2019 ESC Guidelines on the diagnosis and management of chronic coronary syndromes ° @ESC European Society of Cardiology2019 ESC Guidelines on the diagnosis @ESC and management of chronic coronary syndromes Euiopean Society of Cardiciogy Task Force Members: Juhani Knuuti (Chairperson) (Finland), William Wijns (Chairperson) (Ireland) Antti Saraste (Finland) Bernard Gersh (United States of America) Davide Capodanno (italy) Pavel Svitil (Czeck Rebublic) Emanuele Barbato (Italy) Martine Gilard (France) Christian Funck-Brentano (France) David Hasdai (Israe!) Eva Prescott (Denmark) Robert Hatala (Slovak Republic) Robert F. Storey (United Kingdom) Felix Mahfoud (Germany) Christi Deaton (United Kingdom) Josep Masip (Spain) Thomas Cuisset (France) Claudio Muneretto (Italy) Stefan Agewall (Norway) Marco Valgimigli (Switzerland) Kenneth Dickstein (Norway) Stephan Achenbach (Germany) Thor Edvardsen (Norway) Jeroen J. Bax (Netherlands) Javier Escaned (Spain) 8 e ‘wor escateinor/ guidelines 5c audelines onthe olagnosisendmanasenert of chronic coronéry snaromes {European Heart Journal 2029, 10.1083/eurhearti/shs825)ESC Classes of recommendations @eEsc Euopean Society Definition Wording to use 51 cariaiooy Class| Evidence and/or general agreement thata given treatment or procedure is beneficial, useful, effective. Class Conflictingevidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure. Classita Weight of evidence/opinion isin favour of usefulness/efficacy. Class tb Usefulness/efficacy is less well established by evidence/opinion. Class Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful. e ‘wor estas org/guidelines SC Guldelines onthe ciagnos'send managerert of cron coronery syraromes European Heart Journsl 2013, 10.1093/eurhesr!i/sh2425)ESC Levels of evidence @eEsc European Society bt cardiciogr Level of evidence C Consensus of opinion of the experts and/or small studies, retrospective studies, registries. ® ° won escardiocra/guidelines {Se Gigelinesonthe elagnosisene menagenenc of chronic coronery syndromes 4 [European Heart Journal 2049; 10.1093/eurheartj/eha425)Natural history of chronic coronary syndromes @eEsc A dynamic process 7 + ot carooy ‘Cardiac risk (death, Ml) won escardiacrg/guideinesWhat is new in the 2019 Guidelines? @eEsc New/revised concepts (1) European Society of Cardiciogy The Guidelines have been revised to focus on CCS instead of stable CAD. This change emphasizes the fact that the clinical presentations of CAD can be categorized as either ACS or CCS. In the current Guidelines on CCS, six clinical scenarios most frequently encountered in patients are identified: (i) patients with suspected CAD and ‘stable’ anginal symptoms, and/or dyspnoea; (ii) patients with new onset of HF or LV dysfunction and suspected CAD; (iii) asymptomatic and symptomatic patients with stabilized symptoms <1 year atter an ACS or patients with recent revascularization; (iv) asymptomatic and symptomatic patients >1 year after initial diagnosis or revascularization; (v) _ patients with angina and suspected vasospastic or microvascular disease; (vi) asymptomatic subjects in whom CAD Is detected at screening. e ‘wor escatsiocrg/guidelines SC Guidelines onthe ciagnos'send managerert of cron coronary syraromes 5 fiseusouesi tear tdeee ah ai aiecieeangfabalkds}What is new in the 2019 Guidelines? @eEsc New/revised concepts (2) Eopean Society of Cardiclogy ‘The pre-test probabilities (PTP) of CAD based on age, gender and nature of symptoms have undergone major revisions. In addition, we introduced the new phrase “Clinical likelihood of CAD" that utilizes also various risk factors of CAD as PTP modifiers. The application of various diagnostic tests in different patient groups to rulein or rule-out CAD have been updated The Guidelines emphasize the crucial role of healthy lifestyle behaviours and other preventive actions in decreasing the risk of subsequent cardiovascular events and mortality. e ‘wun escrsiocra/guidelines SC Guleelines onthe wiagnosisend menagemert of chronic coronary syndromes 5 Wierivacs beaut kanal seareeab tas)What is new in the 2019 Guidelines? @eEsc New recommendations (1) of Cardicogy Basic testing, diagnostics, and riskassessment Non-invasive functional imagingor _ Invasive ongiographyto diagnose Invasive coronaryangiography with coronaryCTAasthe eialtestfor CAD inpatients wth availabilty of imesive functional diagnosing CAD. ahigh clinical likcitoodand valuation forconfirmationof CAD severesymptomsrefractoryto diagnesisinpatients with uncertain Initial non-invasive diegrostc test medicaltherapy dingrosison nor-invasietesting. basedontheclnicallieihoodof typical angina t low level of CAD, patient characteristics local exerci andelinicalevaluaiion Coronary CiAasanelternetiveto expertise andavailabilty. that indcateshighevent risk. invasive angiography another non inasive test is equivocal or ron- Invasive functional assessment must diagnostic. cchaomlattocowcttteesown be avalableandussd toevaluare eae PONT enases before evacuation, iS ee unless veryhighgrade (200% diameter stenosis). Class | Class Hla IE Class Ib Il Class I e 3c quiselines onthe elaznosisena manegemers ofcheanic coronary synsromes ‘Bas ccs aeat hia sg EAS SA Sc RAGGA wo escateio.cra/guldelinasWhat is new in the 2019 Guidelines? @eEsc New recommendations (2) Euvopean Society of Cardiciogy Antithrombotic therapy in patients Antithrombotic therapy in patients Antithrombotictherapy In post-PCl with CCS and sinus rhythm with CCS and atrial fibrillation patients with indication for OAC ance a ST drug to aspirin forlong-term. secondary prevention in patients Rivaroxaban 15 mg over 20 mg. with high-risk of ischaemic events Dabigatran 110 mg over 150 mg_ and without high bleeding risk ay am (ciwecick aspirin. iy GAcderapy in Triple therapy for1 to6 months. patients with AF and aCHA,0S,- _ INR2.0-2.5 and TTR>70% if VA. \VASc score 1 in males and 2 in fornales. Wi Close | Class lla ME Class Ilb Class 10 = e ‘wo esctdiocra/guidetines SC Gulselines onthe ciagnos'send managemert of cron coronery syndromes 6 We hss ics SEE Nae ce LAA,What is new in the 2019 Guidelines? @eEsc New recommendations (3) pen Scty Screening for CAD in Other pharmacological therapy aapmptomaticsubjeds | APPLin