ESC 2024 2024 ESC Guidelines for the management of chronic coronary syndromes
European Society of Cardiology｜循環器 / 冠動脈疾患｜123 ページ｜チャンク 1295｜推奨 414 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.12 | I | C | history, and symptom characteristics (including onset, duration, type, location, triggers, relieving factors, time of day) is recommended. | Table 3 New major recommendations in 2024 |
| p.12 | IIa | B | fatigue should be considered as potential angina equivalents. | Table 3 New major recommendations in 2024 |
| p.12 | IIa | B | • Additionally, high-sensitivity C-reactive protein and/or fibrinogen plasma levels should be considered. | Table 3 New major recommendations in 2024 |
| p.12 | I | B | It is recommended to estimate the pre-test likelihood of obstructive epicardial CAD using the Risk Factor-weighted Clinical Likelihood model. | Table 3 New major recommendations in 2024 |
| p.12 | IIa | B | In individuals with a very low (≤5%) pre-test likelihood of obstructive CAD, deferral of further diagnostic tests should be considered. | Table 3 New major recommendations in 2024 |
| p.12 | IIa | B | In individuals with a low (>5%–15%) pre-test likelihood of obstructive CAD, CACS should be considered to reclassify subjects and to identify more individuals with very low (≤5%) CACS-weighted clinical likelihood. | Table 3 New major recommendations in 2024 |
| p.12 | IIb | C | In individuals with an initially low (>5%–15%) likelihood of obstructive CAD, exercise ECG and detection of atherosclerotic disease in non-coronary arteries may be considered to adjust the pre-test likelihood estimate. | Table 3 New major recommendations in 2024 |
| p.12 | IIa | B | Ambulatory ECG monitoring should be considered in subjects with suspected vasospastic angina. | Table 3 New major recommendations in 2024 |
| p.12 | I | A | diagnose obstructive CAD and to estimate the risk of MACE. | Table 3 New major recommendations in 2024 |
| p.12 | I | B | recommended to diagnose myocardial ischaemia and to estimate the risk of MACE. | Table 3 New major recommendations in 2024 |
| p.12 | I | B | commercially available intravenous ultrasound contrast agents (microbubbles) to improve diagnostic accuracy. | Table 3 New major recommendations in 2024 |
| p.12 | I | B | is recommended to improve diagnostic accuracy and to refine risk stratification beyond wall motion. | Table 3 New major recommendations in 2024 |
| p.12 | IIb | B | During stress echocardiography, Doppler left anterior descending coronary artery flow reserve may be considered to improve risk stratification beyond wall motion and to assess microvascular function. | Table 3 New major recommendations in 2024 |
| p.12 | I | B | imaging (used for attenuation correction) to improve detection of both non-obstructive and obstructive CAD. | Table 3 New major recommendations in 2024 |
| p.12 | I | B | recommended to diagnose and quantify myocardial ischaemia and/or scar and estimate the risk of MACE. | Table 3 New major recommendations in 2024 |
| p.13 | I | A | When ICA is indicated, radial artery access is recommended as the preferred access site. | |
| p.13 | I | A | When ICA is indicated, it is recommended to have coronary pressure assessment available and to use it to evaluate the functional severity of intermediate non-left main stem stenoses prior to revascularization. | |
| p.13 | I | C | In individuals with de novo symptoms highly suggestive of obstructive CAD that occur at a low level of exercise, ICA with a view towards revascularization is recommended as first diagnostic test after clinical assessment by a cardiologist. | |
| p.13 | I | A | • FFR/iFR (significant ≤0.8 or ≤0.89, respectively); | |
| p.13 | I | B | • QFR (significant ≤0.8). | |
| p.13 | IIa | B | • CFR/HSR/CFC should be considered as a complementary investigation; | |
| p.13 | IIb | C | • resting invasive measurement of Pd/Pa, dPR, RFR, or angiography-derived vessel FFR may be considered as alternative parameters. | |
| p.13 | III | A | Systematic and routine wire-based coronary pressure assessment of all coronary vessels is not recommended. | |
| p.13 | I | B | diagnostic modality. | |
| p.13 | I | B | myocardial ischaemia is not diagnostic. | |
| p.13 | I | B | obstructive CAD or ANOCA/INOCA in individuals with an uncertain diagnosis on non-invasive testing. | |
| p.13 | I | B | diabetes, CKD, LVEF). | |
| p.13 | I | C | An informed discussion on CVD risk and treatment benefits tailored to individual patient needs is recommended. | |
| p.13 | I | A | are recommended. | |
| p.13 | I | B | reduction in sedentary time are recommended. | |
| p.13 | IIa | B | healthy behaviours, and to reduce hospitalizations or cardiac events. | |
| p.13 | I | C | treatment tolerability, and underlying pathophysiology of angina, also considering local drug availability and cost. | |
| p.13 | IIa | B | inadequate control of symptoms, or as part of initial treatment in properly selected patients. | |
| p.14 | III | B | Ivabradine is not recommended as add-on therapy in patients with CCS, LVEF >40%, and no clinical heart failure. | |
| p.14 | III | B | Combination of ivabradine with non-DHP-CCB or other strong CYP3A4 inhibitors is not recommended. | |
| p.14 | I | A | In CCS patients with a prior MI or PCI, clopidogrel 75 mg daily is recommended as a safe and effective alternative to aspirin monotherapy. | |
| p.14 | I | A | After CABG, aspirin 75–100 mg daily is recommended lifelong. | |
| p.14 | I | B | recommended lifelong. | |
| p.14 | I | A | Lipid-lowering treatment with an LDL-C goal of <1.4 mmol/L (55 mg/dL) and a ≥50% reduction in LDL-C vs. baseline is recommended. | |
| p.14 | I | B | For patients who are statin intolerant and do not achieve their goal on ezetimibe, combination with bempedoic acid is recommended. | |
| p.14 | IIa | C | be considered. | |
| p.14 | I | A | or target HbA1c and independent of concomitant glucose-lowering medication. | |
| p.14 | IIa | B | The GLP-1 receptor agonist semaglutide should be considered in CCS patients without diabetes, but with overweight or obesity (BMI ≥27 kg/m2), to reduce CV mortality, MI, or stroke. | |
| p.14 | IIa | A | and need for revascularization. | |
| p.14 | I | C | It is recommended that the decision for revascularization and its modality be patient-centred, considering when possible patient preferences, health literacy, cultural circumstances, and social support. | |
| p.14 | I | A | main stem, true bifurcations and long lesions. | |
| p.14 | I | A | • is recommended to guide lesion selection for intervention in patients with multivessel disease; | |
| p.14 | IIa | B | • should be considered at the end of the procedure to identify patients at high risk of persistent angina and subsequent clinical events; | |
| p.14 | IIb | B | • may be considered at the end of the procedure to identify lesions potentially amenable to treatment with additional PCI. | |
| p.14 | I | C | It is recommended that physicians select the most appropriate revascularization modality based on patient profile, coronary anatomy, procedural factors, LVEF, patient preferences and outcome expectations. | |
| p.14 | I | A | • is recommended over medical therapy alone to improve survival; | |
| p.14 | I | A | • is recommended as the overall preferred revascularization mode over PCI, given the lower risk of spontaneous myocardial infarction and repeat revascularization. | |
| p.15 | I | B | CABG, taking into account the risk-to-benefit ratio of the procedures. | |
| p.15 | I | C | functional imaging is recommended. | |
| p.15 | IIa | B | perfusion or invasive functional coronary testing should be considered to detect or rule out coronary microvascular dysfunction. | |
| p.15 | IIb | C | experienced centres. | |
| p.15 | I | A | the risk of heart failure hospitalization and to improve survival. | |
| p.15 | I | B | hospitalization and death. | |
| p.15 | IIa | A | In symptomatic patients with ANOCA/INOCA, medical therapy based on coronary functional test results should be considered to improve symptoms and quality of life. | |
| p.15 | IIa | B | For the management of endothelial dysfunction, ACE-I should be considered for symptom control. | |
| p.15 | IIa | B | considered for symptom control. | |
| p.15 | I | A | • calcium channel blockers are recommended to control symptoms and to prevent ischaemia and potentially fatal complications; | |
| p.15 | IIa | B | • nitrates should be considered to prevent recurrent episodes. | |
| p.15 | IIb | B | be considered. | |
| p.15 | I | C | Similar guideline-directed cardiovascular preventive therapy is recommended in women and men. | |
| p.15 | I | B | Bleeding risk assessment is recommended using the PRECISE-DAPT score, the qualitative ARC-HBR tool or other, validated methods. | |
| p.15 | I | B | Attention to interaction between antiretroviral treatment and statins is recommended in patients with HIV. | |
| p.15 | IIa | C | guide treatment of modifiable risk factors should be considered. | |
| p.15 | IIb | C | Coronary artery calcium scoring (CACS) may be considered to improve risk classification around treatment decision thresholds. | |
| p.15 | I | A | lifestyles and medical therapy. | |
| p.15 | I | B | Behavioural interventions are recommended to improve adherence. | |
| p.15 | I | B | Simplifying medication regimens (e.g. using fixed-dose drug combinations) is recommended to increase patient adherence to medications. | |
| p.15 | I | C | Multiprofessional and family involvement is recommended to promote adherence, in addition to patient education and involvement. | |
| p.15 | I | B | testing is recommended to define ANOCA/INOCA endotypes and appropriate treatment, considering patient choices and preferences. | |
| p.16 | I | A | with a previous MI or revascularization. | Table 4 Revised recommendations |
| p.16 | I | A | recommended as the default antithrombotic strategy after PCI-stenting. | Table 4 Revised recommendations |
| p.16 | IIb | B | bleeding risk nor at high risk of ischaemic events. | Table 4 Revised recommendations |
| p.16 | IIa | B | Nicorandil, ranolazine, ivabradine, or trimetazidine should be considered as a second-line treatment to reduce angina frequency and improve exercise tolerance in subjects who cannot tolerate, have contraindications to, or whose symptoms are not adequately controlled by beta-blockers, CCBs, and long-acting nitrates. | Table 4 Revised recommendations |
| p.16 | IIb | B | In selected patients, the combination of a beta-blocker or a CCB with second-line drugs (ranolazine, nicorandil, ivabradine, and trimetazidine) may be considered for first-line treatment according to heart rate, blood pressure, and tolerance. Aspirin 75–100 mg daily is recommended in patients | Table 4 Revised recommendations |
| p.16 | IIb | B | patients with either PAD or a history of ischaemic stroke or transient ischaemic attack. | Table 4 Revised recommendations |
| p.16 | IIb | C | Aspirin 75–100 mg daily may be considered in patients without a history of MI or revascularization, but with definitive evidence of CAD on imaging. oral anticoagulation—Section 4 | Table 4 Revised recommendations |
| p.16 | I | A | Clopidogrel 75 mg daily following appropriate loading (e.g. 600 mg or >5 days of maintenance therapy) is recommended, in addition to aspirin, for 6 months following coronary stenting, irrespective of stent type, unless a shorter durations (1–3 months) is indicated due to risk of occurrence of life-threatening bleeding. | Table 4 Revised recommendations |
