ESC/EACTS guideline for chronic coronary syndrome—invasive treatment perspectives important for daily practice

In August 2024, the new ESC Guidelines for the Management of Chronic Coronary Syndrome (CCS), endorsed by EACTS, have been published [1]. From a surgical perspective, this document is pivotal, as the ESC has shifted its guideline development focus from procedure-oriented to patient-centred and disease-based perspectives. This shift integrates several traditionally separate but interconnected documents—such as those for CCS, myocardial revascularization [2], and both STEMI and non-STEMI guidelines [3, 4] into a unified framework for the diagnosis and treatment of CCS [1] and Acute Coronary Syndromes (ACSs) [5]. While EACTS proposed retaining the previous scope and multidisciplinary aspects of the myocardial revascularization Guidelines, the ESC has opted to continue with the new integrated approach. It is also crucial to acknowledge the challenges posed by the strict word count limits of the new guideline document, which must be adhered to even when merging 2 comprehensive documents into one. This constraint may necessitate sacrificing detailed and important recommendations essential for daily clinical practice. However, the new guidelines contain several excellent changes and additions with regard to prevention, diagnosis and the integration of treatment options, in addition to a general upgrade of invasive treatment compared to other current guidelines [6, 7]. Nevertheless, the reduction in a text has relevant consequences, specifically for the recommendations on procedure specifics of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for the invasive treatment of chronic coronary artery disease (CAD). The space allotted to procedural details has been limited to only a fraction of the space in the original myocardial revascularization guidelines [2]. Since the previous recommendations were not renewed and the knowledge, techniques and technology have rapidly evolved since the last version of this document, some of these previous recommendations have become obsolete [8]. Hence, more weight and effort for appropriate ‘decision-making’ will fall onto the Heart Team with regard to individual patient treatment recommendations until perhaps other bodies will fill this guidance gap in the future. Thus, all Heart Team members’ competence and data awareness become increasingly important. The 2024 CCS guidelines now provide up-to-date recommendations for the main scenarios in the daily treatment of patients with CAD. As in all guidelines, these recommendations result from interpreting the data published in peer-reviewed journals following extensive discussions on the available evidence in light of contemporary practice. The committee opted for a non-mechanistic approach to interpreting the data, which allowed some inconsistencies with previous and other guidelines to persist, reflecting the partial contradictions in trial results. In addition, the committee chose not to introduce new terminology, which might have helped to resolve some of these controversies. In the following text, we will present the updated recommendations and address inconsistencies, controversies, strengths and weaknesses, clearly summarizing the new guidelines’ essence and emphasizing the critical information essential for daily clinical practice. All recommendations for the invasive treatment of CCS by CABG or PCI have practically been summarized in 2 recommendation Tables [1]. Table 22 of the original guideline (here reproduced as Table 1) provides the primary indications for invasively treating patients with chronic CAD, while Table 23 of the original guideline (here reproduced as Table 2) then distinguishes between the modes of invasive treatment, specifically CABG or PCI. The content aligns broadly with the current recommendations on the management of CCS of American societies [6, 7] and suggests ‘revascularization’ in patients with relevant obstructive CAD. CABG is the gold standard of care in patients with anatomically complex CAD, as assessed by the SYNergy Between PCI with TAXUS and Cardiac Surgery (SYNTAX) score, as well as those with left main coronary artery disease (LMCAD) with multivessel disease (MVD), diabetes mellitus (DM) and/or heart failure. Table 24 in the original guideline document [1] further details the diagnosis and medical management of CCS patients with heart failure. This recommendation acknowledges that CABG, but not PCI, has been demonstrated to improve prognosis in this specific patient population. Recommendations for invasive therapy in patients with chronic coronary syndrome Informed and shared decisions It is that patients for percutaneous or surgical revascularization information the and to as of shared clinical complex clinical to the treatment in when CABG and PCI the of a Heart Team is from and other the appropriate treatment to improve patient and of It is to the of the Heart Team in a that the patient It is that the for revascularization and its be patient and It is that the Heart Team or with a to the appropriate revascularization in with current guidelines to improve In patients with left fraction In CCS patients with myocardial revascularization is in addition to medical for patients with left main to improve In CCS patients with myocardial revascularization is in addition to medical for patients with disease to improve and to and the of myocardial In CCS patients with myocardial revascularization is in addition to medical for patients with or disease the to and the of myocardial In