patients receiving aspirin |, monotherapy, DAPT, or OAC eo tee Co a eat is 2 inhibitors in patients with monotherapy who areathigh risk 4" Aveta of gestrointestinal bleeding. pees Ezetimibe if ipid goals not peta eee ah Treatment epilonefoe achieved with statins eerie ee refractory angina dey hehibkatoleretackeye | ACEMbitor® in patient at very hel : high risk oF cardiovascular adverse lipid goals with statins and le Close i Class lla Class lb Class = e ‘oe escnciocr/uldtnes fc cuielnesontheaianossenomenegerercatehroniccoronerysyaanes 40 + SiS ae APR REA ORR aa eso OiaWhat is new in the 2019 Guidelines? @ESC Changes in major recommendations (1} oo ote 2013 2019 Exorcise ECG for diagnosis of stable CAD Exercise ECG for risk assessment. Ga in patients with intermediate PTP. Exercise ECG to rule-in or rule-out CAD. i) Exercise ECG to evaluate control of Exercise ECG to evaluate control of symptoms symatomsand ischaemia. and ischaemia. For second-line treatment add long- ee : i Long-acting nitrates fi celine treatment acting nitrates, ivabradine, nicorandil, or ee on ee ine ere after attempts with BE and/ora non-DHP-CCB ranolazine. Nicorandil, ranolavine, ivabradine, or trimetazidine for second-line treatment after For second-line treatment, add attempts with BB, CCB and long-acting trimetazidine. nitrates. Combination of a BB or a CCB with second-line 8 drugs asa first-line treatment. e e ‘won esario ora/guidelines FS Guidelines onthe elagnosiseremencgenert ofchroniccoronarysynaromes 4 ae eee cat aml eg a ae eyWhat is new in the 2019 Guidelines? @ESC Changes in major recommendations (2) European Society ot Cardiology 2013 2019 Guidewire-besed CFR and/or microcirculatory resistance measurements in patients with persistent symptoms but coronary arteries lnk deoronary aeetyieotne and that are either angiographically normal or adenosine with Doppler measurements Have rRiGiate stehescs Wil Gen for patents with xtepectud ierhfen microvascular angina. eo Intracoronary acetylcholine with ECG monitoring to assess microvascular vasospasm. Transthoracic Doppler echocardiography of the LAD for non-invasive Transthoracic Doppler of the LAD, CMR, and measurement of CFR in patients with PET for non-invasive assessment of CFR. suspected microvascular angina, 4 e ‘won esarioor/ sidelines 5c cuiceinesontheciagnosiseromenegenercofchroniccororarysindromes 45Patients with angina and/or dyspnoea and suspected © ESC coronary artery isease srcwracooy. Diagnostic approach (1) STEP 1 Assess symptoms and perform clinical investigations Unstable angina? Follow ACS guidelines STEP 2 Consider comorbidities and quality of life Revascularization futile Medical therapy * ser» Ga saree artnet ver son == STEP 4 Assess pre-test probability and clinical tedlihoad of CAD * Geeta ere Ree ee oer s Mayo enitesinven young ans hestty potaveweh shigh zwpcion a! snaxrocardas susscfcuampen, sin aukimebidpesansinvhomthe echecadiogrofy reaithasrecorsequerceforfurhe balan maragenent “Consier oexise (Gis aan symptons athmias exccisetsiance SP fesronee andevereiakinatetes pateres 3c Gulselines onthe aiaznos 13 ‘won escatcio.crg/uieinesPatients with angina and/or dyspnoea and suspected @eEsc coronary artery disease European Society of carsiciogy Diagnostic approach (2) Offer dlagnoscc testing STEPS jpauepusw Pugeoa ‘>as0u8ep oN, STEP6 Choose appropriate therapy based on spmptonns ad event kt “aoiteyis exercise inevious teeta sh, ne thetnood of snr diagnose es (sue. “High cin al kesoed sndsyripiansinadequareyresporcing tomesia vearment nerves bazsonciriea evalu (xh assT segnert der sson, combifedw Mymacons ata ew workleed >” 9ez01e Uncerateradeor norcasrcsic# Const aso erevauitheukobsrative dese ne eiarSnic ere aes [e=secion6 of MED, ‘won escarci.crg/ suiting: ESC Guidelines ontne aiana and/or dyspnoea and suspected @ESC ease Cogent Secety of Cardiciogy Patients with ang coronary artery Clinical classification of suspected angina Typical angina Meets the following three characteristics: 1. Constricting discomfortin the front of the chest or in the neck, jaw, shoulder, or arm; 2. Precipitated by physical exertion; 3. Relieved by rest or nitrates within min. Atypical angina Meets two of these characteristics. Non-anginal Meets only one or none of these characteristics. chest pain ‘wr escercio org/guidetines sc quiselinesonthePatients with angina and/or dyspnoea and suspected @ ESC coronary artery disease European Society of Cardiciogy Canadian Cardiovascular Society grading of effort angina severity Class Description of angina 1 Angina only with strenuous exertion 0 Angina with moderate exertion jl Angina with mild exertion wv Angina at rest ‘www escardio org/guidetines erity Presence of angina during strenuous, rapid, or prolonged ordinary activity (walkingor climbing the stairs} Slight limitation of ordinary activities when they are performed rapidly, after meals, in cold, in wind, under emotional stress, or during the first few hours after waking up, but also walking uphill, climbing more than one flight of ordinary stairs.at @ normal pace, andin normal conditions. Having difficulties walking one or two blocks, or climbing one flight of stairs, at normal pace and conditions. No exertion needed to trigger angina ESC Guidelines onthe aiagnosisend managerEN Oe ES Re ME ENT eS N TOTES Patients with angina and/or dyspnoea and suspected @ ESC coronary artery disease — Basic biochemistry testing Sampessicity Recommendations Class Level If evaluation suggests clinical instability or ACS, repected measurements of troponin, & a preferably using high-sensitivity or ultrasensitive assays, are recommended to rule out myocardial injury associated with ACS. ‘The following blood tests are recommended in all patients: * Full blood count (including haemoglobin); * Creatinine measurement and estimation of renal function; * Alipid profile (including LDL-C); Itis recommended that screening for type 2 diabetes melitus in patients with suspected and established CCS is implemented with HbAicand fasting plasma glucose measurements, and that an oral glucose tolerance test is added if NbAtcand fasting plasma glucose results are inconclusive. Assessment of thyroid function is recommended in cese of clinical suspicion of thyroid