The 2024 ESC Guidelines on the management of chronic coronary syndromes (CCS) emphasise the importance of addressing both large and small blood vessels in the heart, introducing new models to estimate the likelihood of obstructive coronary artery disease, optimising the selection and sequencing of diagnostic tests, and recommending drugs and interventions to prevent complications and improve symptoms, all while highlighting the essential role of patient involvement.
The new guidelines encourage cardiologists to reconsider chronic coronary syndromes as being caused not only by blockages in large arteries but also by dysfunction in smaller vessels. Over half of those suspected of CCS may have angina or ischaemia with nonobstructive coronary arteries (ANOCA/INOCA) due to coronary artery spasm or microcirculatory dysfunction. This condition is often overlooked because standard tests are not effective in detecting it. Patients may experience severe, persistent symptoms that lead to repeated hospitalisations and even heart failure.
The guidelines recommend that patients with suspected ANOCA/INOCA who continue to have symptoms despite guideline-directed medical therapy should undergo invasive coronary functional testing to identify underlying causes and guide appropriate treatment.
A key new recommendation is the use of the risk factor-weighted clinical likelihood model to estimate the pre-test likelihood of obstructive coronary artery disease. This model identifies nearly half of the individuals assessed for chest pain as having a very low likelihood of large artery blockages (≤5%), suggesting further testing should be deferred, compared to only 19% identified by the 2019 ESC model.
For those with symptoms indicative of chronic coronary syndrome and a low to moderate (5%-50%) likelihood of obstructive coronary artery disease based on clinical factors, coronary computed tomography angiography (CCTA) is highly effective in ruling out coronary atherosclerosis or in estimating the risk of major adverse cardiovascular events based on coronary anatomy.
The indications for coronary revascularisation in the 2024 guidelines largely mirror those from 2018, including ischaemia-related symptoms that do not respond to medical therapy alone, significant disease of the left main stem, the proximal left anterior descending artery, or multiple large epicardial arteries.
The guidelines recommend selecting the most appropriate revascularisation method based on the patient's clinical profile, coronary anatomy, procedural factors, patient preferences, and expected outcomes. Surgery is preferred over percutaneous coronary intervention for patients with extensive disease, particularly those with diabetes or reduced left ventricular ejection fraction.
When performing percutaneous coronary intervention, intracoronary imaging along with pressure measurements is recommended to guide interventions and improve both immediate and long-term outcomes, particularly in complex anatomical scenarios such as left main disease, bifurcations, or long lesions.
Chronic coronary syndromes are a global health challenge as heart damage from coronary circulation diseases can lead to ineffective heart function or life-threatening arrhythmias. Coronary syndromes remain the leading cause of death in the adult population worldwide, resulting in millions of deaths annually. Therefore, the new guidelines emphasise the importance of early detection, appropriate treatment, and thorough long-term follow-up.
Source & Image Creit: ESC Congress 2024
