New 2024 ESC guidelines on the management of chronic coronary syndromes (CCS) include a focus on both larger and smaller blood vessels of the heart and new models to estimate chances of obstructive coronary artery disease.

The guidelines also focus on optimal selection and sequence of tests, drugs and interventions to prevent disease complications and improve symptoms, as well as the role of patient involvement.  

“The guidelines prompt us to rethink chronic coronary syndromes as caused not only by blockages in large arteries but also by dysfunction of smaller vessels,” said guidelines co-chair Prof Christian Vrints, Antwerp University Hospital. 

“Over half of individuals suspected of CCS may have angina/ischaemia with non-obstructive coronary arteries (ANOCA/INOCA) caused by coronary artery spasm or microcirculatory dysfunction. This condition is often missed – on average it is diagnosed only after seeing three cardiologists – because the usual tests don’t work well to detect it.” 

The guidelines highlight that persistently symptomatic patients with suspected ANOCA/INOCA who do not respond to guideline-derived medical therapy should undergo invasive coronary functional testing to determine underlying endotypes and guide appropriate therapy. 

A further new recommendation is the use of the risk factor-weighted clinical likelihood model to estimate the pre-test likelihood of obstructive coronary artery disease. 

With this new model, around half of individuals assessed for chest pain have a very low likelihood of large artery blockage (</ = 5%) in whom further testing should be deferred, whereas with the previous model, only 19% were identified as having a very low likelihood. 

For those with symptoms suggestive of chronic coronary syndrome who have a low to moderate likelihood of obstructive coronary artery disease based on symptoms, age, sex and risk factors, coronary-computed tomography angiography is effective in ruling out coronary atherosclerosis or in estimating the risk of major adverse cardiovascular events based on disease anatomy. 

See www.escardio.org