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“The first, and most obvious, thing to notice about the 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes1 is the new terminology,” says Guideline Review Coordinator, Professor Franz-Josef Neumann (University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany).
No longer referred to as ‘stable coronary artery disease’ (CAD), the term ‘chronic coronary syndromes’ (CCS) is designed to convey the dynamic continuum of CAD. The disease is characterised by phases of stability—CCS—interrupted by phases of instability—acute coronary syndromes—due to processes such as atherosclerotic plaque rupture or erosion and thrombosis-related events.
The new ESC Guidelines feature extensive revision of the pretest probability (PTP) of disease to try to give a more realistic assessment of the patient’s likelihood of having CAD. “Evidence emerging since the 2013 ESC Guidelines made it clear that the model used in that version was overestimating the prevalence of disease, particularly in females, and many patients were assessed as being in worse health than they actually were,” explains Guideline Review Coordinator, Professor Udo Sechtem (Robert Bosch Hospital, Stuttgart, Germany). The new model is still based on age, sex and the nature of symptoms, but it now also includes dyspnoea as a main presenting symptom. The 2019 ESC Guidelines suggest that it is safe to defer routine testing in patients with a PTP <15%, although it can still be considered in these patients if symptoms are limiting or require clarification. “By reducing the need for invasive and non-invasive tests for patients with suspected CAD, the revised PTP model should spare patients unnecessary procedures and should also lower costs,” says Prof. Sechtem.
The presence of factors that increase the likelihood of obstructive CAD—such as cardiovascular disease risk factors—or those that decrease the likelihood of CAD—such as normal exercise electrocardiogram (ECG)—can improve PTP assessment and should also be considered, particularly in patients with PTP 5–15%. This provides the 2019 ESC Guidelines’ novel element of clinical likelihood of CAD. “The new guidelines are a little more liberal when it comes to determining which diagnostic pathway to use,” Prof. Sechtem comments. “Instead of being provided with a prescriptive algorithm, doctors are now given the opportunity to build a clinical estimate of risk into the diagnosis. This gives clinicians more freedom to tailor diagnosis to the individual patients, although this flexibility of approach may not appeal to all practitioners.” The new guidelines give greater prominence to coronary computed tomography angiography (CTA) to confirm CAD. Prof. Neumann explains. “If obstructive CAD cannot be ruled out with sufficient certainty using clinical assessment, non-invasive functional imaging or coronary CTA are equally recommended as alternative initial approaches. If, following coronary CTA, evidence of obstructive CAD is inconclusive, functional imaging is recommended.” The choice of initial test should be based on the clinical likelihood of CAD along with test availability and local expertise. “This will probably lead to a more liberal use of coronary CTA to exclude CAD in patients with a low PTP,” comments Prof. Sechtem.
The role of coronary CTA has been elevated while the use of exercise ECG without imaging to rule in or rule out CAD has been downgraded. “The class of recommendation for exercise ECG has been moved from I (‘recommended’) to IIb (‘may be considered’) and it should only be used when there is no possibility to perform functional imaging,” says Prof. Neumann. Exercise ECG does, however, still have value as what Prof. Neumann calls “a niche indication” and can be used to assess functional capacity, blood pressure and heart rate, dependent on exercise.
As far as antithrombotic treatment is concerned, a new addition to the 2019 ESC Guidelines is the recommendation that dual antithrombotic treatment for long-term prevention should be considered for patients with CCS and sinus rhythm. “Addition to aspirin of another agent should be considered for patients with a high risk of ischaemic events and a low risk of bleeding events and may be considered for patients with a moderately elevated ischaemic risk and no high risk of bleeding,” explains Prof. Neumann. Clopidogrel, prasugrel, rivaroxaban and ticagrelor are each possible combination partners for aspirin in dual antithrombotic therapy.
Prof. Neumann concludes, “CCS covers a range of symptomatic and asymptomatic individuals with different risks for future cardiovascular events that can change over time. The new guidelines should help to more easily and precisely identify those at a greater risk of events and stratify treatment accordingly.”
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