disorders, ‘ere ceccdiacnnpeibiiiesFORD oT NE eT Rete NS ONT ENT OTT TRE Patients with angina and/or dyspnoea and suspected @)ESC coronary artery disease Seopa Sie Resting electrocardiogram ‘Recommendations Class Level Arresting 12-Iead ECG is recommended in all patients with chest pain without e an obvious non-cardiac cause. Aresting 12-lead ECG is recommended in all patients during or immediately after an episode of angina suspected to be indicative of clinical instability of c CAD. ST-segment alterations recorded during supraventricular tachyarrhythmias re should not be used as evidence of CAD. eo iowaniiltencisieities ESC Guivelines onthe Jiaznosisend managemert of chronic coronarysyndramesSr ee Se a ee SC Patients with any i and/or dyspnoea and suspected @ESC coronary artery disease Sapoegt sicety Ambulatory electrocardiogram monitoring Recommendations Ambulatory ECG monitoring is recommenced in patients with chest pain and suspected arrhythmias. Level c Ambulatory ECG recording, preferably monitoring with 12 leads, should be considered in patients with suspected vasospastic angina. Ambulatory ECG monitoring should not be used as a routine examination in patients with suspected CCS. ° BB: e ieadatiidaiiteiitiiies ESC Guitelinesonithe diagnosisendmenagemert ofchroniccoronarysyrdromes ag,ee eee ee eee Patients with any i and/or dyspnoea and suspected @ESC coronary artery disease mores Sicty Resting echocardiography and CMR Recommendations Class Level Aresting transthoracic echocardiogram is recommended in all patients for: 1. Exclusion of alternative causes of angina; 2. Identification of regional wall motion abnormalities suggestive of CAD; 3. Measurement of LVEF for risk stratification purpose; 4, Evaluation of diastolic function. Ultrasound of the carotid arteries should be considered, and be performed by adequately trained clinicians, to detect plaque in patients with suspected c CCS without known atherosclerotic disease. CMR may be considered in patients with an inconclusive echocardiographic tb c test. e ESC Guidelines onthe ciagnosisand management of chronic coronary syndromes eiicillasaniibiiliiiing:Paar Rhea eer ane EARL ME, TER TTS SENS Patients with angina and/or dyspnoea and suspected @ ESC frpeanSacty coronary artery disease of cardiciogy Chest X-ray Chest X-ray is recommended far patients with atypical presentation, signs rn and symptoms of HF, or suspicion of pulmonary disease. sisal ait RnENaON | 5,RET Ree aneereel aeons at eye ee — CO Patients with gine and/or dyspnoea and suspected @ ESC coronary artery disease Bmpescsicity: Pre-test probability of coronary artery disease Typical Atypical Non-anginal Dyspnoea* Age uM w M w M w M w 30-39 | 3% 5% 4% 3% 1% 1% 0% 3% 40-49 10% | 10% 6% 3% 2% 12% | 3% 13% 6% 3% 9% 6% 14% 10% 12% ‘in acemontetheciasceDamane ara Ferree clases patent th ejspross ower oysmnesacthaprimarysympeomareincudes, edakgree sades rezlonsderwtethe geupsin weichrernaire teary moat enc prxtest proba lty-159, The ihigr son shaded raion dene regreupswithpre ‘eetprobonii CAD Eerwaen 15) inushen thazasingforslgraric na) oscovaiered Wr aacergtnevarsicinis|iheshood osedcr Med fersoF pre ‘estprebebily a e "aii Aine |g,PPh ih feet eal 2819, Sy RR tet ae ar eae) Patients with angina and/or dyspnoea and suspected @)ESC coronary artery disease Seopa icy Determinants of clinical likelihood of CAD (PrP based onsex age ardnature ofsymptoms Decreases likelincod Increases ikalinood + Normal exercise ECG * * Risk factors for CVD (dysiipidaernia, + Nocoronary calcium by CT iabetes, hypertension, smoking, (Agatston score =0)* ‘amily history of (VD) * Resting ECG changes (QawaveorST- segment/T wavechanges) + LVdysfunctionsuggestiveof CAD + Abnormalesercise ECG? + CeronarycatiumbyCT® sitet Gas 7 “Gisdasiiuiiactinimidiniias: Riche ok[ieeregeeanr Heart dented 2059; 1A eurhmpartyateaha5) Patientswith angineand/or —_— Ngunvasve @ESC dyspnoea and suspected if rapes Seckty coronary artery disease if Main diagnostic pathways |” ee scorgnery —s Pu | AaemEN coateralt > High clinical Healt (Preterentialy = \ 2 Gece icity Bese » tow elnical tkelhood Pate ¥ arses (Gunny ose ighimage zeros oso | | © with >» High clinical Neolood | Sethad ‘evere Srrdaton 1 ‘o Functional Retoanls » Typical angina ot ren Relat esercee By SEeeE a : Irae ghee ’ » ajetoncion (J segsiteds —) g Revascularization * a ia BORIS = -.[European Heart Journal 2019; 10.1093/eurheartj/ehs425) Patients with angina and/or dyspnoea and suspected @ ESC coronary artery disease Shope sey Test clintalutethood afin sigufearteaD Test Cincalielnoodotrmsienfearecao A resuks 8 results * a a soe oon Stress ECG Ica $ j Coronarycta * SN coronary CTA * Ranges of clinical ert —— rt likelihood for tule-infout Stress CMR SS svescun + Lo set — es i Cina tte neat rango unoratact ane NCAD (Pa tort x cI a cbabitywil nates) Circa ieoat range whee testcenvale-on CAO Poste 8 HE ova win cn benH 58) é i a: ‘Se iaae ies COG teach aint[Burapean Heart Journal 2019; 10.1093/eurheartj/ehs425) Patients with angina and/or dyspnoea and suspected @ ESC coronary artery disease - Use of diagnostic imaging tests (1) EropemSccktr Recommendations Non invasive functional imaging for myocardial ischaemic? or coronary CTA is recommended as the Initial test to diagnose CAD in symptomatic patients in whom obstructive CAD cannot be ‘excluded by clinical assessment alone. Itis recommended that selection of the initial non-invasive diagnostic test Isdone based on the clinical likelinood of CAD and other patient characteristics that influence test c performance.® local expertise. and the availability of tests. Functional imaging for myocardial ischaernia is recommended if coronary CTA has shown CAD of uncertain functional significance or is not diagnostic. Invasive angiography is recommended as an alternative test to diagnose CAD patients with a high clinical likelihood, severe symptoms refractory to medical therapy or typical angina at a low level of exercise, and clinical evaluation that indicates high event risk. Invasive functional assessment must be available and used to evaluate stencses before revascularization, unless very high grade (>90% di *oxressechosrcogrphysrszcardac magnste resonance, angle shotenemissonT, er positon amianontoniogpy.” Cherenesitis deternningabileto > cid geod rage aly, oxpetedratoten expan arcs ronan °[European Heart Journs! 