Chronic coronary syndrome (CCS) affects one in 20 adults globally, with numbers increasing due to better survival rates, improved recognition, and a focus on both larger and smaller heart vessels. Now, new guidelines highlight the importance of addressing emerging factors that cannot be ignored, such as angina/ischemia with nonobstructive coronary arteries (ANOCA/INOCA), new scores for assessing the likelihood of large artery blockage, advanced non-invasive and invasive diagnostic tests for CCS, and the increasing recognition of the benefits of healthy lifestyles along with medical and invasive treatments.

The European Society of Cardiology (ESC, Biot, France) has published its 2024 guidelines on CCS management, emphasizing the importance of assessing both larger and smaller blood vessels of the heart. These guidelines introduce new models for estimating the probability of obstructive coronary artery disease, recommend the best sequence and choice of diagnostic tests, and underscore the efficacy of therapeutic interventions and the critical role of patient engagement. They note that patients with persistent symptoms suggestive of ANOCA/INOCA who do not improve with standard medical treatment should undergo invasive testing to identify specific underlying conditions and tailor their treatment accordingly.

A key new recommendation from the guidelines advocates for a clinical likelihood model that factors in risk elements to predict the pre-test probability of obstructive coronary artery disease. This model suggests that approximately half of individuals evaluated for chest pain are at a very low risk of having significant artery blockage (≤5%), and thus should not undergo further immediate testing. Conversely, the previous model from 2019 identified only 19% in this category. While this model has been validated in Western settings, its effectiveness might differ by region due to racial, cultural, and systemic healthcare variations. For individuals presenting with symptoms indicative of CCS who have a low to moderate likelihood (>5%–50%) of obstructive coronary artery disease based on clinical assessment, coronary computed tomography angiography (CCTA) is highly effective for either confirming or ruling out coronary atherosclerosis and assessing the risk of major adverse cardiovascular events based on the anatomical disease burden.

The 2024 guidelines also maintain similar recommendations for coronary revascularization as those from 2018, targeting symptom management related to ischemia unresponsive to medication, significant disease in major coronary arteries, or extensive disease involvement. It recommends selecting the most suitable revascularization technique based on individual patient profiles, coronary anatomy, procedural specifics, patient preferences, and expected outcomes. In cases of extensive disease, surgical approaches are generally preferred over percutaneous coronary interventions, particularly for patients with diabetes or diminished heart function. For interventions using percutaneous coronary methods, combining intracoronary imaging with pressure measurements is advised to optimize both the immediate and long-term success of the procedure, especially in complex cases like those involving the main coronary artery, bifurcations, or extensive lesions.

“Chronic coronary syndromes are a global health concern because a transient or long-lasting damage of the heart caused by diseases of the coronary circulation can cause ineffective heart pump function or malignant arrhythmias that can be fatal,” stated the guidelines co-chairs. “Coronary syndromes remain the single largest cause of death in the adult population worldwide, resulting in millions dying every year. Therefore, the new guidelines stress the importance of early detection, appropriate treatment, and careful long-term follow-up.” 

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