patients with left fraction In CCS patients with is to between revascularization or medical therapy by the Heart of coronary between coronary artery disease and individual and patient In CCS patients with multivessel and myocardial revascularization with CABG is medical therapy to improve In CCS patients with and surgical or not PCI may be as to CABG to improve In CCS patients with or medical treatment, myocardial revascularization of obstructive is to improve of procedural and In patients with complex in revascularization is is to procedural and to shared clinical of the is to and CABG In patients with multivessel obstructive CAD, of the is to the of disease guidance by or is when PCI on anatomically complex in left main and or or is to for intervention in patients with multivessel disease be the of the procedure to patients of and clinical may be the of the procedure to to treatment with PCI of revascularization It is that the appropriate revascularization on patient coronary procedural and Informed and shared decisions It is that patients for percutaneous or surgical revascularization information the and to as of shared clinical complex clinical to the treatment in when CABG and PCI the of a Heart Team is from and other the appropriate treatment to improve patient and of It is to the of the Heart Team in a that the patient It is that the for revascularization and its be patient and It is that the Heart Team or with a to the appropriate revascularization in with current guidelines to improve In patients with left fraction In CCS patients with myocardial revascularization is in addition to medical for patients with left main to improve In CCS patients with myocardial revascularization is in addition to medical for patients with disease to improve and to and the of myocardial In CCS patients with myocardial revascularization is in addition to medical for patients with or disease the to and the of myocardial In patients with left fraction In CCS patients with is to between revascularization or medical therapy by the Heart of coronary between coronary artery disease and individual and patient In CCS patients with multivessel and myocardial revascularization with CABG is medical therapy to improve In CCS patients with and surgical or not PCI may be as to CABG to improve In CCS patients with or medical treatment, myocardial revascularization of obstructive is to improve of procedural and In patients with complex in revascularization is is to procedural and to shared clinical of the is to and CABG In patients with multivessel obstructive CAD, of the is to the of disease guidance by or is when PCI on anatomically complex in left main and or or is to for intervention in patients with multivessel disease be the of the procedure to patients of and clinical may be the of the procedure to to treatment with PCI of revascularization It is that the appropriate revascularization on patient coronary procedural and coronary artery bypass coronary artery chronic coronary of left of left left multivessel percutaneous coronary of SYNergy Between PCI with TAXUS and Cardiac diabetes and other disease left main and of revascularization and surgical and Recommendations for invasive therapy in patients with chronic coronary syndrome Informed and shared decisions It is that patients for percutaneous or surgical revascularization information the and to as of shared clinical complex clinical to the treatment in when CABG and PCI the of a Heart Team is from and other the appropriate treatment to improve patient and of It is to the of the Heart Team in a that the patient It is that the for revascularization and its be patient and It is that the Heart Team or with a to the appropriate revascularization in with current guidelines to improve In patients with left fraction In CCS patients with myocardial revascularization is in addition to medical for patients with left main to improve In CCS patients with myocardial revascularization is in addition to medical for patients with disease to improve and to and the of myocardial In CCS patients with myocardial revascularization is in addition to medical for patients with or disease the to and the of myocardial In patients with left fraction In CCS patients with is to between revascularization or medical therapy by the Heart of coronary between coronary artery disease and individual and patient In CCS patients with multivessel and myocardial revascularization with CABG is medical therapy to improve In CCS patients with and surgical or not PCI may be as to CABG to improve In CCS patients with or medical treatment, myocardial revascularization of obstructive is to improve of procedural and In patients with complex in revascularization is is to procedural and to shared clinical of the is to and CABG In patients with multivessel obstructive CAD, of the is to the of disease guidance by or is when PCI on anatomically complex in left main and or or is to for intervention in patients with multivessel disease be the of the procedure to patients of and clinical may be the of the procedure to to treatment with PCI of revascularization It is that the appropriate revascularization on patient coronary procedural and Informed and shared decisions It is that patients for percutaneous or surgical revascularization information the and to as of shared clinical complex clinical to the treatment in when CABG and PCI the of a Heart Team is from and other the appropriate treatment to improve patient and of It is to the of the Heart Team in a that the patient It is that the for revascularization and its be patient