2029; 10.1093 /eurheertj/shit25) Patients with angina and/or dyspnoea and suspected @ ESC coronary artery disease - Use of ciagnostic imaging tests (2) Supe Recommendations Class Level Invasive coronary angiography with the availability of invasive functional evaluation should be considered for confirmation of the diagnosis of CAD in patients with an uncertain diagnosis on non-invasive testing. oe © Coronary CTA should be considered as an alternative to invasive angiography if another non-invasive test is equivocal or non-diagnostic. Coronary CTA is not recommended when extensive coronary calcification, irregular heart rate, significant obesity, inability to cooperate with breath- é hold commands, or any other conditions make obtaining good image quality unlikely. Coronary calcium detection by CT is not recommended to identify individuals 1 : with obstructive CAD. e a Se SSae i aN ec i ia9; 10.1093/eurheertj/ehsa25) Patients with angina and/or dyspnoea and suspected @ ESC coronary artery disease of carsiciogy Use of exercise electrocardiogram Recommendations Class Level Exercise ECG is recommended for the assessment of exercise tolerance, c symptoms, arrhythmias, 8P response, and event risk in selected patients. Exercise ECG may be considered as an alternative test to rule-in or rule-out CAD when non-invasive imaging is not available. Exercise FCG may be considered in patients on treatment to evaluate control i of symptoms and ischaemia. Exercise ECG is not recommended for diagnostic purposes in patients with 20.1 mV ST-segment depression on resting ECG or who are being treated with digitalis. c[European Heart Journsl 2013, 10.1093/eurheerti/2hs425) Patients with angina and/or dyspnoea and suspected @ESC coronary artery disease European Society Definitions of high event risk for different tests Exercise ECG SPECT or PET perfusion imaging Stress echocardiography CMR Coronary CTA or ICA Invesive functional testing of Cardiciogy Cardiovascular mortality >3% per year according to Duke Treadmill Score. Area of ischaemia >10% of the left ventricle myocardium. >3 of 16 segments with stress-induced hypokinesia or akinesia. =2 of 16 segments with stress perfusion defects or =3 dobutamine-induced dysfunctional segments Three-vessel disease with proximal stenoses, LM disease, or proximal anterior descending disease. FFR 0.8, iwFR <0.89. g ePatients with angina and/or dyspnoea and suspected coronary artery disease Risk assessmentin primary vs. secondary prevention PRIMARY PREVENTION ‘Asynptomatic apparel hth secs g , it Ih iat 1 ‘Sympomatc pavers withexabted CCS 2] oe Moen rik NOLLN3ASYd AYVONOD3S European Saciety of Cardiciogy[European Heart Journal 2038, 10.1093/eurhearij/eh425) Patients with angina and/or dyspnoea and suspected @ ESC coronary artery disease - Risk assessment (1) rope Sty Recommendations Class Level Risk stratificationis recommended based on clinical assessment andthe result of the diagnostic test initially employed to diagnose CAD. Resting echocardiography is recommended to quantify LV function in all patients é with suspected CAD. Risk stratification, preferably usingstressimagingor coronary CTA (if permitted by local expertise and availability), or alternatively exercise stress ECG (if significant exercise can be performed and the ECG is amenable to the identification of ischaemic changes), is recommended in patients with suspected or newly diagnosed CAD. In symptomatic patients with a high-risk clinical profile, ICA complemented by invasive physiological guidance (FFR) is recommended for cardiovascular risk stratification, particularly if the symptoms are respondinginadequately to medical treatment and revascularization Is considered forimprovernent of prognosis.ee ee at a aE ote ie ae Sy (European HesrtJourns| 2048, 20.1083 /eurheerj/shat25) Patients with angina and/or dyspnoea and suspected @ ESC coronary artery disease - Risk assessment (2) arapean Socity of Cardiciogy. Recommendations: Class Level Inpatients with mild or ne symptoms, ICA complemented by Invasive physiological guidance (FFR/iwER) is recommenced for patients on medical treatment, in whom non-invasive risk stratification indicates a high event risk and revascularization is considered for improvernent of prognosis. ICA complemented by invasive physiological guidance (FFR] should be considered for risk- stratification purposes in patients with inconclusive or conflicting results from non-invasive testi IF coronary CTA is aveilable for event risk stratification, additional stress imaging should be performed before the referral of a patient with few/no symptoms for ICA. Echocardiographic ascecement of glokal longitudinal strain provides incremental information to LVEF and may be considered when LVEF is >35%. Intravasculer ultrasound may be considered for the risk stratification of patients with Intermediate UM stenosis. ICA is not recommended solely for risk stratification.eae ee A eae Ne te Maan Cee este ie 86 ae |turopean Heart Journal 2039, 10.1083/eurheert 2425)Patients with angina and/or dyspnoea and coronary @ESC artery disease Secomngschty The five As of smoking cessation Arrange s 9 Ask about follow-up smoking Assist with Acvise to smoking quit cessation Assess readiness to quitSa tac cceel ERE ern ee ee mE Tre ee he ene ena nie ae |fursoean Heat Journal 2039; 10.1093/eurheari/ahot25) Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Healthy diet characteristics Enxopean Socity of cardexogr Increase consumptionof fruits and vegetables (2200 g each per day). 35-45 g of fibre per day, preferably from wholegrains. Moderate consumption of nuts (30 g per day, unsalted). 