ESC Updates Guidance for the Diagnosis and Management of Chronic Coronary Syndromes

The updated guidelines focus on chronic coronary syndrome as opposed to stable CAD to emphasize that CAD is categorized as either acute coronary syndrome or chronic coronary syndrome.

The European Society of Cardiology (ESC) Scientific Document Group has released new guidelines for the diagnosis and clinical management of chronic coronary syndromes (CCS), including suspected coronary artery disease (CAD), new onset heart failure, left ventricular (LV) dysfunction with suspected CAD, angina, and suspected vasospastic or microvascular disease. The complete guidelines were published in the European Heart Journal.

Angina and/or Dyspnea and Suspected CAD

In their new guidelines, the ESC Task Force recommends repeated measurements of troponin using either high-sensitivity or ultrasensitive assays to rule out myocardial injury associated with acute coronary syndrome (ACS) in cases of suspected CAD. Blood tests recommended by the ESC include a full blood count, a creatinine measurement, an estimate of renal function, and a lipid profile. Screening for type 2 diabetes using glycated hemoglobin and fasting plasma glucose tests is also recommended in patients with suspected and established CCS.

For the initial diagnostic management of patients with suspected CAD, the guidelines recommend ambulatory electrocardiogram (ECG) monitoring in patients with chest pain and suspected arrhythmias (class I evidence). In patients with chest pain without an obvious non-cardiac cause, as well as during or soon after an angina episode suggestive of CAD, a resting 12-lead ECG is also recommended (class I evidence). A resting transthoracic echocardiogram can exclude alternative angina causes, identify regional wall motion abnormalities indicative of CAD, measure LV ejection fraction for risk stratification, and assess diastolic function.

As the initial test to diagnose CAD in symptomatic patients, the guidelines recommend non-invasive functional imaging for myocardial ischemia or coronary computed tomography angiography (class I evidence). In select patients with suspected CAD, exercise ECG is also recommended for assessing exercise tolerance, symptoms, arrhythmias, blood pressure response, and event risk (class I evidence). The guidelines also provide recommendations for lifestyle management, including cognitive behavioral interventions, exercise-based cardiac rehabilitation, the involvement of multidisciplinary healthcare professionals, and an annual influenza vaccination.

Screening for CAD in Asymptomatic Patients

In asymptomatic patients, the ESC recommends the use of a risk-estimation system (ie, Systematic COronary Risk Evaluation [SCORE]) to calculate total risk estimation for asymptomatic patients >40 years of age without evidence of diabetes, chronic kidney disease, cardiovascular disease (CVD), or familial hypercholesterolemia (class I evidence).

The assessment of a family history of premature CVD is recommended (class I evidence). A validated clinical score should be used in patients <50 years of age who have a family history of premature CVD in a first-degree relative (class I evidence).

Vascular Disease in CCS

Prior to valve surgery, the ESC recommends invasive coronary angiography in patients with a history of CVD, suspected myocardial ischemia, LV systolic dysfunction, men >40 years of age, and postmenopausal women (class I evidence). Invasive coronary angiography is also recommended for the assessment of moderate to severe functional mitral regurgitation (class I evidence). In asymptomatic patients with diabetes mellitus, the guidelines recommend a periodic resting ECG for cardiovascular detection of conduction abnormalities, atrial fibrillation, and silent myocardial infarction (class I evidence). In elderly patients with CCS, the guidelines recommend careful monitoring of drug-related adverse events and intolerance, the use of drug-eluting stents, and radial access during interventions (class I evidence).

Additional Recommendations

According to the ESC, the guidelines continue to recommend statins for all patients with CCS. In the presence of heart failure, diabetes, or hypertension, the guidelines recommend the use of angiotensin-converting enzyme inhibitors in patients without contraindications to this drug class. Patients receiving aspirin or combination antithrombotic therapy who are also at high risk for gastrointestinal bleeding should receive proton pump inhibitors. In patients with nonsignificant epicardial CAD and objective evidence of ischemia, the updated guidelines also recommend an assessment of coronary vasomotor function. In addition, the guidelines state that beta-blockers and/or calcium channel blockers should still be considered the first-line drugs in patients with CCS.

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Gaps in Evidence

Current gaps in evidence, particularly regarding diagnosis, assessment, and treatment options are also highlighted in the guidelines. The ESC states that more research is needed to investigate whether an initial invasive strategy can improve outcomes, especially when this strategy is combined with optimal medical therapy. Additional research identifying the need for and duration of beta-blocker therapy after myocardial infarction in the absence of LV systolic dysfunction is recommended. In terms of revascularization procedures, the ESC suggests additional research is needed to evaluate the value of functional vs anatomical guidance for coronary artery bypass grafting.

The guidelines also suggest that greater clarification about the role of biomarkers for stratifying the risk for ischemic events and bleeding and guidance regarding the bleeding risk with dual antiplatelet therapy (DAPT) is needed. “It is uncertain what effect novel lipid-lowering strategies will have on the net clinical benefit of DAPT,” the Task Force wrote, “with similar implications of other strategies such as intensive BP [blood pressure] lowering and, potentially in the future, selective anti-inflammatory therapies.”


Knuuti J, Wijns W,  Saraste A, et al; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC) [published online August 31, 2019]. European Heart Journal. doi:10.1093/eurheartj/ehz425