (Accessed September 20, 2019, at
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