and It is that the Heart Team or with a to the appropriate revascularization in with current guidelines to improve In patients with left fraction In CCS patients with myocardial revascularization is in addition to medical for patients with left main to improve In CCS patients with myocardial revascularization is in addition to medical for patients with disease to improve and to and the of myocardial In CCS patients with myocardial revascularization is in addition to medical for patients with or disease the to and the of myocardial In patients with left fraction In CCS patients with is to between revascularization or medical therapy by the Heart of coronary between coronary artery disease and individual and patient In CCS patients with multivessel and myocardial revascularization with CABG is medical therapy to improve In CCS patients with and surgical or not PCI may be as to CABG to improve In CCS patients with or medical treatment, myocardial revascularization of obstructive is to improve of procedural and In patients with complex in revascularization is is to procedural and to shared clinical of the is to and CABG In patients with multivessel obstructive CAD, of the is to the of disease guidance by or is when PCI on anatomically complex in left main and or or is to for intervention in patients with multivessel disease be the of the procedure to patients of and clinical may be the of the procedure to to treatment with PCI of revascularization It is that the appropriate revascularization on patient coronary procedural and coronary artery bypass coronary artery chronic coronary of left of left left multivessel percutaneous coronary of SYNergy Between PCI with TAXUS and Cardiac diabetes and other disease left main and of revascularization and surgical and and recommendations for invasive therapy in chronic coronary syndrome main disease In CCS patients surgical with left main coronary is medical therapy to improve is as the revascularization PCI, the of myocardial and revascularization In CCS patients with left main coronary of in PCI provide of revascularization to that of CABG, PCI is as to CABG, its and In CCS patients with left main coronary of in PCI provide of revascularization to that of CABG, PCI be its and main disease with In CCS patients surgical with CABG is medical therapy to improve In CCS patients surgical PCI may be medical therapy diabetes In CCS patients with multivessel disease and with to medical CABG is medical therapy and PCI to improve and In CCS patients surgical PCI be medical therapy to and diabetes In CCS patients with diabetes and to medical CABG is medical therapy to improve and other In CCS patients with to medical and disease of in PCI provide of revascularization to that of CABG, PCI is its and or disease the In CCS patients with or disease the and to medical CABG or PCI is medical therapy to improve and In CCS patients with complex or disease the to PCI, and to medical CABG is to improve and revascularization the In CCS patients with or disease not the and with to medical PCI is to improve In CCS patients with or disease not the and with to medical not to revascularization by PCI, CABG may be to improve main disease In CCS patients surgical with left main coronary is medical therapy to improve is as the revascularization PCI, the of myocardial and revascularization In CCS patients with left main coronary of in PCI provide of revascularization to that of CABG, PCI is as to CABG, its and In CCS patients with left main coronary of in PCI provide of revascularization to that of CABG, PCI be its and main disease with In CCS patients surgical with CABG is medical therapy to improve In CCS patients surgical PCI may be medical therapy diabetes In CCS patients with multivessel disease and with to medical CABG is medical therapy and PCI to improve and In CCS patients surgical PCI be medical therapy to and diabetes In CCS patients with diabetes and to medical CABG is medical therapy to improve and other In CCS patients with to medical and disease of in PCI provide of revascularization to that of CABG, PCI is its and or disease the In CCS patients with or disease the and to medical CABG or PCI is medical therapy to improve and In CCS patients with complex or disease the to PCI, and to medical CABG is to improve and revascularization the In CCS patients with or disease not the and with to medical PCI is to improve In CCS patients with or disease not the and with to medical not to revascularization by PCI, CABG may be to improve coronary artery bypass chronic coronary of left of left percutaneous coronary SYNergy Between PCI with TAXUS and Cardiac of previous or or or disease is as the of 2 main coronary and recommendations for invasive therapy in chronic coronary syndrome main disease In CCS patients surgical with left main coronary is medical therapy to improve is as the revascularization PCI, the of myocardial and revascularization In CCS patients with left main coronary of in PCI provide of revascularization to that of CABG, PCI is as to CABG, its and In CCS patients with left main coronary of in PCI provide of revascularization to that of CABG, PCI be its and main disease with In CCS patients surgical with CABG is medical therapy to improve In CCS patients surgical PCI may be medical therapy diabetes In CCS patients with multivessel disease and with to medical CABG is medical therapy and PCI to improve and In CCS patients surgical PCI be medical therapy to and diabetes In CCS patients with diabetes and to medical CABG is medical therapy to improve and other In CCS patients with to