ESC 2024 chronic coronary syndromes guidelines: key recommendations

Who it applies to

Adults with suspected or confirmed chronic coronary syndromes in outpatient and ambulatory cardiology settings.

Key recommendations

• Use pre-test probability assessment based on age, sex, and symptom characteristics to guide initial diagnostic testing rather than relying on older fixed pre-test probability tables alone.
• Coronary CT angiography is recommended as a first-line test in patients with lower clinical likelihood of coronary artery disease or inconclusive stress tests.
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• Functional imaging such as stress echocardiography, nuclear perfusion imaging, or stress MRI is recommended when clinical likelihood is higher or anatomy is already known to be complex.
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• All patients with chronic coronary syndromes should receive optimal medical therapy including antianginal drugs, risk factor modification, and secondary prevention medications.
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• Beta-blockers and/or calcium channel blockers remain first-line antianginal therapy, with the specific choice guided by heart rate, blood pressure, comorbidities, and left ventricular function.
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• High-intensity statin therapy with a low-density lipoprotein cholesterol target is recommended for all patients, with addition of ezetimibe or PCSK9 inhibitors if targets are not met.
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• Antithrombotic therapy should be individualised, balancing ischaemic and bleeding risk, with single antiplatelet therapy as the default long-term strategy in the absence of recent intervention.
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• Revascularisation by percutaneous coronary intervention or bypass surgery should be guided by symptom burden, extent of ischaemia, and anatomical complexity, generally using tools like the SYNTAX score to guide the choice of technique.
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• Lifestyle interventions including smoking cessation, physical activity, weight management, and dietary counselling are recommended for all patients as part of comprehensive secondary prevention.
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• Cardiac rehabilitation programmes are recommended for eligible patients to improve outcomes and quality of life.
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What is new in this edition

• Greater emphasis on coronary CT angiography as a first-line diagnostic tool rather than invasive angiography or older stress testing approaches
• Updated approach to clinical likelihood assessment moving away from traditional fixed pre-test probability tables
• Reinforced individualised, risk-based approach to antithrombotic therapy duration and intensity

Practice points for students

• Think of chronic coronary syndromes as a spectrum rather than a single diagnosis, encompassing stable angina, post-MI, and post-revascularisation states
• Coronary CT angiography has an increasingly prominent role in diagnostic pathways, especially in patients with lower likelihood of disease
• Medical therapy and lifestyle changes are the foundation of management; revascularisation is adjunctive for symptom control or high-risk findings
• Lipid-lowering targets are aggressive, and combination therapy should be considered early if targets are not met with statins alone

Condition

Other guidelines on this topic

• 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice GuidelinesAHA/ACC2023Summary
• Stable angina: management (CG126)NICE2016Summary

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by ESC. It is not medical advice: always read the original guideline before applying it to patients.