The “ESC Guidelines on the management of stable coronary artery disease” are published today on-line in European Heart Journal1 and on the ESC Website www.escardio.org/guidelinesPrevious
ESC Guidelines on this topic were published in 2006. The 2013 version gives more prominence to new imaging techniques such as cardiovascular magnetic resonance (CMR) and coronary computed tomography (CT) angiography in the diagnosis of CAD in patients with stable chest pain. The guidelines clearly define which patients should receive coronary CT angiography to avoid overuse of this technique.
Professor Sechtem said: “Another new aspect is that the diagnostic algorithm is based on pre-test probability, in line with the 2010 UK National Institute for Health and Clinical Excellence (NICE) guidelines on chest pain of recent onset. The estimation of pre-test probability is based on the latest data measuring the prevalence of coronary artery stenosis in a current large cohort of male and female patients of various ages with various clinical presentations.”
As in the 2006 guidelines, invasive coronary angiography and revascularization are recommended mainly for patients at high risk for coronary events. But the definition of risk and the methods for assessing it have been updated. The previous guideline based risk estimation solely on the stress electrocardiogram (ECG) but this has been expanded to include imaging techniques. The high risk group now begins at a slightly higher estimated annual mortality of >3%.
Professor Sechtem said: “The approach to patients with functional coronary disease, i.e. coronary vasospasm or microvascular disease, has been redefined. The definition of this group by clinical and non-invasive evaluation has become more important than in 2006 as more patients, especially females, undergo invasive coronary angiography because of stable angina and are then found to have no epicardial stenosis.”
Controlling heart rate is the new treatment goal for medical therapy in the 2013 guidelines. First line treatment should be with beta-blockers or calcium channel blockers lowering heart rate, both of which are readily available. Second line treatment includes long acting nitrates and new drugs on the market. Professor Montalescot said: “We have roughly the same level of evidence for all of the second line drugs and we recommend that physicians choose according to what is available in their country.”
He added: “Before there is any discussion about revascularization, patients should receive optimal medical therapy. The decision on the type of revascularization should then be based on a discussion between the surgeon and the cardiologist in the heart team. Moreover, revascularization should only be considered in patients with evidence of regional ischemia or a pathological fractional flow reserve (FFR).”
Professor Sechtem said: “We hope these guidelines will make practitioners dealing with patients with stable chest pain and other forms of stable coronary artery disease think more often of functional coronary disease which then should be treated appropriately. Moreover, patients at high pre-test probability do not need to undergo a battery of tests before being directed to invasive coronary angiography on clinical evidence only. Of course, revascularization in such patients should be directed by using FFR measurements liberally.”
He concluded: “We hope that overuse of coronary CT angiography will be discouraged by the clear definition of a patient group at the lower range of intermediate pretest probabilities in whom this technique may be helpful for excluding stenoses.”