medical and disease of in PCI provide of revascularization to that of CABG, PCI is its and or disease the In CCS patients with or disease the and to medical CABG or PCI is medical therapy to improve and In CCS patients with complex or disease the to PCI, and to medical CABG is to improve and revascularization the In CCS patients with or disease not the and with to medical PCI is to improve In CCS patients with or disease not the and with to medical not to revascularization by PCI, CABG may be to improve main disease In CCS patients surgical with left main coronary is medical therapy to improve is as the revascularization PCI, the of myocardial and revascularization In CCS patients with left main coronary of in PCI provide of revascularization to that of CABG, PCI is as to CABG, its and In CCS patients with left main coronary of in PCI provide of revascularization to that of CABG, PCI be its and main disease with In CCS patients surgical with CABG is medical therapy to improve In CCS patients surgical PCI may be medical therapy diabetes In CCS patients with multivessel disease and with to medical CABG is medical therapy and PCI to improve and In CCS patients surgical PCI be medical therapy to and diabetes In CCS patients with diabetes and to medical CABG is medical therapy to improve and other In CCS patients with to medical and disease of in PCI provide of revascularization to that of CABG, PCI is its and or disease the In CCS patients with or disease the and to medical CABG or PCI is medical therapy to improve and In CCS patients with complex or disease the to PCI, and to medical CABG is to improve and revascularization the In CCS patients with or disease not the and with to medical PCI is to improve In CCS patients with or disease not the and with to medical not to revascularization by PCI, CABG may be to improve coronary artery bypass chronic coronary of left of left percutaneous coronary SYNergy Between PCI with TAXUS and Cardiac of previous or or or disease is as the of 2 main coronary Table Table is into with and shared a for the Heart Team and the of detailed patient information treatment is new in this is the recommendation for a Heart Team in CABG and PCI the of This recommendation a of recommendation and has as the PCI and the of shared in these the the Heart and critical in that will guidelines and This recommendation to all Heart have on or of the Heart Team and in between percutaneous coronary intervention and coronary artery bypass grafting in patients with multivessel and/or left main coronary artery coronary artery bypass medical left left main coronary artery left multivessel percutaneous coronary of of The of Table provides recommendations for invasive therapy the clinical for individual a for patients with left fraction and as well as for patients with or on the available the for these from to or myocardial In patients with CCS and Heart between revascularization and medical CABG has a for patients to improve the committee has a for PCI as a treatment in patients not not a treatment In the of Table a general is for revascularization of obstructive to improve medical therapy is not The the recommendations for the of the of for CABG and the for the of CAD. It also details the of for PCI and the of individual patient treatment Table 2 Table then the of the in the previous guidelines, which compared CABG PCI, this is The Table with with or CABG is the treatment PCI, the of and the for revascularization PCI for with and a for those with between 22 and in patients in PCI provide of revascularization to patients now integrated into a new with While this patients with a score, also to clinical scenarios for patients with and Thus, not be for only to patients with In this CABG while PCI is a for patients in is not a patients with and CABG has a general to improve PCI a for in patients with with CABG has for all disease patients while PCI the for patients with or and in PCI provide of revascularization to CABG, on its compared to CABG in this patient population. for patients with or both CABG and PCI have a when the left artery is In the of the primary to with PCI and CABG as It is crucial to the new for with complex In CABG, invasively is PCI for its to and new recommendations the by previous myocardial revascularization guidelines and from the American guidelines with its recommendation for invasive treatment in patients with and The American been for of the The new guidelines the crucial of the Heart in with emphasizing the of in that may from CABG, as in patients with complex a primary CABG PCI is endorsed for its in patients with complex medical to in the appropriate revascularization procedure for patients with multivessel or left main coronary artery The of recommendations and of evidence on the of the PCI and CABG as on the 2024 ESC Guidelines for the management of chronic coronary in with coronary artery bypass coronary artery left left main coronary artery multivessel percutaneous coronary relevant to focus on individual or to in on changes from previous guidelines since these to of available and new data, as well as the of and However, is important to not by the current guidelines or for to in This is to the of the and the of the of invasive treatment, of that is more extensive in other a and 2 recommendation the of the from complex to complex CAD. The 2024 CCS guidelines acknowledge the treatment of CABG in these in Table 2 Table that CABG is as the revascularization PCI to its of and revascularization [1]. the of the guideline a document to the previous recommendations for invasive