2024 ESC Guidelines for the management of chronic coronary syndromes
Felicita Andreotti, Italy; Christiaan J M Vrints, Belgium
Session overview: New ESC Guidelines [30 Aug 2024]1
The 2024 ESC Guidelines for chronic coronary syndrome (CCS) update the previous 2018 ESC/European Association for Cardio-Thoracic Surgery (EACTS) guidelines regarding myocardial revascularization, as well as the 2019 ESC guidelines that are also endorsed by EACTS. These guidelines propose a structured, stepwise approach for managing CCS patients that includes four key steps: an initial clinical assessment, further cardiac evaluations, diagnostic testing, and modifications to lifestyle and risk factors, including medication. Importantly, the new guidelines redefine CCS to encompass a wider range of clinical presentations stemming from both structural and functional abnormalities within the macro- and microvascular systems. This revised definition includes conditions that may cause angina and ischemia even in patients with non-obstructive coronary arteries (ANOCA) and ischemia with non-obstructive coronary arteries (INOCA). The 2024 guidelines encourage the use of a risk factor- weighted clinical likelihood model to determine the pretest likelihood of obstructive coronary artery disease (CAD).
Key findings
The newly introduced prediction model is capable of classifying up to 50% of patients as having a very low likelihood of obstructive CAD, potentially leading to a deferral of further diagnostic testing. However, it is essential that this model be adapted based on clinical information, and the ultimate diagnosis must be a clinical decision that integrates all relevant data.
For each patient suspected of having CCS, a lipid profile—including total cholesterol, high-density lipoprotein cholesterol (HDL-C), and triglycerides, which allows for the calculation of LDL-C—should be obtained to diagnose comorbidities and to inform treatment strategies.
Routine assessments should include the lipid profile with LDL-C (IA), a complete blood count (including hemoglobin) (IB), creatinine levels with an estimation of renal function (IB), and an evaluation of glycemic status through HbA1c and/or fasting plasma glucose (IB).
In patients suspected of having CCS, it is advisable to evaluate thyroid function at least once (IB).
Consideration should also be given to measuring high-sensitivity C-reactive protein and/or fibrinogen plasma levels (IIaB).
For patients with established ASCVD, reducing LDL-C levels is effective in lowering the risk of recurrent major adverse cardiovascular events (MACE).
Recommendations on lipid-lowering therapy (LLT) for patients with CCS
New recommendations are highlighted in the below grey boxes
- It is recommended to implement lipid-lowering treatment targeting an LDL-C level of <1.4 mmol/L (55 mg/dL) and achieving a reduction of ≥50% in LDL-C compared to baseline (new recommendation; IA).
- A high-intensity statin should be administered at the highest tolerated dose to meet LDL-C goals for all patients with CCS (IA).
- If a patient's goals are not met with the maximum tolerated dose (MTD) of statin, the incorporation of ezetimibe is suggested (IB).
- For patients who cannot tolerate statins and do not reach their goals with ezetimibe, the addition of bempedoic acid is recommended (new recommendation; IB).
- For patients who fail to achieve their target with MTD of statin and ezetimibe, combining treatment with a PCSK9 inhibitor is advised (IA).
- In cases where patients do not meet their goals with MTD of statin and ezetimibe, the addition of bempedoic acid should be considered (new recommendation; IIaC).
- For patients experiencing a recurrent atherothrombotic event (which may differ from the original event) while on maximally tolerated statin therapy, targeting an LDL-C level of <1.0 mmol/L (<40 mg/dL) may be an option (IIbB).
SGLT2 inhibitors and/or GLP-1 receptor agonists in patients with CCS
- SGLT2 inhibitors with established cardiovascular benefits are recommended for patients with type 2 diabetes (T2D) and CCS to reduce CV events, regardless of baseline or target HbA1c and independent of other glucose-lowering medications (IA).
- Semaglutide should be considered for CCS patients who do not have diabetes but are overweight or obese (BMI >27 kg/m2) to help reduce risk of cardiovascular mortality, myocardial infarction (MI), or stroke (IIaB).
Update on the following Recommendation
Revised recommendation is highlighted in bold below
Previously, statins were recommended for all patients with CCS (IA). A high-intensity statin at the highest tolerated dose to achieve LDL-C goals remains recommended for all CCS patients (IA).
Key messages
The guidelines advocate for a multidisciplinary strategy to ensure comprehensive management, focusing on non- invasive diagnostic methods, proactive LDL-C reduction, and revascularization for patients with chronic coronary syndrome (CCS) who are at high risk. The importance of lipid testing is also underscored.
The recommended LDL-C target is consistent with the 2019 ESC/EAS Guidelines for dyslipidaemia management as well as the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice.
It is advisable to consider the addition of PCSK9 inhibitors for patients who do not reach the guideline- recommended LDL-C targets, even with maximally tolerated doses of statins and ezetimibe.
Referanser
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Vrints C et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J, ehae177, https://doi.org/10.1093/eurheartj/ehae177 2024