1-2 servings of fish per week (one to be cily fish) Limited lean meat, lowfat dairy products, and liquid vegetable oils. Saturated fatsto account for <10% of total energy intake; replace with polyunsaturated fats. As little intake of trans unsaturated fats as possible, preferably no intake from processed food, and<1% of total energy intake. <5-€ g of salt per day. IF alcohol is consumed, limiting intake to $100 g/week or <15 g/day is recommended, Avoid energy-dense foads such as sugar-sweetened soft drinksDian SRR ee Ee eee eee ere Car ree en eee |furszean Heart Journal 2039; 0.1093/eurheari/*ho25) Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Lifestyle management Cuiapean Society of cardciogy Recommendations Improvement of lifestyle factors in addition to appropriate pharmacological management is recommended. Cognitive behavioural interventions are recommended to help individuals achieve a healthy lifestyle. Exercise-based cardiac rehabilitation is recommended as an effective means for patients Bi Bi with CCS to achieve a healthy lifestyle and manage risk factors. Involvement of muktidisciplinary healthcare professionals (e.g. cardiologists, GPs, nurses, dieticians, physiotherapists, psychologists, and pharmacists) is recommended. Psychological interventions are recommended to improve symptoms of depression in patients with CCS Annual influenza vaccination is recommended for patients with CCS, especially in the elderly.ene eomaicio cre/peteines: REISS Rn UE ERE e EE EDL EEE OIC Tees |furspean Heart Journal 2059; 10.1093/eurheari/*hat25) Patients with anginaand/or dyspnoea and coronary artery disease — longterm art-schaemic dug theraay inpatients wth chronic coronary syndkomes and specticbaselivechoacteritics@) ESC ae = ae [ wmnéca | [ once | | oss | + 4 4 + aeaceat suitentouan peruvior | ( ncor ae + + + + + seq [sierieae] [sorrmoine | [omcarun | [inte™ | nse | 4 Teg ao Sg EOS, ped oles oe] SS raseis Gur caer ye nee Soe [ny Sato ces cas nee SECS aye oe oem eT Ma py LTS ‘usc: navDuP-cce=rahytoyrOne site anal boar “Sonar efa Sewn aGkeOss asst sreomad ma ig coat ataeeeraceavin ssmencioe Sra. Peyton 2 fe eh emboatn sta Cds nop PGCE ste uty an oes ohach cng aoe care mrtg stars pated ea mieansneee sean B Basie ubor nese ronate-ice mone w sses ne love noromg o esoe (Rin faerie ots Boo Pesan “arab aus noe tae We PTO EOE ‘Boogie ons Seow sisz ten tence sea! ove sesane nnats userid exeae ee eee re ‘waemmcinara/peiaincs |furspean Heart Journal 20395 10.1093/eurhearti/sheA25) Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Anti-ischaemic drugs (1) ororacogr Recommendations Class Level General considerations Medical treatment of symptomatic patients requires one or more drug(s) for . angina/ischaemia relief in association with drug(s) for event prevention Itis recommended that patients are educated about the disease, risk factors, e and treatment strategy. Timely review of the patient's response to medical therapies (eg. 2-4 weeks Z after drug initiation) is recommended.ES a Soe seen eee Oe een Cena ‘ere eccenciincra/peiaines: |fursoean Heart Journal 2039; 0.1093/eurheari/ahot25) Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Anti-ischaemic drugs (2) cersog Recommendations feb] (et Angina relief ‘Short-acting nitrates are recommended far immediate relief of etfort angina. irstine treatment is indicated with beta-blockers and/or CCBs to contral heart rate Hi | and symptoms. Ifarginasymptoms are not successfully controlled on a beta-blacker or a CCB, the a z combination of a beta-blocker with a DHP-CCB should be considored. first-line treatment with the combination of a heta-blocker and a DHP-CCR should Init be considered. Long-acting nitrates should be consideredas a second-line treatment option when initial therapy with a beta-blocker and/or a non-DHP-CCB is contraindicated, poorly tolerated, orinadequate to control angina symptoms, ‘When long-acting nitratas are prescribed, a nitrate-free or low-nitrate interval should be considered to reduce tolerance.wwrw escardio.org/ guidelines DE RAR EINE OnINe SiamnOS TEE EMETL OT TONE RIOT SITERENES = ag, |fursoean Heart Journal 2059; 10.1093/eurheari/*hat25) Patients with angina and/or dyspnoea and coronary © ESC artery disease - Anti-ischaemic drugs (3) European Sockty of Cardiciogy Class Level Nicorandil, ranolazing, ivabradine, or trimetazidine should be considered as asecond- line treatment to reduce angina frequency and improve exercise tolerance in subjects who cannot tolerate, have contraindications to, or whose symptoms are not adequately controlled by beta-blockers, CCBs, and long-acting nitrates, Insubjects with baseline low heart rate and low BP, ranolazine or trimetazidine may be considered as 2 first-line drug to reduce angina frequency and improve exercise © tolerance. Inselected patients, the combination of a beta-blocker or a CCB with second: edrugs (ranolazine, nicorandil, ivabradine, and trimetazidine) may be considered for first-line treatment according to heart rate, BP, and tolerance. Nitrates are not recommended in patients with hypertrophic obstructive cardiomyopathy and co-administration of phosphodiesterase inhibitors.www escardia org/guidetines, ESC. Guidelines. onthe diagnosisand management of chronic coronary syndromes 0 |furopean ear Journal 2039; 10.1093/eurhearti/eha25) Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Event prevention (1) pean scty Recommendations Class | Level Antithrombotic therapy in patients with CCS and in sinus rhythm Aspirin 75-400 mg daily is recommended in patients with a previous MI or revascularization. Clopidogrel 75 mg daily is recommended as an alternative to aspirin in patients with aspirin intolerance. Clopidogrel 75 mg daily may be considered in preference to aspirin in symptomatic or asymptomatic patients, with either PAD or a history of ischaemic stroke or transient ischaemic attack. = . Aspirin 75-100 mg daily may be considered in patients without a history of MI or revascularization, but with definitive evidence of CAD on imaging, | ewurw escardio.org/ guidelines ESC Guidelines onthe diagnosis and manager |Furspean Heart Journ 920.1093 eutheari/ehe#25) Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Event prevention (2) srearicogr Recommendations Claes Level Antithrombotic therapy in patients with CCS and in sinus rhythm ‘Adding a second antithrombotic drug to aspirin for long-term secondary prevention should be considered in patients with high risk of ischaemic events? and without high bleeding risk® ‘Adding a second antithrombotic drug to aspirin for long-term secondary prevention may ke considered in patients with at least a moderately increased risk of ischaemic events* and without