| p.16 | IIb | C | Clopidogrel 75 mg daily following appropriate loading (e.g. 600 mg or >5 days of maintenance therapy) may be considered for 1 month in patients with very high risk of life-threatening bleeding. | Table 4 Revised recommendations |
| p.16 | IIa | A | Clopidogrel 75 mg daily following appropriate loading (e.g. 600 mg or >5 days of maintenance therapy) should be considered for 3 months in patients with a higher risk of life-threatening bleeding. | Table 4 Revised recommendations |
| p.16 | IIa | B | Long-acting nitrates or ranolazine should be considered as add-on therapy in patients with inadequate control of symptoms while on treatment with beta-blockers and/ or CCBs, or as part of initial treatment in properly selected patients. | Table 4 Revised recommendations |
| p.16 | IIb | B | Nicorandil or trimetazidine may be considered as add-on therapy in patients with inadequate control of symptoms while on treatment with beta-blockers and/ or CCBs, or as part of initial treatment in properly selected patients. | Table 4 Revised recommendations |
| p.16 | I | A | In CCS patients with a prior MI or remote PCI, aspirin 75–100 mg daily is recommended lifelong after an initial period of DAPT. | Table 4 Revised recommendations |
| p.16 | I | B | In patients without prior MI or revascularization but with evidence of significant obstructive CAD, aspirin 75–100 mg daily is recommended lifelong. and clopidogrel 75 mg daily for up to 6 months is | Table 4 Revised recommendations |
| p.16 | I | A | In patients at high bleeding risk but not at high ischaemic risk, it is recommended to discontinue DAPT 1–3 months after PCI and continue single antiplatelet therapy. Stopping DAPT after 1–3 months from PCI-stenting may be considered in patients who are not at high | Table 4 Revised recommendations |
| p.17 | IIa | C | considered to identify ST-segment deviation in the absence of increased heart rate. | |
| p.17 | I | A | When oral anticoagulation is initiated in a patient with AF who is eligible for a NOAC, a NOAC is recommended in preference to a VKA. | |
| p.17 | I | A | Long-term OAC therapy (NOAC or VKA with time in therapeutic range >70%) is recommended in patients with AF and a CHA2DS2-VASc score ≥2 in males and ≥3 in females. | |
| p.17 | IIa | B | Long-term OAC therapy (NOAC or VKA with time in therapeutic range >70%) should be considered in patients with AF and a CHA2DS2-VASc score of 1 in males and 2 in females. | |
| p.17 | IIb | B | Aspirin 75–100 mg daily (or clopidogrel 75 mg daily) may be considered in addition to long-term OAC therapy in patients with AF, history of MI, and at high risk of recurrent ischaemic events who do not have a high bleeding risk. anticoagulation—Section 4 | |
| p.17 | IIa | B | After uncomplicated PCI, early cessation (≤1 week) of aspirin and continuation of dual therapy with an OAC and clopidogrel should be considered if the risk of stent thrombosis is low, or if concerns about bleeding risk prevail over concerns about the risk of stent thrombosis, irrespective of the type of stent used. | |
| p.17 | IIa | C | Triple therapy with aspirin, clopidogrel, and an OAC for ≥1 month should be considered when the risk of stent thrombosis outweighs the bleeding risk, with the total duration (≤6 months) decided according to assessment of these risks and clearly specified at hospital discharge. | |
| p.17 | I | A | Statins are recommended in all patients with CCS. | |
| p.17 | IIa | B | Guidewire-based CFR and/or microcirculatory resistance measurements should be considered in patients with persistent symptoms, but coronary arteries that are either angiographically normal or have moderate stenoses with preserved iwFR/FFR. | |
| p.17 | IIb | B | are either angiographically normal or have moderate stenoses with preserved iwFR/FFR, to assess microvascular vasospasm. Diagnostic tests for vasospastic angina—Section 5 Ambulatory ST-segment monitoring should be | |
| p.17 | I | B | In CCS patients with a long-term indication for OAC, an AF-therapeutic-dose of VKA alone or, preferably, of DOAC alone (unless contraindicated) is recommended lifelong. | |
| p.17 | I | A | After uncomplicated PCI in CCS patients with concomitant indication for OAC: • early cessation of aspirin (≤1 week); • followed by continuation of OAC and clopidogrel: ⚬up to 6 months in patients not at high ischaemic risk or ⚬up to 12 months in patients at high ischaemic risk; • followed by OAC alone; is recommended. | |
| p.17 | IIa | B | Continuation of aspirin up to 1 month after PCI, in addition to OAC and clopidogrel, should be considered in patients at high thrombotic risk or with anatomical/ procedural characteristics judged to outweigh the bleeding risk. | |
| p.17 | I | A | A high-intensity statin up to the highest tolerated dose to reach the LDL-C goals is recommended for all patients with CCS. In persistently symptomatic patients despite medical treatment with suspected ANOCA/INOCA (i.e. anginal symptoms with normal coronary arteries or non-obstructive lesions at non-invasive imaging, or intermediate stenoses with normal FFR/iFR at coronary | |
| p.17 | IIa | B | arteriography) and poor quality of life, invasive coronary functional testing is recommended to identify potentially treatable endotypes and to improve symptoms and quality of life, considering patient choices and preferences. In individuals with suspected vasospastic angina and frequent symptoms, ambulatory ST-segment monitoring should be considered to identify ST-segment deviation during angina. | |
| p.18 | IIb | B | For left main disease with high SYNTAX score (≥33), PCI. III B In CCS patients at high surgical risk, PCI may be considered over medical therapy alone. | |
| p.18 | III | A | For CCS patients with diabetes and three-vessel disease with low SYNTAX score 0–22, PCI. IIb A In CCS patients at very high surgical risk, PCI should be considered over medical therapy alone to reduce symptoms and adverse outcomes. IIa B For CCS patients with diabetes and three-vessel disease with intermediate or high SYNTAX score (>22), PCI. | |
| p.18 | I | C | Total risk estimation using a risk-estimation system such as SCORE is recommended for asymptomatic adults >40 years of age without evidence of CVD, diabetes, CKD, or familial hypercholesterolaemia. | |
| p.18 | I | B | Risk stratification is recommended in patients with new or worsening symptom levels, preferably using stress imaging or, alternatively, exercise stress ECG. 2018 ESC/EACTS Guidelines on myocardial revascularization | |
| p.18 | IIa | C | Revascularization to improve outcomes In CCS patients with LV ejection fraction ≤35% In patients with one- or two-vessel disease, PCI should be considered as an alternative to CABG when complete revascularization can be achieved. | |
| p.18 | I | A | Left main disease Left main disease with low SYNTAX score (0–22), PCI. | |
| p.18 | IIa | A | Left main disease with intermediate SYNTAX score (23–32), PCI. Left main with multivessel disease Multivessel disease and diabetes | |
| p.18 | I | A | For one or two-vessel disease with proximal LAD stenosis, CABG, or PCI are recommended. | |
| p.18 | I | C | Opportunistic screening of healthy individuals for cardiovascular risk factors and to estimate risk of future cardiovascular events using scoring systems, e.g. SCORE2 and SCORE2-OP, is recommended to detect individuals at high risk and guide treatment decisions. | |
| p.18 | I | C | Risk stratification is recommended in patients with new or worsening symptoms, preferably using stress imaging. In selected CCS patients with functionally significant MVD and LVEF ≤35% who are at high surgical risk or not operable, PCI may be considered as an alternative | |
| p.18 | I | A | In CCS patients with significant left main coronary stenosis of low complexity (SYNTAX score ≤22), in whom PCI can provide equivalent completeness of revascularization to that of CABG, PCI is recommended as an alternative to CABG, given its lower invasiveness and non-inferior survival. | |
| p.18 | IIa | A | In CCS patients with significant left main coronary stenosis of intermediate complexity (SYNTAX score 23–32), in whom PCI can provide equivalent completeness of revascularization to that of CABG, PCI should be considered, given its lower invasiveness and non-inferior survival. | |
| p.18 | I | A | In CCS patients with significant single- or double-vessel disease involving the proximal LAD and insufficient response to guideline-directed medical therapy, CABG or PCI is recommended over medical therapy alone to improve symptoms and outcomes. | |
| p.18 | I | B | In CCS patients with complex significant single- or double-vessel disease involving the proximal LAD, less amenable to PCI, and insufficient response to guideline-directed medical therapy, CABG is recommended over PCI to improve symptoms and reduce revascularization rates. | |
| p.19 | I | C | For one or two-vessel disease without proximal LAD stenosis PCI is recommended. | |
| p.19 | IIb | C | For one or two-vessel disease without proximal LAD stenosis, CABG may be considered. | |
| p.19 | I | B | In symptomatic CCS patients with single- or double-vessel disease not involving the proximal LAD and with insufficient response to guideline-directed medical therapy, PCI is recommended to improve symptoms. | |
| p.19 | IIb | C | In symptomatic CCS patients with single- or double-vessel disease not involving the proximal LAD and with insufficient response to guideline-directed medical therapy, not amenable to revascularization by PCI, CABG may be considered to improve symptoms. | |
| p.22 | I | C | History taking and risk factor assessment In individuals reporting symptoms of suspected myocardial ischaemic origin, a detailed assessment of cardiovascular risk factors, medical history, and symptom characteristics (including onset, duration, type, location, triggers, relieving factors, time of day) is recommended. | Recommendation Table 1 — Recommendations for history taking, risk factor assessment, and resting electrocardiogram in individuals with suspected chronic coronary syndrome (see also Evidence Table 1) |
| p.22 | IIa | B | Symptoms like chest pain triggered by emotional stress; dyspnoea or dizziness on exertion; pain in the arms, jaw, neck, or upper back; or fatigue should be considered as potential angina equivalents.18,33,57,59,77 Resting ECG | Recommendation Table 1 — Recommendations for history taking, risk factor assessment, and resting electrocardiogram in individuals with suspected chronic coronary syndrome (see also Evidence Table 1) |
| p.22 | I | B | If clinical or ECG assessment suggests ACS rather than CCS, immediate referral to the emergency department and/or repeated measurement of blood troponin, preferably using high-sensitivity or ultrasensitive assays, to rule out acute myocardial injury, is recommended.78,79 | Recommendation Table 1 — Recommendations for history taking, risk factor assessment, and resting electrocardiogram in individuals with suspected chronic coronary syndrome (see also Evidence Table 1) |
| p.22 | I | C | A resting 12-lead ECG is recommended in all individuals reporting chest pain (unless an obvious non-cardiac cause is identified), particularly during, or immediately after, an episode suggestive of myocardial ischaemia. | Recommendation Table 1 — Recommendations for history taking, risk factor assessment, and resting electrocardiogram in individuals with suspected chronic coronary syndrome (see also Evidence Table 1) |
