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compared with men could contribute to unfavourable outcomes. There are also risk factors that are unique to women.1014,1015 Not only premature menopause,1016 but also hypertensive disorders of pregnancy, pre-term delivery, gestational diabetes, small-for-gestational-age delivery, placental abruption, and pregnancy loss are predictors of subsequent CVD.1017 Also, the association between low socioeconomic status and increased cardiovascular risk seems stronger in women.1018 In addition, higher levels of residential segregation are associated with incident CVD and obesity among black women.1019 Women are less likely to be referred for diagnostic testing and are under-treated for essential secondary prevention therapies.1020 Compared with men, women have a shorter survival after PCI1021 and CABG.1022 In a large-scale, individual-patient data pooled analysis of contemporary PCI trials with early and new-generation DES, women had a higher risk of MACE and ischaemia-driven target-lesion revascularization compared with men at 5 years following PCI.1021 However, the excess risk after PCI among women can be primarily explained by a greater burden of cardiovascular risk factors and comorbid conditions.1023 Nevertheless, in a population undergoing contemporary PCI, women and men had similar risks of death or new Q-wave MI at 2 years, but women faced a higher risk of bleeding and haemorrhagic stroke compared with men.1024 Women with signs and symptoms suggestive of cardiac ischaemia should be investigated carefully. The same guideline-recommended cardiovascular preventive therapy should be provided to women and men.1025 Hormone replacement therapy in post-menopausal women does not reduce the risk of ischaemic myocardial disease1015 and it may come at the cost of other health risks,1026 which should be discussed with the patient.

5.3.3 High bleeding-risk patients

An HBR is increasingly present in many CCS patients referred for coronary revascularization. The ARC-HBR consortium provided a consistent definition of HBR for patients undergoing PCI. Patients are considered at HBR if at least one major or two minor criteria are met.590 In the context of PCI in HBR patients, short duration of DAPT (1–3 months) and PCI with a DES was beneficial in many recent studies.1009,1027–1032

5.3.4 Inflammatory rheumatic diseases

Patients with inflammatory rheumatic diseases have an increased risk of CVD compared with the general population.1033,1034 Accumulating evidence has shown elevated cardiovascular morbidity and mortality in other rheumatic and musculoskeletal diseases, including gout, vasculitis, systemic sclerosis, myositis, mixed connective tissue disease, Sjögren syndrome, SLE, and the antiphospholipid syndrome.1035–1044 Some of these patient categories have two- to three-fold higher prevalences of asymptomatic ASCVD compared with the general population,1045–1051 which is linked to ASCVD outcomes.1049,1052–1054 Thus, identification of ASCVD such as carotid artery plaque(s) may be considered in ASCVD and CAD risk evaluation.1050,1055–1057 In patients with inflammatory rheumatic diseases and CCS, CVD preventive medications such as lipid-lowering medications and antihypertensive treatment should be used as in the general population.1058–1062

5.3.5 Hypertension

Blood pressure lowering has been associated with favourable cardiovascular outcomes in patients regardless of the presence of CAD.1063 Due to concerns of a possible J-curve relationship between achieved BP and cardiovascular outcomes in patients with CAD, previous guidelines did not recommend a target BP of <120/70 mmHg. In line with the 2024 ESC Hypertension Guidelines1064, the present guidelines recommend that treated systolic BP values in most CCS patients be targeted to 120–129 mmHg, provided the treatment is well tolerated. In cases where on-treatment systolic BP is at or below target (120–129 mmHg) but diastolic BP is not at target (≥80 mmHg), intensifying BP-lowering treatment to achieve an on-treatment diastolic BP of 70–79 mmHg may be considered to reduce CVD risk.1065 More lenient targets (e.g. 140/90 mmHg) can be considered in older patients (≥85 years of age) or patients with pre-treatment symptomatic orthostatic hypotension. In hypertensive patients with a history of MI, beta-blockers and RAS blockers are first-line treatments. In patients with symptomatic angina, beta-blockers and/or CCBs can be useful.1065

5.3.6 Atrial fibrillation

Diagnostic assessment of CAD (CCTA and non-invasive tests) may be difficult in AF with a high ventricular rate. In patients with CAD and AF, rhythm or rate control strategies may help improve symptoms of myocardial ischaemia. Amiodarone or dronedarone are drugs of choice for rhythm control, as an alternative to catheter ablation, in patients with CAD and AF. Sotalol may also be considered. Beta-blockers, diltiazem, verapamil, or digoxin can be used for rate control depending on the LVEF.613 After PCI, combined anticoagulant and antiplatelet therapies are needed. Recommendations on post-PCI antithrombotic therapy in patients with AF and indication for OAC are detailed in Section 4.3.1.2.2 and Recommendation Table 17.613,621,659 Surgical ablation of AF during isolated CABG seems to be safe and effective in improving long-term outcomes.1066 Concomitant surgical closure of the left atrial appendage is recommended as an adjunct to oral anticoagulation in patients with AF undergoing cardiac surgery (e.g. CABG) to prevent ischaemic stroke and thrombo-embolism (see the ESC 2024 Guidelines for the management of Atrial Fibrillation).1067

5.3.7 Valvular heart disease

In patients with valvular heart disease with a risk for associated CAD who require surgery or in whom a decision of a percutaneous or surgical approach is still pending, ICA or CCTA is recommended to determine the need for coronary revascularization.1068 Evidence of CAD in patients with valvular heart disease can drive to a surgical instead of a percutaneous treatment of valvular heart disease. Invasive coronary angiography is recommended in patients with secondary mitral regurgitation as this condition is frequently due to ischaemic LV dysfunction.1068 Routine stress testing to detect CAD associated with severe symptomatic valvular heart disease is not recommended because of low diagnostic value and potential risk. The usefulness of FFR or iFR in patients with valvular heart disease is not well established, and caution is warranted in interpreting these measurements, especially in the presence of aortic stenosis.1068 Beta-blockers need to be used with caution in patients with aortic valve disease. Coronary artery bypass grafting is recommended in patients with a primary indication for aortic/mitral/tricuspid valve surgery and significant coronary stenosis. Percutaneous coronary intervention should be considered in patients with a primary indication of transcatheter aortic valve implantation or transcatheter mitral valve intervention and coronary artery diameter stenosis of >70% in proximal segments.1068 Downloaded from academic.oup.com/eurheartj/article/45/36/3415/7743115 by guest on 07 October 2026