high bleeding risk” *DiusemultvesmicA0 wh at lentorectzhefelowing iabetesmettusrequting medication recurrer Mi, FAO, orCXO with \GFR 25-53 m/min V.73 = br himaryaf resematraFnerrhaos.rtchaavis cai hit of cena satan pathology, raceregacrcorec'nabimeding or =rson custo possibagacrorvestra bissdloes other gaarontenna pat nleg aren: aeedw'h inermcesbladingri, iyer'iire bleeding disreceorceaa.cr=h, frvame cidageos ray, orenafsiure ecu dajesor nitheGFR <1 mlmin/t 72m “at ieam one oftnefolewrg: mutivese suse CAD, innetes velitucrequing esiation recurert WI PAD, Mr erCXO wth GRAS £9 m/min/L73m2wun escardio org/ guidelines ESC Guidelines onthe diagnosisend menagemert of chronic coronary syndromes, |furgoean Heart Journal 2039; 0.1093/eurheari/*hot25) Patients with angina and/or dyspnoea and coronary @eEsc artery disease Treatment options for dual antithrombotic therapy Drug option Clopidogrel Prasugrel Rivaroxaban Ticagrelor Dose 75 mg o.d. 10 mg o.d. or 5 mg od. if body weight <80 kg or age>75 years: 2.5 mg bid. 60 mg b.id. Indication Post-MI in petientswho have tolerated DAPT for 1 year Post-PCI for MI in patients who have tolerated DAPT for 1 year Post-Mi >1 year or multivessel cAD Post-MI in patients who have tolerated DAPT for 1 year European Society of cardiciogy Additional cautions Age >75 years eGFR 15-79 ml/min/1.73 m?wove escardiorg/guidelines ESC Guidelines ontne diagnosisand management of crronic coronary syndromes 3 |fursoean Heart Journal 2059; 10.1093/eurheari/*ha25) a Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Event prevention (3) aerscog Recommendations Class Level Antithrombotic therapy post-PCl in patients with CCS and in sinus rhythm Aspirin 75-100 mg daily is recommended following stenting. Clopidogrel 75 mg daily following appropriate loading (e.g. 600 mg ar >5 days of maintenance therapy) is recommended, in addition to aspirin, for 6 months following coronary stenting, irrespective of stent type, unless a shorter duration (1-3 months) is indicated due to risk or the occurrence of life-threatening bleeding. Clopidogrel 75 mg daily following appropriate loading (e.g. 600 mg ar >5 days. of maintenance therapy) should be considered for 3 months in patients with e ahigher risk of life-threatening bleeding.wow escardin.org/guidelines ESC Guilgelines onthe diagnosis2nd menagemert of chronic coronary syndromes 39; 10.1093/eurheari/*hat25) Patients with angina and/or dyspnoea and coronary artery disease - Event prevention (4) Recommendations Antithrombotic therapy post-PCl in patients with CCS and in sinus rhythm Clopidogrel 75 mg daily following appropriate loading (e.g. 600 mg or >5 days of maintenance therapy) may be considered fer 1 month in patients with very high risk of life-threatening bleeding. Prasugrel or ticagrelor may he considered, at least as therapy, in specific high-risk situations of elective stenting (e.g. suboptimal stent deployment or other procedural characteristics associated with high risk of stent thrombosis, complex left main stem, or multivessel stenting) or if DAPT cannot be used because of aspirin intolerance. @eEsc jupean Society of Cardiciogy Class Level‘www escerdio org/ guidelines ESC Guidelines onthe Giagnosisand menagemerc of chronic coronerysyndromes 5, |fursoean Heart Journal 2039; 10.1093/eurheari/#ha25) Patients with angina and/or dyspnoea and coronary @ ESC European Society artery disease - Event prevention (5) nangeet Recommendations: Class Level Antithrombotic therapy in patients with CCS and AF When oral anticoagulation Is initiated ina patient with AF who is eligible for a NOAC,? 3 NOAC is recommended in preference to a VKA. Long-term OAC therapy (NOAC or VKA with time in therapeutic range >70%) is recommended in patients with AF and a CHA,DS,-VASc score® =? in males and >3 in females. *SeeSummen offredus Charactersice for educeddace orcontinditersfo' exhIIONC in pitiets wthCID, bocy weight-S0lg,age°TS-£0ye=, andi Scongestre!, bypacersien,2g2275yeor(? pots), dieicie wis suele/tamia interne tz\/=rius(2 poi vac cieme|CAD aniniagingr tngiogeoiy pier Mi PAD, 2 Plaque) ogc6-75 yeas and feraieaeESC Guidelines onthe dlagnosis2nd menagemerc of chronic coronary syndromes, ‘won escerdio org/quidetines |fursoean Heart Journal 2039; 10.1093/eurheari/ahat25) Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Event prevention (6) Eves Sait Recommendations Class Level Antithrombotic therapy in patients with CCS and AF Long-term OAC therapy (NOAC or VKA with time in therapeutic range >70%) should be considered in patients with AF and 2 CHA,DS,-VASc score* of 1 in males and 2 in females. Aspirin 75-100 mg daily (or clopidogrel 75 mg daily) may be considered in adcition to long-term OAC therapy in patients with AF, history of Ml, and at high risk of recurrent ischaemic events? who do not have a high bleeding tisk© *Congesever= Nene 5625 vats) sores abate pr pole Vansent irae stat/arbhis(? por va cies H0 on magne anpomaohy,prierM),PtO, ar sancelague) age€=-7é years a iDintss mubvesna (Ab wht earonectinatalovig cater tng mesiatin, ecurentil PAD, orCKO wth aGF225-58m_/mn/LI3M Sbriorhitay st ntatetraltserertagecr sheer tela nazin/c* she inravans paul, "ees gaarcintenirl eco or angen aduet sevesrralbiood ex ota ganromenina fat og sesorareowt ireresceaDescingrit ineriiurepeccingesneczorcanevoosthy, gage orfraiy,orravaitolur equrng dinjasar ithe “SE mm/s TOP z‘wiv escardioorg/quidetines ESC Guivelines onthe olagnosisenamenagemert of ctyonic coronéry syndromes 7 |furspean Heart Journal 2059; 10.1093/eurheari/*hat25) Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Event prevention (7) Eran scty Recommendations Ces Ga Antithrombotic therapy in post-PCI patients with AF or another indication for an OAC Itis recommended that peri-procedural aspirin and clopidogrel are administered to patients undergoing coronary stent implantation il E In patients who are eligible for a NOAC, it is recommended that a NOAC (apixaban 5 mg bi.d,, dabigatran 150 mg b.i.d., edoxaban 60 mg o.d,, or rivaroxaban 20 mg 0.4)? is used in preference toa VKA in combination with antiplatelet therapy.ESC quicelines onthe ciagosisendmenegemerr otctroniccoronerysyneromes 4a, wor esate ora/guidelines |fursoean Heart Journal 2039; 