| p.22 | III | B | Using ST-segment deviations during supraventricular tachyarrhythmias, particularly during re-entrant atrioventricular tachycardias, per se, as reliable evidence of obstructive CAD, is not recommended.80–84 | Recommendation Table 1 — Recommendations for history taking, risk factor assessment, and resting electrocardiogram in individuals with suspected chronic coronary syndrome (see also Evidence Table 1) |
| p.23 | I | A | • lipid profile including LDL-C;64,128 | Recommendation Table 2 — Recommendations for basic biochemistry in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 2) |
| p.23 | I | B | • full blood count (including haemoglobin);129–133 | Recommendation Table 2 — Recommendations for basic biochemistry in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 2) |
| p.23 | I | B | • creatinine with estimation of renal function;134 | Recommendation Table 2 — Recommendations for basic biochemistry in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 2) |
| p.23 | I | B | glucose.16,86,135,136 | Recommendation Table 2 — Recommendations for basic biochemistry in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 2) |
| p.23 | I | B | to assess thyroid function at least once.137,138 | Recommendation Table 2 — Recommendations for basic biochemistry in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 2) |
| p.23 | IIa | B | should be considered.109–118,121,125 | Recommendation Table 2 — Recommendations for basic biochemistry in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 2) |
| p.24 | I | B | It is recommended to estimate the pre-test likelihood of obstructive epicardial CAD using the Risk Factor-weighted Clinical Likelihood model.139,140,142,143,161,162 | Recommendation Table 3 — Recommendations for estimating, adjusting and reclassifying the likelihood of obstructive atherosclerotic coronary artery disease in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 3) |
| p.24 | I | C | It is recommended to use additional clinical data (e.g. examination of peripheral arteries, resting ECG, resting echocardiography, presence of vascular calcifications on previously performed imaging tests) to adjust the estimate yielded by the Risk Factor-weighted Clinical Likelihood model.163 | Recommendation Table 3 — Recommendations for estimating, adjusting and reclassifying the likelihood of obstructive atherosclerotic coronary artery disease in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 3) |
| p.24 | IIa | B | In individuals with a very low (≤5%) pre-test likelihood of obstructive CAD, deferral of further diagnostic tests should be considered.139,164 | Recommendation Table 3 — Recommendations for estimating, adjusting and reclassifying the likelihood of obstructive atherosclerotic coronary artery disease in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 3) |
| p.24 | IIa | B | In individuals with a low (>5%–15%) pre-test likelihood of obstructive CAD, CACS should be considered to reclassify subjects and to identify more individuals with very low (≤5%) CACS-weighted clinical likelihood.139,143,165 | Recommendation Table 3 — Recommendations for estimating, adjusting and reclassifying the likelihood of obstructive atherosclerotic coronary artery disease in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 3) |
| p.24 | IIb | C | In individuals with an initially low (>5%–15%) likelihood of obstructive CAD, exercise ECG and detection of atherosclerotic disease in non-coronary arteries may be considered to adjust the pre-test likelihood estimate.144,166 | Recommendation Table 3 — Recommendations for estimating, adjusting and reclassifying the likelihood of obstructive atherosclerotic coronary artery disease in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 3) |
| p.26 | I | B | A resting transthoracic echocardiogram is recommended: to measure LVEF, volumes and diastolic function; • identify regional wall motion abnormalities; • identify non-coronary cardiac disease (e.g. hypertrophy, cardiomyopathy, valve disease, pericardial effusion); • assess right ventricular function and estimate systolic pulmonary artery pressure; to refine risk stratification and guide | Recommendation Table 4 — Recommendations for resting transthoracic ultrasound and cardiac magnetic resonance imaging in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 4) |
| p.26 | IIb | C | treatment.167,183,184 CMR, if available, may be considered as an alternative imaging test in individuals with inconclusive echocardiographic evaluation.185,186 | Recommendation Table 4 — Recommendations for resting transthoracic ultrasound and cardiac magnetic resonance imaging in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 4) |
| p.27 | IIb | B | stratification and treatment.188 | Recommendation Table 5 — Recommendations for exercise ECG in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 5) |
| p.27 | I | C | subjects with chest pain and suspected arrhythmias. | Recommendation Table 7 — Recommendations for ambulatory ECG monitoring in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 7) |
| p.27 | IIa | B | in subjects with suspected vasospastic angina.192–194 | Recommendation Table 7 — Recommendations for ambulatory ECG monitoring in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 7) |
| p.27 | I | C | Exercise ECG is recommended in selected patientsc for the assessment of exercise tolerance, symptoms, arrhythmias, BP response, and event risk. | Recommendation Table 5 — Recommendations for exercise ECG in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 5) |
| p.27 | IIb | B | Exercise ECG may be considered as an alternative test to rule in and rule out CAD when non-invasive imaging tests are unavailable.148,166,188,190,191 An exercise ECG may be considered to refine risk | Recommendation Table 5 — Recommendations for exercise ECG in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 5) |
| p.27 | IIb | C | In individuals with a low (>5%–15%) pre-test likelihood of obstructive CAD, an exercise ECG may be considered to identify patients in whom further testing can be deferred.144 | Recommendation Table 5 — Recommendations for exercise ECG in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 5) |
| p.27 | III | C | Exercise ECG is not recommended for diagnostic purposes in patients with ≥0.1 mV ST-segment depression on resting ECG, left bundle branch block or who are being treated with digitalis. | Recommendation Table 5 — Recommendations for exercise ECG in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 5) |
| p.27 | III | C | In individuals with a low or moderate (>5%–50%) pre-test likelihood of obstructive CAD, an exercise ECG is not recommended to rule out CAD if CCTA or functional imaging tests are available.148 | Recommendation Table 5 — Recommendations for exercise ECG in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 5) |
| p.27 | IIa | C | A chest X-ray should be considered for individuals with: • signs and symptoms suggestive of heart failure; • suspected acute pulmonary disease; • suspected aortic, non-coronary cardiac, or other thoracic causes of chest pain. aClass of recommendation. bLevel of evidence. | Recommendation Table 6 — Recommendations for chest X-ray in the initial diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 6) |
| p.28 | I | A | In individuals with suspected CCS and low or moderate (>5%–50%) pre-test likelihood of obstructive CAD, CCTA is recommended to diagnose obstructive CAD and to estimate the risk of MACE.33,34,145,212,214–221 | Recommendation Table 8 — Recommendations for non-invasive anatomical imaging tests in the initial diagnostic management of individuals with suspected chronic coronary syndrome—coronary computed tomography angiography, if available, and supported by local expertise (see also Evidence Table 8) |
| p.28 | I | B | CCTA is recommended in individuals with low or moderate (>5%–50%) pre-test likelihood of obstructive CAD to refine diagnosis if another non-invasive test is non-diagnostic.222 CCTA is not recommended in patients with severe | Recommendation Table 8 — Recommendations for non-invasive anatomical imaging tests in the initial diagnostic management of individuals with suspected chronic coronary syndrome—coronary computed tomography angiography, if available, and supported by local expertise (see also Evidence Table 8) |
| p.28 | III | C | renal failure (eGFR <30 mL/min/1.73 m2), decompensated heart failure, extensive coronary calcification, fast irregular heart rate, severe obesity, inability to cooperate with breath-hold commands, or any other conditions that can make obtaining good imaging quality unlikely. | Recommendation Table 8 — Recommendations for non-invasive anatomical imaging tests in the initial diagnostic management of individuals with suspected chronic coronary syndrome—coronary computed tomography angiography, if available, and supported by local expertise (see also Evidence Table 8) |
| p.29 | I | B | In individuals with suspected CCS and moderate or high (>15%–85%) pre-test likelihood of obstructive CAD, stress echocardiography is recommended to diagnose myocardial ischaemia and to estimate the risk of MACE.33,241–246 | Recommendation Table 9 — Recommendations for non-invasive tests in the initial diagnostic management of individuals with suspected chronic coronary syndrome —stress echocardiography, if available, and supported by local expertise (see also Evidence Table 9) |
| p.29 | I | B | During stress echocardiography, when two or more contiguous myocardial segments are not visualized, it is recommended to use commercially available intravenous ultrasound contrast agents (microbubbles) to improve diagnostic accuracy.177,229,236,247,248 | |
| p.29 | I | B | During stress echocardiography, myocardial perfusion using commercially available intravenous ultrasound contrast agents (microbubbles) is recommended to improve diagnostic accuracy and to refine risk stratification beyond wall motion.177,230,232,236,249–254 | |
| p.29 | IIb | B | During stress echocardiography, Doppler left anterior descending coronary artery flow reserve may be considered to improve risk stratification beyond wall motion and to assess microvascular function.177,238,255 | |
| p.30 | I | B | In individuals with suspected CCS and moderate or high (>15%–85%) pre-test likelihood of obstructive CAD, stress SPECT or, preferably, PET myocardial perfusion imaging is recommended to: • diagnose and quantify myocardial ischaemia and/or scar; • estimate the risk of MACE; • quantify myocardial blood flow (PET).33,44,223,257,263,268,270,271,281–288 | Recommendation Table 10 — Recommendations for non-invasive functional myocardial imaging tests in the initial diagnostic management of individuals with suspected chronic coronary syndrome—resting and stress single-photon emission computed tomography/ positron emission tomography—cardiac magnetic resonance imaging, if available, and supported by local expertise (see also Evidence Table 10) |
| p.31 | I | B | In patients selected for PET or SPECT myocardial perfusion imaging, it is recommended to measure CACS from unenhanced chest CT imaging (used for attenuation correction) to improve detection of both non-obstructive and obstructive CAD.289–293 | |
| p.31 | I | B | In individuals with suspected CCS and moderate or high (>15%–85%) pre-test likelihood of obstructive CAD, stress CMR perfusion imaging is recommended to diagnose and quantify myocardial ischaemia and/or scar and estimate the risk of MACE.148,273,276,278,294–297 | |
| p.32 | I | A | recommended as the preferred access site.327–330 | Recommendation Table 11 — Recommendations for invasive coronary angiography in the diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 11) |
