Management of chronic coronary syndromes: comparison of Italian and non-Italian cohort, insight from the EORP EURECA imaging registry

Introduction The EURECA registry showed that adoption of ESC Guidelines for Chronic Coronary Syndromes (CCS) is suboptimal. The present sub-analysis compared Italian and non-Italian cohorts and explored regional differences within Italy. Methods Patients population were grouped into Italian and non-Italian cohorts. The Italian cohort was further stratified into subgroups from Northern, Central, and Southern regions. Adoption of Guidelines was assessed for the choice of first diagnostic test (Endpoint A) and for the overall diagnostic process (Endpoint B). A 6-month follow-up was performed. Results Among 4,262 patients, 1,636 (38.4%) were enrolled in Italian centers from May 2019 to March 2020. Adoption of 2019 ESC CCS guidelines was suboptimal in both cohorts but higher in Italy for Endpoint A (69.9% vs. 62.3%; p<0.001) and Endpoint B (62.1% vs. 57.0%; p<0.001). In the Italian cohort, there was a more frequent use of exercise ECG (39.6% vs. 25.5%, p<0.001) and a less frequent use of stress imaging (39.4% vs. 45.9%, p<0.001,). On the other hand, there was a more frequent use of coronary CT angiography (CCTA) (39.6% vs. 25.5%, p<0.001) and a less frequent use of invasive coronary angiography (ICA) (22.9% vs. 34.5%, p<0.001). Exercise ECG and ICA remained the main drivers of non-adoption of guidelines in both cohorts. A 6-month low rate of major adverse cardiovascular events was observed in both cohorts, not associated with guidelines adoption. In the Italian cohort, a lower rate of obstructive coronary artery disease (O-CAD) (19.9% vs 26.9%, p<0.001) with a similar rate of revascularization were observed (12.8% vs 14.0%; p=0.27), likely due to a similar prevalence of inducible ischemia (19.1% vs 18.9%) (p=0.74). Despite a higher rate of non-O-CAD (46.4% vs 32.9%, p=0.001) medical treatment was less frequently introduced/changed (33.1% vs 40.4%, p<0.001). The adoption of guidelines, the use of CCTA, stress imaging and ICA were less frequent in southern Italy than in the other regions and associated with lower recognition of O-CAD and ischemia, changes in medical treatment and revascularizations. Conclusions Adoption of ESC CCS guidelines was higher in the Italian than in non-Italian cohort but still suboptimal, mainly associated with the use of exercise ECG and ICA as first test. Across Italian regions, adoption of guidelines and use of imaging test were jeopardized, possibly depending on availability of imaging tests and local health policy.