10.1093/eurheari/*hat25) Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Event prevention (8) aroma Recommendations Sctiss] [set Antithrombotic therapy in post-PCI patients with AF or another indication for an OAC When rivaroxaban is used and concerns about high bleeding risk* prevail over concerns about stent thrambasis* or ischaemicstroke,® rivaroxaban 15 mg o.d, should be considered in preference to rivaroxaban 20 mg o.d. for the duration of concomitant single or dual antiplatelet therapy. When dabigatranisused and concerns ahout high bleeding risk? prevail over concerns, about stent thrombosis® or ischaemicstroke,“ dabigatran 110mg b.i.d, should be considered in preference to dabigatran 150 mg b.i.d. tor the duration of concomitant single or dual antiplatelet therapy death spoudstentnvemone cur bot of viet rite‘wor escediocra/guidetines SC Guidelines onthe Giagnosisendmensgewers ofctroniccoronérysyeromes 4) |furspean Hear Journal 2039; 0.1093/eurhesri/*hat25) Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Event prevention (9) Eran scty Recommendations Class Level Antithrombotic therapy in post-PCI patients with AF or another indication for an OAC After uncomplicated PCI, early cessation (<1 week) of aspirin and continuation of dual therapy with an OAC and clopidogrel should be considered if the risk of stent thrombosis? is low, or If concerns about bleeding risk prevail aver concerns about the risk of stent thrombosis, Irrespective of the type of stent used. ‘Triple therapy with aspirin, clopidogrel, and an OAC for 21 month should be considered when ‘the risk of stent thrombosis outweighs the bleeding risk, with the total duration (<> months] c decided according to assessment of these risks and clearly specified at hospita! discharge. fication for a VKA in combination with aspirin and/or dlopidogrel, the dose intensity of the VKA should be carefully regulated with a target international normalized ratlo in the range of 2.0-2 5 and with time in therapeutic rang> 97056‘won escedioora/guidelines ESC Guloelines onthe ciagnos'send managerert ofctronic coronary syraromes [European Heart Journal 2019; 10.1093/eurheertj/ehs425) 59, Patients with angina and/or dyspnoea and coronary @eEsc artery disease - Event prevention (10) Saupe Sock Recommendations Class Level Antithrombotic therapy in post-PCI patients with AF or another indication for an OAC Dual therapy with an OAC and either ticagrelor or prasugrel may be considered as an alternative to uiple therapy with an OAC, aspirin, and clopidogrelin patients 2 with a moderate or high risk of stent thrombosis,’ irrespective of the type of stent used. The use of ticagrelor or prasugrel is notrecommended as part of triple e antithrombotic therapy with aspirin and an OAC.‘wor escatsioora/guideines ESC Guidelinesontne clagrosisenamenegenert of chronic coronerysyndomnes 4 |fursoean Heart Journal 2039; 10.1093/eurheari/*hat25) Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Event prevention (11) Gepessicite Concomitant use of a proton-pump inhibitor is recommended in patients receiving aspirin monotherapy, DAPT, or OAC monotherapy who are at high risk of gastrointestinal bleeding.ie ‘wor escraioorg/guideines FSC Gulvelines onthe clagnosisend menagemert ofetronic coronary syndromes |fursoean Heart Journal 2059; 10.1093/eurheori/ehs25) Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Event prevention (12) pias ‘Recommendations Class Level Lipid-lowering drugs Statins are recommended in all patients with CCS. Ifa patient's goals not achieved with the maximum tolerated dose of statin, ic | Bi combination with ezetimibe is recommended. For pationts at very high risk who do not achiove thair goal on a maximum tolorated dose of statin and ezetimibe, a combination with a PCSK9 inhibitor is recommended. ACEinhibitors ACEinhibitors (or ARBs) are recommended if a patient has other conditions (e.g. heart failure, hypertension, or diabetes). ACE inhibitors should be considered in CCS patients at very high risk of cardiovascular = By events. 4i ‘won esctciocrg/guideines ESC Gulselines onthe iagnosisend managemercotchroniccoronerysyneromes 3 |fursoean Heart Journal 2039; 10.1093/eurheari/aho25) Patients with angina and/or dyspnoea and coronary @ ESC artery disease - Event prevention (13) sreadtogy Recommendations es a ‘Other drugs Beta-blockers are recommended in patients with LV dysfunction or systolic HF. In patients with a previous STEMI, long-term oral treatment with a beta- blocker should be consideredSC Guidelines onthe dlagnosisendmensgewert ofchroniccoronéry syndromes ay ‘wo scr orgudelines a [European Heart Journs! 2019; 10.1093/eurheertj/shs425) Patients with angina aa @ESC and/or dyspnoea sec and coronary artery = a disease Ea Decision tree for patients undergoing invasive coronary angiography Diameter Siemiter i cas =a ree OE rene — ene acer (eee resmayeir a es fees etewowene ee co Wrens ee an wsrane cre Mvb= nultwesset demea: won escrciocrg/guideines SC Gulselines onthe wiagnosisend menegerert of chronic coronery syndromes |furgpean Heart Journal 2039; 10.1093/eurheari/*hat25) P Patients with new onset of heart failure or reduced @ ESC left ventricular function Spenser Recommendations for drug therapy (1) Recommendations Class Level Diuretictherapyisrecommended in symptomatic patients with signs of pulmonary Hl | | or systemic congestion to relieve HF symptoms. Beta-blockers are recommended as essential components of treatment due to their efficacy in both relieving anging, and reducing morbidity and mortality inHiF. ACE inhibitor therapy is recommendedin patients with symptomatic HF or asymptomaticLV dysfunction following MI, to improve symptoms and reduce morbidity and mortality. An ARB is recommendedas an alternative in patients who do not tolerate ACE inhibition, or an angiotensinreceptor-neprilysin inhibitor in patients with persistent symptoms despite optimal medical therapy.