| p.32 | I | A | When ICA is indicated, radial artery access is When ICA is indicated, it is recommended to have coronary pressure assessment available and to use it to evaluate the functional severity of intermediate non-left main stem stenosesc prior to revascularization.49,195,308,313,321,322,325,331–333 | Recommendation Table 11 — Recommendations for invasive coronary angiography in the diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 11) |
| p.32 | I | C | Invasive coronary angiography is recommended to diagnose obstructive CAD in individuals with a very high (>85%) clinical likelihood of disease, severe symptoms refractory to guideline-directed medical therapy, angina at a low level of exercise, and/or high event risk. | Recommendation Table 11 — Recommendations for invasive coronary angiography in the diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 11) |
| p.32 | I | C | In individuals with de novo symptoms highly suggestive of obstructive CAD that occur at a low level of exercise, ICA with a view towards revascularization is recommended as first diagnostic test after clinical assessment by a cardiologist. | Recommendation Table 11 — Recommendations for invasive coronary angiography in the diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 11) |
| p.32 | IIa | A | When ICA is indicated, measurement of FFR/iFR should be considered to evaluate the functional severity of intermediate left main stem stenosesc prior to revascularization.331,334,335 | Recommendation Table 11 — Recommendations for invasive coronary angiography in the diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 11) |
| p.32 | IIa | B | When ICA is indicated, IVUS should be considered to evaluate the severity of intermediate stenoses of left main stemc prior to revascularization.336,337 | Recommendation Table 11 — Recommendations for invasive coronary angiography in the diagnostic management of individuals with suspected chronic coronary syndrome (see also Evidence Table 11) |
| p.33 | I | A | • FFR/iFR (significant ≤0.8 or ≤0.89, respectively);49,308,310,311,313,321–323,332,373 | Recommendation Table 12 — Recommendations for functional assessment of epicardial artery stenosis severity during invasive coronary angiography to guide revascularization (see also Evidence Table 12) |
| p.33 | I | B | • QFR (significant ≤0.8).325,355,374,375 | Recommendation Table 12 — Recommendations for functional assessment of epicardial artery stenosis severity during invasive coronary angiography to guide revascularization (see also Evidence Table 12) |
| p.33 | IIa | B | complementary investigation;359,360,366–368,376 | Recommendation Table 12 — Recommendations for functional assessment of epicardial artery stenosis severity during invasive coronary angiography to guide revascularization (see also Evidence Table 12) |
| p.33 | IIb | C | In addition: • CFR/HSR/CFC should be considered as a • resting invasive measurement of Pd/Pa, dPR, RFR, or angiography-derived vessel FFR may be considered as alternative parameters.353,377 | Recommendation Table 12 — Recommendations for functional assessment of epicardial artery stenosis severity during invasive coronary angiography to guide revascularization (see also Evidence Table 12) |
| p.33 | III | A | Systematic and routine wire-based coronary pressure assessment of all coronary vessels is not recommended.346,347 | Recommendation Table 12 — Recommendations for functional assessment of epicardial artery stenosis severity during invasive coronary angiography to guide revascularization (see also Evidence Table 12) |
| p.39 | I | C | Selection of non-invasive testing It is recommended to select the initial non-invasive diagnostic test based on pre-test likelihood of obstructive CAD, other patient characteristics that influence the performance of non-invasive tests,c and local expertise and availability.29,148 | Recommendation Table 13 — Recommendations for selection of initial diagnostic tests in individuals with suspected chronic coronary syndrome (see also Evidence Table 13) |
| p.39 | I | B | In symptomatic patients in whom the pre-test likelihood of obstructive CAD by clinical assessment is >5%, CCTA or non-invasive functional imaging for myocardial ischaemia is recommended as the initial diagnostic test.33,148,178,187,189,211,212,219,222,390 | Recommendation Table 13 — Recommendations for selection of initial diagnostic tests in individuals with suspected chronic coronary syndrome (see also Evidence Table 13) |
| p.39 | I | B | To rule out obstructive CAD in individuals with low or moderate (>5%–50%) pre-test likelihood, CCTA is recommended as the preferred diagnostic modality.29,148 | Recommendation Table 13 — Recommendations for selection of initial diagnostic tests in individuals with suspected chronic coronary syndrome (see also Evidence Table 13) |
| p.39 | I | B | CCTA is recommended in individuals with low or moderate (>5%–50%) pre-test likelihood of obstructive CAD if functional imaging for myocardial ischaemia is not diagnostic.391 | Recommendation Table 13 — Recommendations for selection of initial diagnostic tests in individuals with suspected chronic coronary syndrome (see also Evidence Table 13) |
| p.39 | I | B | Functional imaging for myocardial ischaemia is recommended if CCTA has shown CAD of uncertain functional significance or is not diagnostic.392–394 | Recommendation Table 13 — Recommendations for selection of initial diagnostic tests in individuals with suspected chronic coronary syndrome (see also Evidence Table 13) |
| p.39 | IIb | B | In patients with a known intermediate coronary artery stenosisd in a proximal or mid coronary segment on CCTA, CT-based FFR may be considered.395–401 Subsequent invasive testing | Recommendation Table 13 — Recommendations for selection of initial diagnostic tests in individuals with suspected chronic coronary syndrome (see also Evidence Table 13) |
| p.39 | I | B | Invasive coronary angiography with the availability of invasive functional assessments is recommended to confirm or exclude the diagnosis of obstructive CAD or ANOCA/INOCA in individuals with an uncertain diagnosis on non-invasive testing.36,49,308,384 | Recommendation Table 13 — Recommendations for selection of initial diagnostic tests in individuals with suspected chronic coronary syndrome (see also Evidence Table 13) |
| p.40 | I | B | An initial stratification of risk of adverse events is recommended based on basic clinical assessment (e.g. age, ECG, anginal threshold, diabetes, CKD, LVEF).406–408 The use of one or more of the following test results is recommended to identify individuals at high risk of adverse events:405 • exercise ECG: | Recommendation Table 14 — Recommendations for definition of high risk of adverse events (see also Evidence Table 14) |
| p.40 | I | B | ⚬Duke Treadmill Score < −10;191 • stress SPECT or PET perfusion imaging: ⚬area of ischaemia ≥10% of the LV myocardium;287,315,422,423,435 • stress echocardiography: ⚬≥3 of 16 segments with stress-induced hypokinesia or akinesia;435 • stress CMR: ⚬≥2 of 16 segments with stress perfusion defects or ≥3 dobutamine-induced dysfunctional segments;435 • CCTA: ⚬left main disease with ≥50% stenosis, three-vessel | Recommendation Table 14 — Recommendations for definition of high risk of adverse events (see also Evidence Table 14) |
| p.40 | I | A | disease with ≥70 stenosis, or two-vessel disease with ≥70% stenosis, including the proximal LAD or317 one-vessel disease of the proximal LAD with ≥70% stenosis and FFR-CT ≤0.8. In individuals at high risk of adverse events (regardless of symptoms), ICA—complemented by invasive coronary pressure (FFR/iFR) when appropriate—is recommended, with the aim of refining risk stratification and improving symptoms and cardiovascular outcomes by revascularization.318,319 | Recommendation Table 14 — Recommendations for definition of high risk of adverse events (see also Evidence Table 14) |
| p.43 | I | C | An informed discussion on CVD risk and treatment benefits tailored to individual patient needs is recommended.16 | Recommendation Table 15 — Recommendations for cardiovascular risk reduction, lifestyle changes, and exercise interventions in patients with established chronic coronary syndrome (see also Evidence Table 15) |
| p.43 | I | A | Multidisciplinary behavioural approaches to help patients achieve healthy lifestyles, in addition to appropriate pharmacological management, are recommended.484,498–503 | Recommendation Table 15 — Recommendations for cardiovascular risk reduction, lifestyle changes, and exercise interventions in patients with established chronic coronary syndrome (see also Evidence Table 15) |
| p.43 | I | A | A multidisciplinary exercise-based programme to improve cardiovascular risk profile and reduce cardiovascular mortality is recommended.480–482 | Recommendation Table 15 — Recommendations for cardiovascular risk reduction, lifestyle changes, and exercise interventions in patients with established chronic coronary syndrome (see also Evidence Table 15) |
| p.43 | I | B | Aerobic physical activity of at least 150–300 min per week of moderate intensity or 75–150 min per week of vigorous intensity and reduction in sedentary time are recommended.16,473,478,479 | Recommendation Table 15 — Recommendations for cardiovascular risk reduction, lifestyle changes, and exercise interventions in patients with established chronic coronary syndrome (see also Evidence Table 15) |
| p.43 | IIa | B | Home-based cardiac rehabilitation and mobile health interventions should be considered to increase patients’ long-term adherence to healthy behaviours, and to reduce hospitalizations or cardiac events.480,493,494 CVD, cardiovascular disease. aClass of recommendation. bLevel of evidence. | Recommendation Table 15 — Recommendations for cardiovascular risk reduction, lifestyle changes, and exercise interventions in patients with established chronic coronary syndrome (see also Evidence Table 15) |
| p.45 | I | B | Short-acting nitrates are recommended for immediate relief of angina.536,537 | Recommendation Table 16 — Recommendations for antianginal drugs in patients with chronic coronary syndrome (see also Evidence Table 16) |
| p.45 | I | C | General strategy It is recommended to tailor the selection of antianginal drugs to the patient’s characteristics, comorbidities, concomitant medications, treatment tolerability, and underlying pathophysiology of angina, also considering local drug availability and cost. Selection of antianginal medication | Recommendation Table 16 — Recommendations for antianginal drugs in patients with chronic coronary syndrome (see also Evidence Table 16) |
| p.45 | I | B | Initial treatment with beta-blockers and/or CCBs to control heart rate and symptoms is recommended for most patients with CCS.c 518,538 | Recommendation Table 16 — Recommendations for antianginal drugs in patients with chronic coronary syndrome (see also Evidence Table 16) |
| p.45 | IIa | B | If anginal symptoms are not successfully controlled by initial treatment with a beta-blocker or a CCB alone, the combination of a beta-blocker and a DHP-CCB should be considered, unless contraindicated.505,538,539 | Recommendation Table 16 — Recommendations for antianginal drugs in patients with chronic coronary syndrome (see also Evidence Table 16) |
| p.45 | IIa | B | Long-acting nitrates or ranolazine should be considered as add-on therapy in patients with inadequate control of symptoms while on treatment with beta-blockers and/or CCBs, or as part of initial treatment in properly selected patients.d 513,540 | Recommendation Table 16 — Recommendations for antianginal drugs in patients with chronic coronary syndrome (see also Evidence Table 16) |
