What has changed in the management of chronic ischaemic heart disease? The new European Society of Cardiology Guidelines 2024

The 2024 ESC Guidelines for the management of chronic coronary syndromes expand the concept of CCS (chronic coronary syndrome), adopting a broader vision that includes structural and functional alterations throughout the coronary tree. A significant update concerns the stratification of coronary artery disease risk, with a central role played by the integration of cardiovascular risk factors. In the choice of diagnostic test, coronary computed axial tomography remains the 'gatekeeper' to exclude the disease in low-risk patients. Non-invasive functional tests are preferred in intermediate-high-risk patients, while coronary angiography is recommended for high-risk patients. There is renewed interest in angina and/or ischaemia in the absence of obstructive coronary artery disease (ANOCA/INOCA) patients, in whom the persistence of symptoms requires a complete invasive functional assessment to identify the specific endotype and personalize treatment. The therapeutic approach is characterized by a holistic vision of the patient. The role of aspirin in primary prevention is emphasized. In secondary prevention, revascularization remains essential, especially in patients with ejection fraction > 35% and high anatomical or ischaemic risk. Bypass is preferred in diabetics and patients with complex coronary anatomy, while percutaneous coronary intervention represents a valid alternative, supported by the aid of intracoronary imaging. Increased use of colchicine and semaglutide is recommended.