° ‘won esctcoorg/guidelines SC Gulvelinesontie ciagnosisend menagemertofchroriccoronerysynaromes |furgoean Heart Journ 0.1093 eutheeri/ehst25) Patients with new onset of heart failure or reduced @ ESC left ventricular function Smpepr sity Recommendations for drug therapy (2) Recommendations Class Level A short-acting oral or transcutaneous nitrate should be considered (affective antianginal treatment, safe in HF). Wabradine shouldbe considered in patients with sinus rhythm, an LVEF £35% and a resting heart rate>70 b.p.m. who remain symptomatic despite adequate ‘treatment with a beta-blocker, ACE inhibitor, and MRA, to reduce morbidity and mortality An MRA is recommended in patients who remain symptomatic despite adequate treatment with an ACE inhibitor and beta-blocker, to reduce morbidity and mortality. Amlodipine may be considered for relief of angina in patients with HF who do not tolerate beta-blockers, and is considered safe in HF.° ‘wor escatéiocra/guidelines SC Gulvelines onthe ciagnosisend menagemertotctroric coronary syndromes |fursoean Heart Journal 2039; 10.1093/eurheari/ahat25) Patients with new onset of heart failure or reduced © ESC left ventricular function Siope sey Devices, comorbidities and revascularization (1) Recommendations Class Level” In patients with HF and bradycardia with high-degree atrioventricular block who require pacing, a CRT with a pacemaker rather than right ventricular pacing is recommended. An implantable cardioverter-defibrillator is recommended in patients with documented ventricular dysthythmia causing haemodynamic instability (secondary prevention), as well as in patients with symptomatic HF and an LVEF <35%, to reduce the risk of sudden death and all-cause mortality. CRT is recommended for symptomatic patients with HF in sinus rhythm with a QRS duration >150 ms and LEBB QRS morphology, and with LVEF <35%, despite optimal medical therapy to improve symptoms, and reduce morbidity and mortality.er ‘won escediocre/guidelines FSC culdelines onthe eiagnasisandmanagemers otchraviccoronarysynavames a. |furgpean Heart Journal 2039; 40.1093/eurheari/2ho425) Patients with new onset of heart failure or reduced @ ESC left ventricular function Spas sits Devices, comorbidities and revascularization (2) Recommendations Class Level CRT is recommended for symptomatic patients with HF in sinus rhythm with a QRS duration 130-149 ms and LBBB QRS morphology, and with LVEF <35%, despite optimal medical therapy to improve symptoms, and reduce morbidity and mortality. Comprehensive risk profiling and multidisciplinary management, induding treatment of major comorbidities such as hypertension, hyperlipidaemia, diabetes, anaemia, and obesily, as well as smoking cessetion and lifestyle modification, are recommended Myocardial revascularization is recommended when angina persists despite treatment with antianginal drugsESC quidetinesonthe clagnosisend menegemere of ctroniccoronerysyndromes 5g acl [European Heart Journs! 2019, 10.1093 /eurheertj/ehs425) Patients with a long- @ESC standing diagnosis of Saya ety chronic coronary 3 syndromes i ' Follow-up (1) Time for decision making on optional © sisi ancencomaoscherary Time for decision making o7 DAPT © cortinenon in PG patients © siisatetimepint © oxtiotttmercin “The raquencyoffollowapmarbesubjetovaratonbasedon inl udgerere. $cerdiciogis rent, generpracttoner,orcerdevaclar°® SC Gulselines ont ciagnos'send manegerert of cron coronary syndromes |fursoean Heart Journal 2039; 40.1093/eurheari/*hat25) @eEsc Patients with a long-standing diagnosis of chronic coronary syndromes - Follow-up (2) oreracogr 60 ‘wor escatsiocra/guidelines Carer at rest Coes eee Cee) h crye ‘won esctaiaorg/guideines SC Gulselines onthe ciagnos'send managerert oftronic coronary syndromes |Fursoean Heart Journal 2039; 10.1093/eurheari/ahs25) Patients with a long-standing diagnosis of chronic @ ESC coronary syndromes - Asymptomaticpatients ope soy Recommendations Class Level A periodicvisit to a cardiovascular healthcare professional is recommended to. reassess any potentialchange in the risk status of patients, entailing clinical evaluation of lifestyle mocification measures, adherence to targets of cardiovascular risk factors, and the development of comorbidities that may affect treatments and outcomes. In patients with mild or nosymptoms receiving medical treatment in whom non Invasive risk stratification indicates ahigh risk, and for who revascularization is considered for improvement of prognosis, invasive coronary angiography (with FFR when necessary) is recommended. Coronary CTAis not recommended as a routine fallow-up test for patients with established CAD. ° Invasive coronary angiggraphyis not recommended solely for risk stratification.e Solaire bees SC Guidelines onthe dlagnosisandmanagemers otchroniecoronarysyrerames a |furopean Heart Journal 2039;10.1093/eurheari/2ho425) Patients with a long-standing diagnosis of chronic @eEsc coronary syndromes - Symptomatic patients Sappeet Sige Recommendations Class Level Reassessment of CAD status is recommended in patients with deteriorating LV systolic function that cannot be attributed to a reversible cause (2.g. long- c standing tachycardia or myocarditis). Risk stratification is recommended in patients with new or worsening symptom levels, preferably using stress imaging or, alternatively, exercise stress ECG, Al © Itis recommended to expeditiously refer patients with significant worsening of symptoms for evaluation. Invasive coronary angiography (with FFR/iwFR when necessary) is recommended for risk stratification in patients with severe CAD, particularly if the symptoms are refractory to medical treatment or if they have a high- risk clinical profilee ‘wor scarce cra/guidetines SC Gulselines one Giagnos'send menagerert ofctronic coronary syraromes |fursoean Heart Journal 2059; 40.1093/eurheari/*hat25) Angina without obstructive disease in the epicardial @ ESC coronary arteries - Microvascular angina oe Recommendations ae STS with preserved iwER/FFR. Intracoronary acetylcholine with ECG monitoring may be considered during angiography, if coronary arteries are either angiographically normal or fave moderate stenoses with preserved iwFR/FFR, to assess microvascular ‘vasospasm. Guidewire-based CFR and/or microcirculatory resistance measurements should be considered in patients with persistent symptoms, but coronary arteries that are either angiographically normal or have moderate stenoses Transthoracic Doppler of the LAD, CMR, and PET may be considered for non- invasive assessment of CFR.