| p.45 | IIa | B | When long-acting nitrates are prescribed, a nitrate-free or low-nitrate interval should be considered to reduce tolerance.540 | |
| p.45 | IIa | B | Ivabradine should be considered as add-on antianginal therapy in patients with left ventricular systolic dysfunction (LVEF <40%) and inadequate control of symptoms, or as part of initial treatment in properly selected patients.541,542 | |
| p.45 | IIb | B | Nicorandil or trimetazidine may be considered as add-on therapy in patients with inadequate control of symptoms while on treatment with beta-blockers and/or CCBs, or as part of initial treatment in properly selected patients.543–550 | |
| p.45 | III | B | Ivabradine is not recommended as add-on therapy in patients with CCS, LVEF >40%, and no clinical heart failure.509 | |
| p.45 | III | B | Combination of ivabradine with non-DHP-CCB or other strong CYP3A4 inhibitors is not recommended.551 | |
| p.45 | III | B | Nitrates are not recommended in patients with hypertrophic cardiomyopathy or in co-administration with phosphodiesterase inhibitors.552,553 | |
| p.51 | I | A | In CCS patients with a prior MI or remote PCI, aspirin 75–100 mg daily is recommended lifelong after an initial period of DAPT.558,559 | Recommendation Table 17 — Recommendations for antithrombotic therapy in patients with chronic coronary syndrome (see also Evidence Table 17) |
| p.51 | I | A | In CCS patients with a prior MI or remote PCI, clopidogrel 75 mg daily is recommended as a safe and effective alternative to aspirin monotherapy.562,564–566,649 | Recommendation Table 17 — Recommendations for antithrombotic therapy in patients with chronic coronary syndrome (see also Evidence Table 17) |
| p.51 | I | A | After CABG, aspirin 75–100 mg daily is recommended lifelong.558,559,629 | Recommendation Table 17 — Recommendations for antithrombotic therapy in patients with chronic coronary syndrome (see also Evidence Table 17) |
| p.51 | I | B | lifelong.557–559 | Recommendation Table 17 — Recommendations for antithrombotic therapy in patients with chronic coronary syndrome (see also Evidence Table 17) |
| p.51 | IIa | A | ischaemic riskc and without high bleeding riskd (options and definitions in Table 8 and in the Supplementary data online, Tables S2 and S3).592–594 | Recommendation Table 17 — Recommendations for antithrombotic therapy in patients with chronic coronary syndrome (see also Evidence Table 17) |
| p.52 | I | A | months is recommended as the default antithrombotic strategy after PCI-stenting.650–654 | |
| p.52 | I | A | continue with single antiplatelet therapy.587,591 | |
| p.52 | IIb | B | ischaemic events.588,655–657,c,d | |
| p.52 | I | B | contraindicated) is recommended lifelong.609,627 | |
| p.52 | I | C | maintenance dose) in addition to OAC and clopidogrel. | |
| p.52 | I | A | In patients who are eligible for OAC, DOAC (unless contraindicated) is recommended in preference to VKA.619,658 | |
| p.52 | IIa | B | or with anatomical/procedural characteristics judged to outweigh the bleeding risk.620–622,e | |
| p.52 | IIa | B | rivaroxaban 15 mg daily should be considered in preference to rivaroxaban 20 mg daily for the duration of concomitant antiplatelet therapy;616 | |
| p.52 | IIa | B | antiplatelet therapy.617 | |
| p.52 | IIa | B | part of the recommended range and to a time in therapeutic range >70% should be considered.615,660–663 | |
| p.52 | III | C | The use of ticagrelor or prasugrel is generally not recommended as part of triple antithrombotic therapy with aspirin and an OAC. | |
| p.52 | I | B | It is recommended to initiate aspirin post-operatively as soon as there is no concern over bleeding.629,630 | |
| p.52 | IIb | B | DAPT may be considered after CABG in selected patients at greater risk of graft occlusionf and at low risk of bleeding.635 | |
| p.52 | I | A | A proton pump inhibitor is recommended in patients at increased risk of gastrointestinal bleeding for the duration of combined antithrombotic therapy (antiplatelet therapy and/or OAC).646–648,664 | |
| p.52 | IIa | A | A proton pump inhibitor should be considered when a single antithrombotic (antiplatelet or anticoagulant) drug is used, considering the gastrointestinal bleeding risk of the individual patient.646,665–668 | |
| p.53 | I | A | Lipid-lowering treatment with an LDL-C goal of <1.4 mmol/L (55 mg/dL) and a ≥50% reduction in LDL-C vs. baseline is recommended.64,670,671 | Recommendation Table 18 — Recommendations for lipid-lowering drugs in patients with chronic coronary syndrome (see also Evidence Table 18) |
| p.53 | I | A | A high-intensity statin up to the highest tolerated dose to reach the LDL-C goals is recommended for all patients with CCS.670,671 | Recommendation Table 18 — Recommendations for lipid-lowering drugs in patients with chronic coronary syndrome (see also Evidence Table 18) |
| p.53 | I | B | If a patient’s goal is not achieved with the maximum tolerated dose of statin, combination with ezetimibe is recommended.674 | Recommendation Table 18 — Recommendations for lipid-lowering drugs in patients with chronic coronary syndrome (see also Evidence Table 18) |
| p.53 | I | B | For patients who are statin intolerant and do not achieve their goal on ezetimibe, combination with bempedoic acid is recommended.680 | Recommendation Table 18 — Recommendations for lipid-lowering drugs in patients with chronic coronary syndrome (see also Evidence Table 18) |
| p.53 | I | A | For patients who do not achieve their goal on a maximum tolerated dose of statin and ezetimibe, combination with a PCSK9 inhibitor is recommended.675,676 | Recommendation Table 18 — Recommendations for lipid-lowering drugs in patients with chronic coronary syndrome (see also Evidence Table 18) |
| p.53 | IIa | C | For patients who do not achieve their goal on a maximum tolerated dose of statin and ezetimibe, combination with bempedoic acid should be considered. | Recommendation Table 18 — Recommendations for lipid-lowering drugs in patients with chronic coronary syndrome (see also Evidence Table 18) |
| p.53 | IIb | B | For patients with a recurrent atherothrombotic event (not necessarily of the same type as the first event) while taking maximally tolerated statin therapy, an LDL-C goal of <1.0 mmol/L (<40 mg/dL) may be considered.675,676 | Recommendation Table 18 — Recommendations for lipid-lowering drugs in patients with chronic coronary syndrome (see also Evidence Table 18) |
| p.54 | I | A | CCS patients with type 2 diabetes SGLT2 inhibitors with proven CV benefitc are recommended in patients with T2DM and CCS to reduce CV events, independent of baseline or target HbA1c and independent of concomitant glucose-lowering medication.86,688,695,697,700 | Recommendation Table 19 — Recommendations for sodium–glucose cotransporter 2 inhibitors and/or glucagon-like peptide-1 receptor agonists in patients with chronic coronary syndrome (see also Evidence Table 19) |
| p.54 | I | A | GLP-1 receptor agonists with proven CV benefitd are recommended in patients with T2DM and CCS to reduce CV events, independent of baseline or target HbA1c and independent of concomitant glucose-lowering medication.710,711 | Recommendation Table 19 — Recommendations for sodium–glucose cotransporter 2 inhibitors and/or glucagon-like peptide-1 receptor agonists in patients with chronic coronary syndrome (see also Evidence Table 19) |
| p.54 | IIa | B | CCS patients without type 2 diabetes The GLP-1 receptor agonist semaglutide should be considered in overweight (BMI ≥27 kg/m2) or obese CCS patients without diabetes to reduce CV mortality, MI, or stroke.465 | Recommendation Table 19 — Recommendations for sodium–glucose cotransporter 2 inhibitors and/or glucagon-like peptide-1 receptor agonists in patients with chronic coronary syndrome (see also Evidence Table 19) |
| p.55 | IIa | A | high risk of cardiovascular events.686,687,690,691 | Recommendation Table 21 — Recommendations for angiotensin-converting enzyme inhibitors in patients with chronic coronary syndrome (see also Evidence Table 21) |
| p.55 | IIa | A | In CCS patients with atherosclerotic CAD, low-dose colchicine (0.5 mg daily) should be considered to reduce myocardial infarction, stroke, and need for revascularization.714–716 CAD, coronary artery disease; CCS, chronic coronary syndrome. aClass of recommendation. bLevel of evidence. | Recommendation Table 20 — Recommendations for anti-inflammatory drugs in patients with chronic coronary syndrome (see also Evidence Table 20) |
| p.55 | I | A | In CCS patients, ACE-Is (or ARBs) are recommended in the presence of specific comorbidities, such as hypertension, diabetes, or heart failure.683–685 ACE-Is should be considered in CCS patients at very | Recommendation Table 21 — Recommendations for angiotensin-converting enzyme inhibitors in patients with chronic coronary syndrome (see also Evidence Table 21) |
| p.62 | I | C | risks, therapeutic consequences, and alternatives to revascularization, as part of shared clinical decision-making.847,848,857 | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | I | C | It is recommended to communicate the proposal of the Heart Team in a balanced way using language that the patient can understand. | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | I | C | literacy, cultural circumstances, and social support.849–851 | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | I | C | revascularization strategy in accordance with current guidelines.855,856,858 | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | I | A | patients with functionally significant left main stem stenosis to improve survival.718,719,859,860 | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | I | B | medical therapy alone to improve long-term survival.53,54,749,861 | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | IIb | B | considered as an alternative to CABG.526,729 | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | I | A | In CCS patients with persistent angina or anginal equivalent, despite guideline-directed medical treatment, myocardial revascularization of functionally significant obstructive CAD is recommended to improve symptoms.50,321,402,732,734,757 | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | I | C | In patients with complex CAD in whom revascularization is being considered, it is recommended to assess procedural risks and post-procedural outcomes to guide shared clinical decision-making. | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | I | B | Calculation of the STS score is recommended to estimate in-hospital morbidity and 30-day mortality after CABG.777,862–864 | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | I | B | disease.786,865 | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | I | A | main stem, true bifurcations, and long lesions.866,337,810,840,841 | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | I | A | • is recommended to guide lesion selection for intervention in patients with multivessel disease; 308,826,866,867 | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | IIa | B | events;828,830,831,868 | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.62 | IIb | B | • may be considered at the end of the procedure to identify lesions potentially amenable to treatment with additional PCI.350,829,831 | Recommendation Table 22 — Recommendations for revascularization in patients with chronic coronary syndrome (see also Evidence Table 22) |