treatment by between the myocardial revascularization guideline committee that of the trial data This new document for CABG and for PCI in patients with between and It also the as a of and a with specific treatment or the other the 2024 CCS guidelines the left main in the recommendation PCI to the From a surgical perspective, is crucial to that the guidelines now address the of left main on PCI clinical with compared to This information is critical to in Heart Team In addition, the Heart Team to acknowledge that the of patients with also have crucial for the Heart Team is the of The 2024 CCS guidelines continue to the of for surgical which However, is recommendation for PCI, even the from the trial have this It is essential to that in all data as well as in data CABG or PCI practically It is also important to the 2024 CCS guidelines to surgical surgical is as of of with as and between and is important when CABG and PCI recommendations for the surgical is PCI may be medical therapy in patients with with of This is important in the treatment as the previous PCI in this patient has been to The Heart now has more to PCI as a for patients as which on the a well The recommendations for patients with not the have the with that is relevant for on the Heart patients with or CABG has a primary recommendation PCI when with complex that to PCI [1]. This a for more multidisciplinary patient compared to the previous myocardial revascularization guidelines, which that CABG or PCI be and left the for more the for CABG in patients with or disease has been the of CABG may now be for in patients not for PCI and have not to medical This is to the that is evidence that CABG these has a In patients with and as the clearly clinical and changes in of the to a in the recommendation for PCI. This trial compared PCI medical therapy medical therapy in patients with and The guidelines have now the recommendations for PCI in these patients to of surgical PCI as a treatment only in CCS patients with and surgical or not on the demonstrated by the for CABG has been the of as the gold standard of care in these patients for the future. As the of the on invasive treatment of has limited the to address all important aspects of care for both CABG and PCI As a and procedural guidance or not to in daily practice. important that may further or in is of a which CABG or PCI be the Heart Team has invasive to to the previous which that a for PCI or CABG is the procedure be a for patients and for all [2]. The be in light of new evidence from the trial which that invasive and treatment not a in patients with However, this trial also a of or of in the Thus, the to invasive treatment has been this to the invasive one. the for intervention or with chronic to recommendations both the myocardial revascularization and STEMI guidelines as well as those from the ESC guidelines the CCS to patients with this recommendation to all patients patients not but be 24 [5]. The for this approach is on the that patients with complex the treatment from CABG, to the of surgical as in the text This is to be by that not a for these as also by It the of these recommendations in the treatment of the invasive treatment of to CABG as the only treatment on the of as the main clinical Since the of from the coronary the primary treatment is CABG and PCI were that of is for a treatment However, that the ‘revascularization’ not the treatment to individual treatment approach to the invasive treatment of may resolve some from published is the of invasive treatment when is This is the main treatment for patients with those with In CCS, is has to be to Thus, the for the treatment of is not but the in coronary more is when All available evidence from several and suggests that the treatment of but not CABG in patients with CCS demonstrated of CABG both PCI and medical therapy and this treatment be to to as a to this of CABG It is on the of and may even to PCI. the of PCI on is limited the of from and of coronary and myocardial as by The more individual coronary is the more to and/or to by obstructive and result from the of the Thus, myocardial from that only to obstructive from with from myocardial From this perspective, may to ‘revascularization’ to improve as in Table 22 of the 2024 CCS guidelines for patients with and CAD, this has been demonstrated for PCI. However, the specific recommendations in Table 23 2) on the of invasive treatment for the treatment recommendation also be with a approach approach Heart in the to the of from the of present in with the for invasive the is CABG will be to PCI of the with the is and the of PCI be to be a in the to be the This also the new primary recommendation for CABG in and disease the is This 2024 for the management of CCS in of the 2 which from a approach to this disease the in The new guideline a in the challenges with the discussions the Guidelines on myocardial It a of guideline development that we critical for to patients and the medical The document multidisciplinary for patients with CCS for both PCI and CABG the of of It the of and clinical with shared with the to comprehensive care that patient and in between previous guideline for a more multidisciplinary approach to guideline the surgical and other as is essential for recommendations that This to the of critical decisions on individual of shared this guideline the to the procedural of both CABG and PCI, which the from these a that has This specific from in the or of for for and with the following and The other have that have relevant to the of this to new data were or in of this