Chronic Coronary Syndromes Clinical Practice Guidelines (2019)

European Society of Cardiology

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

November 04, 2019

New Recommendations

Basic testing, diagnostics, and risk assessment

It is recommended that the initial test for diagnosing CAD in symptomatic patients in whom obstructive CAD cannot be ruled out based on clinical assessment alone be noninvasive functional imaging for myocardial ischemia or coronary computed tomography angiography (CTA). If coronary CTA reveals CAD of uncertain functional significance or is not diagnostic, functional imaging for myocardial ischemia is recommended.

The choice of the initial noninvasive diagnostic test is based on the clinical likelihood of CAD as well as other patient characteristics that influence test performance, local expertise, and the availability of tests.

Invasive angiography is recommended as an alternative test to diagnose CAD in patients with a high clinical likelihood and severe symptoms refractory to medical therapy, or typical angina at a low level of exercise and clinical evaluation that indicates high event risk. Invasive functional assessment must be available and used to evaluate stenoses before revascularization, unless the stenoses are very high grade (>90% diameter stenosis).

Consider the use of invasive coronary angiography with the availability of invasive functional evaluation to confirm the diagnosis of CAD in patients with an uncertain diagnosis on noninvasive testing.

Consider coronary CTA as an alternative to invasive angiography if another noninvasive test is equivocal or nondiagnostic. However, coronary CTA is not recommended in the setting of extensive coronary calcification, irregular heart rate, significant obesity, inability to cooperate with breath-hold commands, or any other conditions that would make good image quality unlikely.

When screening for CAD in asymptomatic patients, carotid ultrasound intima-media thickness (IMT) is not recommended for cardiovascular (CV) risk assessment.

Antithrombotic therapy

In patients with CCS and sinus rhythm, consider the addition of a second antithrombotic drug to aspirin for long-term secondary prevention in patients with a high risk of ischemic events and without a high bleeding risk. This drug regimen may be considered in those with at least a moderately increased risk of ischemic events and without a high bleeding risk.

In patients with CCS and atrial fibrillation (AF) in whom oral anticoagulation (OAC) is initiated and who are eligible for a non-vitamin K antagonist OAC (NOAC), NOAC is preferred to a vitamin K antagonist (VKA). Long-term OAC therapy (a NOAC or VKA with time in the therapeutic range >70%):

  • Is recommended in patients with AF and a CHA2DS2- VASc score of at least 2 in males and at least 3 in females [CHA2DS2- VASc: Cardiac failure, Hypertension, Age ≥75 [doubled], Diabetes, Stroke [doubled], Vascular disease, Age 65-74, Sex [female])

  • Should be considered in patients with AF and a CHA2DS2- VASc score of 1 in males and 2 in females

In post-percutaneous coronary intervention (PCI) patients with AF or another indication for OAC:

  • In those eligible for a NOAC, NOAC (apixaban 5 mg bid, dabigatran 150 mg bid, edoxaban 60 mg od, or rivaroxaban 20 mg od) is preferred to a VKA in combination with antiplatelet therapy.

  • When rivaroxaban is used and concerns about high bleeding risk outweigh those about stent thrombosis or ischemic stroke, consider rivaroxaban 15 mg od over rivaroxaban 20 mg od for the duration of the concomitant single or dual antiplatelet therapy (DAPT).

  • When dabigatran is used and concerns about high bleeding risk outweigh those about stent thrombosis or ischemic stroke, consider dabigatran 110 mg bid over dabigatran 150 mg bid for the duration of the concomitant single or dual antiplatelet therapy.

  • After uncomplicated PCI, consider early aspirin cessation (≤1 week), and continuation of dual therapy with OAC and clopidogrel, if there is a low risk of stent thrombosis or if concerns about bleeding risk outweigh those about the risk of stent thrombosis, irrespective of the type of stent used.

  • Consider triple therapy with aspirin, clopidogrel, and an OAC for at least 1 month when the risk of stent thrombosis outweighs the bleeding risk, with the total duration (≤6 months) decided upon according to the assessment of these risks and clearly specified at hospital discharge.

  • In patients with an indication for a VKA in combination with aspirin and/or clopidogrel, carefully regulate the VKA dose intensity with a target international normalized ratio (INR) in the range of 2.0-2.5 and with time in the therapeutic range above 70%.

  • In patients with a moderate or high risk of stent thrombosis, irrespective of the type of stent used, dual therapy with an OAC and either ticagrelor or prasugrel may be considered as an alternative to triple therapy with an OAC, aspirin, and clopidogrel.

Other pharmacotherapy

Concomitant use of a proton pump inhibitor is recommended in patients receiving aspirin monotherapy, DAPT, or OAC monotherapy who are at high risk of gastrointestinal bleeding.

Lipid-lowering drugs:

  • If goals are not achieved with the maximum tolerated statin dose: Combination with ezetimibe is recommended.

  • For patients at very high risk who do not achieve their goals on a maximum tolerated dose of statin and ezetimibe: Combination with a PCSK9 (proprotein convertase subtilisin-kexin type 9) inhibitor is recommended.

Consider angiotensin-converting enzyme inhibitors in CCS patients at very high risk of CV adverse events.

In patients with diabetes mellitus and CV disease (CVD):

  • The sodium-glucose co-transporter 2 inhibitors empagliflozin, canagliflozin, or dapagliflozin are recommended.

  • A glucagon-like peptide-1 receptor agonist (liraglutide or semaglutide) is recommended.

Treatment options for refractory angina

A reducer device for coronary sinus constriction may be considered to ameliorate symptoms of debilitating angina refractory to optimal medical and revascularization strategies.

For more information, please go to Primary and Secondary Prevention of Coronary Artery Disease, Acute Coronary Syndrome, and Atrial Fibrillation.

For more Clinical Practice Guidelines, please go to Guidelines.

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