| p.63 | I | C | procedural factors,e LVEF, preferences, and outcome expectations.719,725,728,792–795,801,816,820,822,859,869 | |
| p.63 | I | A | • is recommended over medical therapy alone to improve survival;719 | Recommendation Table 23 — Recommendations for mode of revascularization in patients with chronic coronary syndrome (see also Evidence Table 23) |
| p.63 | I | A | repeat revascularization.728,730,782 | Recommendation Table 23 — Recommendations for mode of revascularization in patients with chronic coronary syndrome (see also Evidence Table 23) |
| p.63 | I | A | In CCS patients at low surgical risk with suitable anatomy, CABG is recommended over medical therapy alone to improve survival.718,719,870 | Recommendation Table 23 — Recommendations for mode of revascularization in patients with chronic coronary syndrome (see also Evidence Table 23) |
| p.63 | IIb | B | In CCS patients at high surgical risk, PCI may be considered over medical therapy alone.728,813 | Recommendation Table 23 — Recommendations for mode of revascularization in patients with chronic coronary syndrome (see also Evidence Table 23) |
| p.63 | I | A | In CCS patients with significant multivessel disease and diabetes, with insufficient response to guideline-directed medical therapy, CABG is recommended over medical therapy alone and over PCI to improve symptoms and outcomes.801,824,871–874 | Recommendation Table 23 — Recommendations for mode of revascularization in patients with chronic coronary syndrome (see also Evidence Table 23) |
| p.63 | IIa | B | In CCS patients at very high surgical risk, PCI should be considered over medical therapy alone to reduce symptoms and adverse outcomes.55,874 | Recommendation Table 23 — Recommendations for mode of revascularization in patients with chronic coronary syndrome (see also Evidence Table 23) |
| p.63 | I | A | In CCS patients with significant three-vessel disease, preserved LVEF, no diabetes, and insufficient response to guideline-directed medical therapy, CABG is recommended over medical therapy alone to improve symptoms, survival, and other outcomes.719,722,875 | Recommendation Table 23 — Recommendations for mode of revascularization in patients with chronic coronary syndrome (see also Evidence Table 23) |
| p.63 | I | A | In CCS patients with significant single- or double-vessel disease involving the proximal LAD and insufficient response to guideline-directed medical therapy, CABG or PCI is recommended over medical therapy alone to improve symptoms and outcomes.52,321,719,791,792 | Recommendation Table 23 — Recommendations for mode of revascularization in patients with chronic coronary syndrome (see also Evidence Table 23) |
| p.63 | I | B | In CCS patients with complex significant single- or double-vessel disease involving the proximal LAD, less amenable to PCI, and insufficient response to guideline-directed medical therapy, CABG is recommended to improve symptoms and reduce revascularization rates.877–879 | Recommendation Table 23 — Recommendations for mode of revascularization in patients with chronic coronary syndrome (see also Evidence Table 23) |
| p.63 | I | B | In symptomatic CCS patients with significant single- or double-vessel disease not involving the proximal LAD and with insufficient response to guideline-directed medical therapy, PCI is recommended to improve symptoms.50,321,732 | Recommendation Table 23 — Recommendations for mode of revascularization in patients with chronic coronary syndrome (see also Evidence Table 23) |
| p.63 | IIb | C | In symptomatic CCS patients with significant single- or double-vessel disease not involving the proximal LAD and with insufficient response to guideline-directed medical therapy, not amenable to revascularization by PCI, CABG may be considered to improve symptoms. | Recommendation Table 23 — Recommendations for mode of revascularization in patients with chronic coronary syndrome (see also Evidence Table 23) |
| p.64 | I | B | CABG, taking into account the risk-to-benefit ratio of the procedures.54,729,749,908 | Recommendation Table 24 — Recommendations for management of chronic coronary syndrome patients with chronic heart failure (see also Evidence Table 24) |
| p.64 | I | C | functional imaging is recommended.887 | Recommendation Table 24 — Recommendations for management of chronic coronary syndrome patients with chronic heart failure (see also Evidence Table 24) |
| p.64 | I | C | QFR when needed) is recommended.887 | Recommendation Table 24 — Recommendations for management of chronic coronary syndrome patients with chronic heart failure (see also Evidence Table 24) |
| p.65 | IIb | C | experienced centres.905–907 | |
| p.65 | I | A | hospitalization and to improve survival.526,909–911 | |
| p.65 | I | A | patients with HFrEF to reduce the risk of HF hospitalization and death.526,704,705,912,913 | |
| p.65 | I | A | (HFmrEF) or HFpEF to reduce the risk of HF hospitalization or cardiovascular death.706,707 | |
| p.65 | I | B | hospitalization and cardiovascular death.914 | |
| p.65 | I | B | hospitalization and of cardiovascular and all-cause death.693 | |
| p.65 | I | B | capacity, and reduce HF hospitalizations.915 | |
| p.65 | I | A | an LBBB QRS morphology to improve symptoms and survival and to reduce morbidity.526,921,922 | |
| p.65 | I | A | indication for ventricular pacing for high-degree AV block in order to reduce morbidity. This includes patients with AF. 923–925 | |
| p.71 | IIa | B | episodes.993,997,998 | Recommendation Table 25 — Recommendations for diagnosis and management of patients with angina/ ischaemia with non-obstructive coronary arteries (see also Evidence Table 25) |
| p.71 | I | B | Diagnosis of ANOCA/INOCA endotypes In persistently symptomatic patients despite medical treatment with suspected ANOCA/ INOCA (i.e. anginal symptoms with normal coronary arteries or non-obstructive lesions at non-invasive imaging, or intermediate stenoses with normal FFR/iFR at coronary arteriography) and poor quality of life, invasive coronary functional testing is recommended to identify potentially treatable endotypes and to improve symptoms and quality of life, considering patient choices and | Recommendation Table 25 — Recommendations for diagnosis and management of patients with angina/ ischaemia with non-obstructive coronary arteries (see also Evidence Table 25) |
| p.71 | IIb | B | preferences.36,37,298,930,939,985 In persistently symptomatic patients with documented or suspected ANOCA/INOCA, transthoracic Doppler of the LAD, stress echocardiography, CMR, and PET may be considered for the non-invasive assessment of coronary/myocardial flow reserve.44,231,233– 235,300,986,987 | Recommendation Table 25 — Recommendations for diagnosis and management of patients with angina/ ischaemia with non-obstructive coronary arteries (see also Evidence Table 25) |
| p.71 | I | C | Diagnostic tests for vasospastic angina In individuals with suspected vasospastic angina, a resting 12-lead ECG recording during angina is recommended. In patients with suspected vasospastic angina and | Recommendation Table 25 — Recommendations for diagnosis and management of patients with angina/ ischaemia with non-obstructive coronary arteries (see also Evidence Table 25) |
| p.71 | I | C | repetitive episodes of rest angina associated with ST-segment changes that resolve with nitrates and/or calcium antagonists, invasive coronary functional testing is recommended to confirm the diagnosis and to determine the severity of underlying atherosclerotic disease. | Recommendation Table 25 — Recommendations for diagnosis and management of patients with angina/ ischaemia with non-obstructive coronary arteries (see also Evidence Table 25) |
| p.71 | IIa | B | In individuals with suspected vasospastic angina and frequent symptoms, ambulatory ST-segment monitoring should be considered to identify ST-segment deviation during angina.192–194 | Recommendation Table 25 — Recommendations for diagnosis and management of patients with angina/ ischaemia with non-obstructive coronary arteries (see also Evidence Table 25) |
| p.71 | IIa | A | Management of ANOCA/INOCA In symptomatic patients with ANOCA/INOCA, medical therapy based on coronary functional test results should be considered to improve symptoms and quality of life.298,977 | Recommendation Table 25 — Recommendations for diagnosis and management of patients with angina/ ischaemia with non-obstructive coronary arteries (see also Evidence Table 25) |
| p.71 | IIa | B | For the management of endothelial dysfunction, ACE-I should be considered for symptom control.988 | Recommendation Table 25 — Recommendations for diagnosis and management of patients with angina/ ischaemia with non-obstructive coronary arteries (see also Evidence Table 25) |
| p.71 | IIa | B | For the management of microvascular angina associated with reduced coronary/myocardial blood flow reserve, antianginal medications aiming at preventing demand myocardial ischaemia should be considered for symptom control.989,990 | Recommendation Table 25 — Recommendations for diagnosis and management of patients with angina/ ischaemia with non-obstructive coronary arteries (see also Evidence Table 25) |
| p.71 | I | A | potentially fatal complications.991–996 Nitrates should be considered to prevent recurrent | Recommendation Table 25 — Recommendations for diagnosis and management of patients with angina/ ischaemia with non-obstructive coronary arteries (see also Evidence Table 25) |
| p.71 | IIb | B | For the treatment of overlapping endotypes In patients with evidence of overlapping endotypes, combination therapy with nitrates, calcium channel blockers, and other vasodilators may be considered.999,1000 | Recommendation Table 25 — Recommendations for diagnosis and management of patients with angina/ ischaemia with non-obstructive coronary arteries (see also Evidence Table 25) |
| p.74 | I | C | Similar guideline-directed cardiovascular preventive therapy is recommended in women and men. | Recommendation Table 26 — Recommendations for older, female, high bleeding risk, comorbid, and socially/ geographically diverse patients (see also Evidence Table 26) |
| p.74 | IIb | C | around treatment decision thresholds.1104–1106 | Recommendation Table 27 — Recommendations for screening for coronary artery disease in asymptomatic individuals (see also Evidence Table 27) |
| p.74 | I | C | Older adults In older adults (≥75 years), particular attention to drug side effects, intolerance, drug–drug interactions, overdosing, and procedural complications is recommended. | Recommendation Table 26 — Recommendations for older, female, high bleeding risk, comorbid, and socially/ geographically diverse patients (see also Evidence Table 26) |
| p.74 | I | C | In older, as in younger, individuals, diagnostic and revascularization decisions based on symptoms, extent of ischaemia, frailty, life expectancy, comorbidities, and patient preferences are recommended. Sex | Recommendation Table 26 — Recommendations for older, female, high bleeding risk, comorbid, and socially/ geographically diverse patients (see also Evidence Table 26) |
| p.74 | III | A | Systemic post-menopausal hormone therapy is not recommended in women with CCS, given the lack of cardiovascular benefit and an increased risk of thrombo-embolic complications.1026,1094,1095 | Recommendation Table 26 — Recommendations for older, female, high bleeding risk, comorbid, and socially/ geographically diverse patients (see also Evidence Table 26) |
