What are the ESC treatment guidelines for stable coronary artery disease and coronary artery atherosclerosis?

Updated: Apr 09, 2021
  • Author: Sandy N Shah, DO, MBA, FACC, FACP, FACOI; Chief Editor: Yasmine S Ali, MD, MSCI, FACC, FACP  more...
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The European Society of Cardiology (ESC) released updated guidelines on the management of stable coronary artery disease (CAD). [92, 93] These guidelines note that microvascular angina and vasospasm are more common as causes of angina than previously believed, and they increase reliance on pretest probabilities (PTP) for stable CAD as well as discuss a larger role for modern imaging modalities (eg, cardiac magnetic resonance [CMR] imaging and coronary computed-tomography angiography [CCTA]).

Highlights of the 2013 ESC guidelines include the following [92, 93] :

  • PTP for a CAD diagnosis uses more contemporary data than those used in the Diamond and Forrester Chest Pain Prediction Rule: For example, in patients with suspected CAD using the 2013 criteria, if the PTP is < 15%, investigate other possible causes and consider a diagnosis of functional coronary disease; if the PTP is intermediate (eg, 15%-85%), send the patient for noninvasive testing; if the PTP is high (eg, >85%), a diagnosis of CAD is established, and patient risk stratification should follow

  • In stable CAD, the functional impact of coronary lesions relative to their angiographic severity has a larger role than previously in determining the role of PCI

  • In patients with severe symptoms or clinical characteristics suggestive of high-risk coronary anatomy: Initiate guideline-directed medical therapy

  • For noncomplex coronary disease: Consider medical therapy first; in the presence of complex coronary lesions or if the patient has many comorbidities, CABG is preferred over PCI; however, if the patient prefers PCI, use drug-eluting stents

  • In patients within the lower range of intermediate PTP for stable CAD (in whom good image quality can be obtained): Consider CCTA as an alternative to stress-imaging techniques (1) to exclude stable CAD and (2) after an inconclusive exercise electrocardiogram (ECG) or stress imaging test or those in whom stress testing is contraindicated

  • On first contact in every person with chest pain: Obtain a resting echocardiogram

  • In patients with a clinically important left main coronary artery stenosis: If there is only 1-vessel involvement, use PCI for ostial or mid-shaft lesions but also include a heart team discussion to decide on PCI or CABG for lesions at a distal bifurcation; for multivessel involvement, use the SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score (eg, if ≤22, the team should discuss, but if ≥23, CABG should be chosen)

  • Second-line anti-anginal agents include ranolazine, nicorandil, and ivabradine (not approved for angina in the United States)

However, the following three studies are not recommended [92, 93] :

  • Coronary calcium scoring on CT imaging in asymptomatic patients

  • Screening for CAD with CCTA in asymptomatic patients

  • Stenosis quantification with CCTA in patients with a high likelihood of calcifications

In collaboration with the European Association for the Study of Diabetes (EASD), the ESC also developed guidelines on diabetes, prediabetes, and cardiovascular diseases; these guidelines place emphasis on the following [92, 94] :

  • Patient-centered care

  • Less aggressive approach to glycemic control for the elderly and patients with "long-standing diabetes with autonomic neuropathy”

  • A “simplified diagnostics” algorithm in which glycosylated hemoglobin or fasting plasma glucose studies have priority in the workup, but the oral glucose-tolerance test is reserved for "cases of uncertainty”

  • CABG as the preferred/first revascularization choice, rather than PCI

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