The ‘10 commandments’ of the 2024 European Society of Cardiology guidelines for the management of chronic coronary syndromes

The 2024 European Society of Cardiology guidelines for the management of chronic coronary syndromes1 update and combine two previous guidelines.2,3 The text and Figure 1 summarize key messages. View chronic coronary syndromes as caused by structural and functional alterations of the epicardial and smaller coronary vessels, affecting patients over time. Note symptoms in clear, descriptive terms. Avoid ‘typical’ and ‘atypical.’ Include dyspnoea, jaw pain, and adynamia among anginal equivalents. Estimate the likelihood of obstructive epicardial coronary artery disease (CAD). Assess cardiovascular risk factors, physical signs, a 12-lead electrocardiogram, transthoracic echocardiography, and blood data. Apply the risk factor–weighted clinical likelihood (RF-CL) score and adjust it upwards in the presence of abnormal findings. Consider measuring the Agatston coronary artery calcium score (CACS) in individuals with a low RF-CL to reclassify them to a very low likelihood if CACS is 0 or, in selected cases, between 1 and 9. Treat risk factors promptly; start anti-anginal/anti-ischaemic therapy if needed; motivate healthy lifestyles. Select diagnostic tests guided by the likelihood of obstructive CAD as follows: Very-low likelihood (≤5%): consider deferring further testing. Treat risk factors and symptoms. Low-to-moderate likelihood (>5% to 50%): coronary computed tomography angiography (CCTA). Moderate-to-high likelihood (>15% to 85%): functional cardiac imaging to assess inducible ischaemia and its severity. Very-high likelihood (>85%): invasive coronary angiography (ICA). Refine diagnosis and treatment based on: CCTA: for no or non-obstructive CAD, consider angina/ischaemia with non-obstructive coronary arteries (ANOCA/INOCA). For intermediate (40%–90%) stenoses, perform functional cardiac imaging before ICA. For high-risk CADa, refer to ICA for possible early revascularization. Functional cardiac imaging: without ischaemia, consider possible ANOCA. With marked ischaemiab and unknown coronary anatomy, perform CCTA or ICA. ICA: assess intermediate epicardial stenosis severity functionally. With no or non-obstructive CAD, favour coronary functional testing for vasospasm and microvascular dysfunction. For high-risk CADa, consider early revascularization. Prescribe event-preventing antithrombotic and lipid-lowering drugs and consider colchicine in patients with significant CAD, prior acute coronary syndrome, or prior coronary revascularization. Target LDL cholesterol to <55 mg/dL. Tailor medications to comorbidities, drug interactions, and patient preferences. Recommend revascularization (percutaneous or surgical) for high-risk obstructive CADa, marked ischaemiab, and/or persistent CAD-related angina despite guideline-directed medical therapy. Favour surgical over percutaneous options for patients not at high surgical risk who have diabetes mellitus, high anatomical complexity CAD, or reduced left ventricular ejection fraction. Tailor options to patient’s profile and preferences. Discuss complex cases in a multidisciplinary heart team. Follow patients for long-term adherence, treatment effects, side effects, and disease progression. Favour (re-)evaluating coronary and cardiac anatomy/function in the presence of new/persistent symptoms, heart failure, or other indices of disease progressiona,b. Flowchart summarizing 10 key messages from the 2024 ESC guidelines for the management of chronic coronary syndromes. ANOCA/INOCA, angina/ischaemia with non-obstructive coronary arteries; CAD, epicardial coronary artery disease; CACS, coronary artery calcium score; CCS, chronic coronary syndromes; CCTA, coronary computed tomography angiography; echo, echocardiography; CMR, cardiac magnetic resonance; FFR, fractional flow reserve; iFR, instantaneous wave-free ratio; GDMT, guideline-directed medical therapy; RF-CL, risk factor–weighted clinical likelihood; SPECT, single-photon emission computed tomography. aHigh-risk epicardial coronary artery disease: ≥50% stenosis of the left main stem; three-vessel disease with severe stenoses (≥70% diameter stenosis); single- or two-vessel disease with severe stenoses, including the proximal left anterior descending artery. bMarked ischaemia: affecting ≥10% of left ventricular myocardium; ≥3 of 16 ischaemic segments. C.J.M.V. reports no conflicts of interest. F.A. reports speaker or consultancy fees from Amgen, AstraZeneca, Bayer, Menarini, Novo Nordisk, and Servier.