| p.74 | I | B | High bleeding risk Bleeding risk assessment is recommended using the PRECISE-DAPT score, the qualitative ARC-HBR tool or other, validated methods.589,590 | Recommendation Table 26 — Recommendations for older, female, high bleeding risk, comorbid, and socially/ geographically diverse patients (see also Evidence Table 26) |
| p.74 | I | B | HIV Attention to interaction between antiretroviral treatment and statins is recommended in patients with HIV.1096 | Recommendation Table 26 — Recommendations for older, female, high bleeding risk, comorbid, and socially/ geographically diverse patients (see also Evidence Table 26) |
| p.74 | I | C | Continued targeted efforts are recommended: • to increase delivery of safe and effective cardiac care to all CCS patients, especially those of lower socioeconomic classes; and • to enhance inclusion in future clinical trials of geographical, social, or other groups that are currently underrepresented. | Recommendation Table 26 — Recommendations for older, female, high bleeding risk, comorbid, and socially/ geographically diverse patients (see also Evidence Table 26) |
| p.74 | I | C | Opportunistic screening of healthy individuals for cardiovascular risk factors and to estimate the risk of © ESC 2024 future cardiovascular events using scoring systems, e.g. SCORE2 and SCORE-OP, is recommended to detect individuals at high risk and guide treatment decisions.16,1101,1112 | Recommendation Table 27 — Recommendations for screening for coronary artery disease in asymptomatic individuals (see also Evidence Table 27) |
| p.74 | IIa | C | When coronary artery calcification findings are available from previous chest CT scans, using these findings to enhance risk stratification and guide treatment of modifiable risk factors should be considered.17,1108–1110 CACS may be considered to improve risk classification | Recommendation Table 27 — Recommendations for screening for coronary artery disease in asymptomatic individuals (see also Evidence Table 27) |
| p.74 | IIb | B | An ultrasound of the carotid arteries may be considered as an alternative when CACS is unavailable or not feasible to detect atherosclerotic disease and to improve risk classification around treatment decision thresholds.1111 | Recommendation Table 27 — Recommendations for screening for coronary artery disease in asymptomatic individuals (see also Evidence Table 27) |
| p.78 | I | B | improve adherence.491,1140,1144 | Recommendation Table 28 — Recommendations for adherence to medical therapy and lifestyle changes (see also Evidence Table 28) |
| p.78 | I | A | Mobile health interventions (e.g. using text messages, apps, wearable devices) are recommended to improve patient adherence to healthy lifestyles and medical therapy.491,1148,1149,1154,1156,1164 Behavioural interventions are recommended to | Recommendation Table 28 — Recommendations for adherence to medical therapy and lifestyle changes (see also Evidence Table 28) |
| p.78 | I | B | Simplifying medication regimens (e.g. using fixed-dose drug combinations) is recommended to increase patient adherence to medications.1139,1163,1166 | Recommendation Table 28 — Recommendations for adherence to medical therapy and lifestyle changes (see also Evidence Table 28) |
| p.78 | I | C | Multiprofessional and family involvement is recommended to promote adherence, in addition to patient education and involvement.1139 aClass of recommendation. bLevel of evidence. | Recommendation Table 28 — Recommendations for adherence to medical therapy and lifestyle changes (see also Evidence Table 28) |
| p.81 | I | C | syndromes Regardless of symptoms, periodic visits (e.g. annual) to a general practitioner or cardiovascular healthcare professional are recommended to evaluate cardiovascular risk factor control and to assess changes in risk status, disease status, and comorbidities that may require lifestyle, medical, or procedural interventions. | Recommendation Table 29 — Recommendations for diagnosis of disease progression in patients with established chronic coronary syndrome (see also Evidence Table 29) |
| p.81 | I | C | Reassessment of CAD status is recommended in patients with deteriorating LV systolic function that cannot be attributed to a reversible cause (e.g. longstanding tachycardia or myocarditis). | Recommendation Table 29 — Recommendations for diagnosis of disease progression in patients with established chronic coronary syndrome (see also Evidence Table 29) |
| p.81 | I | C | Risk stratification is recommended in patients with new or worsening symptoms, preferably using stress imaging. In patients with symptoms refractory to medical | Recommendation Table 29 — Recommendations for diagnosis of disease progression in patients with established chronic coronary syndrome (see also Evidence Table 29) |
| p.81 | I | C | treatment or at high risk of adverse events, invasive coronary angiography (with FFR/iFR when necessary) is recommended for risk stratification and for possible revascularization aimed at improving symptoms and prognosis. | Recommendation Table 29 — Recommendations for diagnosis of disease progression in patients with established chronic coronary syndrome (see also Evidence Table 29) |
| p.81 | IIa | B | In CCS patients with symptoms refractory to medical treatment, and who have had previous coronary revascularization, CCTA should be considered to evaluate bypass graft or stent patency (for stents ≥3 mm).1174–1176 | Recommendation Table 29 — Recommendations for diagnosis of disease progression in patients with established chronic coronary syndrome (see also Evidence Table 29) |
| p.82 | I | A | treatment of in-DES restenosis.1186–1188 | Recommendation Table 30 — Recommendations for treatment of revascularization failure (see also Evidence Table 30) |
| p.82 | IIa | B | without a patent LIMA graft to the LAD. 842,1192,1196 | Recommendation Table 30 — Recommendations for treatment of revascularization failure (see also Evidence Table 30) |
| p.82 | IIa | B | considered over PCI of the bypass graft.1197 | Recommendation Table 30 — Recommendations for treatment of revascularization failure (see also Evidence Table 30) |
| p.82 | I | B | DES is recommended over drug-coated balloons for LIMA is indicated as the conduit of choice for redo CABG in patients in whom the LIMA was not used previously.1195 Redo CABG should be considered for patients PCI of the bypassed native artery should be | Recommendation Table 30 — Recommendations for treatment of revascularization failure (see also Evidence Table 30) |
| p.82 | I | B | In patients with refractory angina leading to poor quality of life and with documented or suspected ANOCA/INOCA, invasive coronary functional testing is recommended to define ANOCA/INOCA endotypes and appropriate treatment, considering patient choices and preferences.36,37,298,930,939,985 | Recommendation Table 31 — Recommendations for recurrent or refractory angina/ischaemia (see also Evidence Table 31) |
| p.82 | IIb | B | In patients with debilitating angina and obstructive CAD refractory to optimal medical and revascularization strategies, a reducer device for coronary sinus constriction may be considered to improve symptoms, in experienced centres.1199– 1201,1204 | Recommendation Table 31 — Recommendations for recurrent or refractory angina/ischaemia (see also Evidence Table 31) |
| p.85 | I | C | In individuals reporting symptoms of suspected myocardial ischaemic origin, a detailed assessment of cardiovascular risk factors, medical history, and symptom characteristics (including onset, duration, type, location, triggers, relieving factors, time of day) is recommended. | Table 10 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.85 | I | C | during, or immediately after, an episode suggestive of myocardial ischaemia. | Table 10 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.85 | III | B | as reliable evidence of obstructive CAD, is not recommended. | Table 10 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.85 | I | A | • lipid profile including LDL-C; | Table 10 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.85 | I | B | • full blood count (including haemoglobin); | Table 10 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.85 | I | B | • creatinine with estimation of renal function; | Table 10 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.85 | I | B | • glycaemic status with HbA1c and/or fasting plasma glucose. | Table 10 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.85 | I | B | In patients with suspected CCS, it is recommended to assess thyroid function at least once. | Table 10 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.85 | III | C | branch block or who are being treated with digitalis. | Table 10 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.85 | III | C | CAD if CCTA or functional imaging tests are available. | Table 10 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.85 | I | C | Ambulatory ECG monitoring is recommended in subjects with chest pain and suspected arrhythmias. | Table 10 lists all Class I and Class III recommendations from the text alongside their level of evidence. |
| p.86 | I | A | diagnose obstructive CAD and to estimate the risk of MACE. | |
| p.86 | I | B | non-diagnostic. | |
| p.86 | I | B | recommended to diagnose myocardial ischaemia and to estimate the risk of MACE. | |
| p.86 | I | B | commercially available intravenous ultrasound contrast agents (microbubbles) to improve diagnostic accuracy. | |
| p.86 | I | B | is recommended to improve diagnostic accuracy and to refine risk stratification beyond wall motion. | |
| p.86 | I | B | In patients selected for PET or SPECT myocardial perfusion imaging, it is recommended to measure CACS from unenhanced chest CT imaging (used for attenuation correction) to improve detection of both non-obstructive and obstructive CAD. | |
| p.86 | I | B | In individuals with suspected CCS and moderate or high (>15%–85%) pre-test likelihood of obstructive CAD, CMR perfusion imaging is recommended to diagnose and quantify myocardial ischaemia and/or scar and estimate the risk of MACE. | |
| p.86 | I | A | When ICA is indicated, radial artery access is recommended as the preferred access site. | |
| p.86 | I | A | intermediate non-left main stem stenoses prior to revascularization. | |
| p.86 | I | C | symptoms refractory to guideline-directed medical therapy, angina at a low level of exercise, and/or high event risk. | |
| p.86 | I | C | revascularization is recommended as first diagnostic test after clinical assessment by a cardiologist. | |
| p.86 | I | A | • FFR/iFR (significant ≤0.8 or ≤0.89, respectively); | |
| p.86 | I | B | • QFR (significant ≤0.8). | |
| p.86 | III | A | Systematic and routine wire-based coronary pressure assessment of all coronary vessels is not recommended. | |
| p.86 | I | C | characteristics that influence the performance of non-invasive tests, and local expertise and availability. | |
| p.86 | I | B | imaging for myocardial ischaemia is recommended as the initial diagnostic test. | |
| p.86 | I | B | diagnostic modality. | |
| p.86 | I | B | not diagnostic. | |
| p.87 | I | B | obstructive CAD or ANOCA/INOCA in individuals with an uncertain diagnosis on non-invasive testing. | |
| p.87 | I | B | An initial stratification of risk of adverse events is recommended based on basic clinical assessment (e.g. age, ECG, anginal threshold, diabetes, CKD, LVEF). | |
| p.87 | I | C | An informed discussion on CVD risk and treatment benefits tailored to individual patient needs is recommended. | |
| p.87 | I | A | are recommended. | |
