In Paris, during the European Society of Cardiology (ESC) Congress 2019 Scientific Sessions, new guidelines for the diagnosis and treatment of chronic coronary syndromes were presented. This document, simultaneously published in Euro Heart J, updates the 2013 guidelines on stable ischemic heart disease and takes out the word “stable” so as to emphasize that the disease is anything but that.
Ischemic heart disease can have long stable periods, but it can become unstable at any time. This is typically due to plaque rupture or erosion.
This terminological change was in part to remind us that this disease requires different approaches depending on the time. There are more stable phases and less stable phases, but, in most cases, the disease advances. The point is to intervene on the disease to prevent such advancement and, consequently, events.
These guidelines focus on the most common scenarios: patients with angina and suspected coronary artery disease; asymptomatic and symptomatic patients with stabilized symptoms less than one year after an initial diagnosis or revascularization; patients with angina and suspected vasospastic or microvascular disease; asymptomatic patients in whom coronary artery disease is detected at a preventive checkup, and patients with heart failure or left ventricular dysfunction and coronary artery disease.
One of the key aspects of the new guidelines that they acknowledge that the pretest probability of disease in patients presenting with chest pain is dramatically reduced compared to 2013 numbers.
Invasive tests are recommended in patients at high probability of coronary artery disease, while functional tests are recommended in patients at moderate probability. For the growing proportion of patients in whom coronary artery disease seems unlikely, computerized tomography (CT) is recommended.
Another new recommendation in the 2019 guidelines is the addition of a second antithrombotic drug to aspirin, particularly for primary prevention in patients at high risk of ischemic events and low risk for bleeding.
In patients with coronary artery disease and atrial fibrillation or another indication for anticoagulation, direct oral anticoagulants are now recommended over vitamin-K antagonists.
As regards revascularization, more evidence has arisen on the usefulness of invasive functional assessments (FFR or iFR), where angioplasty can improve symptoms and also reduce the risk of acute myocardial infarction.
Lastly, following the trend of all other recently published documents, writers emphasized the importance of lifestyle modifications, pollution exposure, and other primary prevention measures that were mentioned briefly in the 2013 version.
Original title: 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.
Reference: Knuuti J et al. Euro Heart J. 2019; Epub ahead of print.
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