| p.87 | I | A | A multidisciplinary exercise-based programme to improve cardiovascular risk profile and reduce cardiovascular mortality is recommended. | |
| p.87 | I | B | reduction in sedentary time are recommended. | |
| p.87 | I | C | treatment tolerability, and underlying pathophysiology of angina, also considering local drug availability and cost. | |
| p.87 | I | B | Short-acting nitrates are recommended for immediate relief of angina. | |
| p.87 | I | B | Initial treatment with beta-blockers and/or CCBs to control heart rate and symptoms is recommended for most patients with CCS. | |
| p.87 | III | B | Ivabradine is not recommended as add-on therapy in patients with CCS, LVEF >40%, and no clinical heart failure. | |
| p.87 | III | B | Combination of ivabradine with non-DHP-CCB or other strong CYP3A4 inhibitors is not recommended. | |
| p.87 | III | B | Nitrates are not recommended in patients with hypertrophic cardiomyopathy or in co-administration with phosphodiesterase inhibitors. | |
| p.87 | I | A | In CCS patients with a prior MI or remote PCI, aspirin 75–100 mg daily is recommended lifelong after an initial period of DAPT. | |
| p.87 | I | A | In CCS patients with a prior MI or remote PCI, clopidogrel 75 mg daily is recommended as a safe and effective alternative to aspirin monotherapy. | |
| p.87 | I | A | After CABG, aspirin 75–100 mg daily is recommended lifelong. | |
| p.87 | I | B | In patients without prior MI or revascularization but with evidence of significant obstructive CAD, aspirin 75–100 mg daily is recommended lifelong. | |
| p.87 | I | A | In CCS patients with no indication for oral anticoagulation, DAPT consisting of aspirin 75–100 mg and clopidogrel 75 mg daily for up to 6 months is recommended as the default antithrombotic strategy after PCI-stenting. | |
| p.87 | I | A | In patients at high bleeding risk, but not at high ischaemic risk, it is recommended to discontinue DAPT 1–3 months after PCI and to continue with single antiplatelet therapy. | |
| p.87 | I | B | In CCS patients with a long-term indication for OAC, an AF therapeutic dose of VKA alone or, preferably, of DOAC alone (unless contraindicated) is recommended lifelong. | |
| p.87 | I | C | In patients with an indication for OAC who undergo PCI, initial low-dose aspirin once daily is recommended (loading dose when not on maintenance dose) in addition to OAC and clopidogrel. | |
| p.88 | I | A | In patients who are eligible for OAC, DOAC (unless contraindicated) is recommended in preference to VKA. | |
| p.88 | III | C | The use of ticagrelor or prasugrel is generally not recommended as part of triple antithrombotic therapy with aspirin and an OAC. | |
| p.88 | I | B | It is recommended to initiate aspirin post-operatively as soon as there is no concern over bleeding. | |
| p.88 | I | A | A proton pump inhibitor is recommended in patients at increased risk of gastrointestinal bleeding for the duration of combined antithrombotic therapy (antiplatelet therapy and/or OAC). | |
| p.88 | I | A | Lipid-lowering treatment with an LDL-C goal of <1.4 mmol/L (55 mg/dL) and a ≥50% reduction in LDL-C vs. baseline is recommended. | |
| p.88 | I | A | A high-intensity statin up to the highest tolerated dose to reach the LDL-C goals is recommended for all patients with CCS. | |
| p.88 | I | B | If a patient’s goal is not achieved with the maximum tolerated dose of statin, combination with ezetimibe is recommended. | |
| p.88 | I | B | For patients who are statin intolerant and do not achieve their goal on ezetimibe, combination with bempedoic acid is recommended. | |
| p.88 | I | A | recommended. | |
| p.88 | I | A | or target HbA1c and independent of concomitant glucose-lowering medication. | |
| p.88 | I | A | baseline or target HbA1c and independent of concomitant glucose-lowering medication. | |
| p.88 | I | C | It is recommended that patients scheduled for percutaneous or surgical revascularization receive complete information about the benefits, risks, therapeutic consequences, and alternatives to revascularization, as part of shared clinical decision-making. | |
| p.88 | I | C | It is recommended that the decision for revascularization and its modality be patient-centred, considering patient preferences, health literacy, cultural circumstances, and social support. | |
| p.88 | I | C | It is recommended that the Heart Team (on site or with a partner institution) develop institutional protocols to implement the appropriate revascularization strategy in accordance with current guidelines. | |
| p.88 | I | A | In CCS patients with LVEF >35%, myocardial revascularization is recommended, in addition to guideline-directed medical therapy, for patients with functionally significant left main stem stenosis to improve survival. | |
| p.89 | I | B | medical therapy alone to improve long-term survival. | |
| p.89 | I | A | functionally significant obstructive CAD is recommended to improve symptoms. | |
| p.89 | I | C | post-procedural outcomes to guide shared clinical decision-making. | |
| p.89 | I | B | Calculation of the STS score is recommended to estimate in-hospital morbidity and 30-day mortality after CABG. | |
| p.89 | I | B | In patients with multivessel obstructive CAD, calculation of the SYNTAX score is recommended to assess the anatomical complexity of disease. | |
| p.89 | I | A | Intracoronary imaging guidance by IVUS or OCT is recommended when performing PCI on anatomically complex lesions, in particular left main stem, true bifurcations, and long lesions. | |
| p.89 | I | A | Intracoronary pressure measurement (FFR or iFR) or computation (QFR) is recommended to guide lesion selection for intervention in patients with multivessel disease. | |
| p.89 | I | C | It is recommended that physicians select the most appropriate revascularization modality based on patient profile, coronary anatomy, procedural factors, LVEF, preferences, and outcome expectations. | |
| p.89 | I | A | • is recommended over medical therapy alone to improve survival | |
| p.89 | I | A | repeat revascularization | |
| p.89 | I | A | In CCS patients at low surgical risk with suitable anatomy, CABG is recommended over medical therapy alone to improve survival. | |
| p.89 | I | A | In CCS patients with significant multivessel disease and diabetes, with insufficient response to guideline-directed medical therapy, CABG is recommended over medical therapy alone and over PCI to improve symptoms and outcomes. | |
| p.89 | I | A | In CCS patients with significant three-vessel disease, preserved LVEF, no diabetes, and insufficient response to guideline-directed medical therapy, CABG is recommended over medical therapy alone to improve symptoms, survival, and other outcomes. | |
| p.89 | I | A | In CCS patients with significant single- or double-vessel disease involving the proximal LAD and insufficient response to guideline-directed medical therapy, CABG or PCI is recommended over medical therapy alone to improve symptoms and outcomes. | |
| p.89 | I | B | In CCS patients with complex significant single- or double-vessel disease involving the proximal LAD, less amenable to PCI, and insufficient response to guideline-directed medical therapy, CABG is recommended over PCI to improve symptoms and reduce revascularization rates. | |
| p.89 | I | B | guideline-directed medical therapy, PCI is recommended to improve symptoms. | |
| p.89 | I | B | CABG, taking into account the risk-to-benefit ratio of the procedures. | |
| p.89 | I | C | functional imaging is recommended. | |
| p.89 | I | C | QFR when needed) is recommended. | |
| p.90 | I | A | It is recommended that CCS patients with HF be enrolled in a multidisciplinary HF management programme to reduce the risk of HF hospitalization and to improve survival. | |
| p.90 | I | A | An ACE-I, an MRA, an SGLT2 inhibitor (dapagliflozin or empagliflozin), and, in stable conditions, a beta-blocker are recommended for CCS patients with HFrEF to reduce the risk of HF hospitalization and death. | |
| p.90 | I | A | An SGLT2 inhibitor (dapagliflozin or empagliflozin) is recommended in patients with HF with mildly reduced ejection fraction (HFmrEF) or HFpEF to reduce the risk of HF hospitalization or cardiovascular death. | |
| p.90 | I | B | An ARB is recommended in symptomatic patients with CCS and HFrEF unable to tolerate an ACE-I or ARNI to reduce the risk of HF hospitalization and cardiovascular death. | |
| p.90 | I | B | Sacubitril/valsartan is recommended as a replacement for an ACE-I or ARB in CCS patients with HFrEF to reduce the risk of HF hospitalization and death. | |
| p.90 | I | B | Diuretics are recommended in CCS patients with HF and signs and/or symptoms of congestion to alleviate symptoms, improve exercise capacity, and reduce HF hospitalizations. | |
| p.90 | I | A | an LBBB QRS morphology to improve symptoms and survival and to reduce morbidity. | |
| p.90 | I | A | CRT rather than right ventricular pacing is recommended for patients with HFrEF regardless of NYHA class or QRS width who have an indication for ventricular pacing for high-degree AV block in order to reduce morbidity. This includes patients with AF. | |
| p.90 | I | C | In individuals with suspected vasospastic angina, a resting 12-lead ECG recording during angina is recommended. | |
| p.90 | I | A | • calcium channel blockers are recommended to control symptoms and to prevent ischaemia and potentially fatal complications. | |
| p.90 | I | C | complications is recommended. | |
| p.90 | I | C | comorbidities, and patient preferences are recommended. | |
| p.90 | I | C | Similar guideline-directed cardiovascular preventive therapy is recommended in women and men. | |
| p.90 | III | A | increased risk of thrombo-embolic complications. | |
| p.90 | I | B | Bleeding risk assessment is recommended using the PRECISE-DAPT score, the qualitative ARC-HBR tool or other, validated method. | |
| p.90 | I | B | Attention to interaction between antiretroviral treatment and statins is recommended in patients with HIV. | |
| p.90 | I | C | Opportunistic screening of healthy individuals for cardiovascular risk factors and to estimate the risk of future cardiovascular events using scoring systems, e.g. SCORE2 and SCORE-OP, is recommended to detect individuals at high risk and guide treatment decisions. | |
| p.91 | I | A | Mobile health interventions (e.g. using text messages, apps, wearable devices) are recommended to improve patient adherence to healthy lifestyles and medical therapy. | |
| p.91 | I | B | Behavioural interventions are recommended to improve adherence. | |
| p.91 | I | B | Simplifying medication regimens (e.g. using fixed-dose drug combinations) is recommended to increase patient adherence to medications. | |
| p.91 | I | C | Multiprofessional and family involvement is recommended to promote adherence, in addition to patient education and involvement. | |
| p.91 | I | C | cause (e.g. longstanding tachycardia or myocarditis). | |
| p.91 | I | C | Risk stratification is recommended in patients with new or worsening symptoms, preferably using stress imaging. | |
| p.91 | I | C | In patients with symptoms refractory to medical treatment or at high risk of adverse events, invasive coronary angiography (with FFR/iFR when necessary) is recommended for risk stratification and for possible revascularization aimed at improving symptoms and prognosis. | |
| p.91 | I | A | DES is recommended over drug-coated balloons for treatment of in-DES restenosis. | |
| p.91 | I | B | LIMA is indicated as the conduit of choice for redo CABG in patients in whom the LIMA was not used previously. |