Ischemic Heart Disease (Chronic Coronary Syndromes) — Management Guideline
Source: ESC Guidelines for the Management of Chronic Coronary Syndromes, European Heart Journal, 2024
Guideline: Strong
Guideline: Conditional
Guideline: Not recommended
ClinicoQ pathway suggestion (not from the cited guideline)
Diagnosis
Diagnostic criteria
Suspected chronic coronary syndrome is evaluated with a pretest probability assessment followed by noninvasive anatomic or functional imaging to confirm obstructive coronary artery disease.
⚠ Alarm features (investigate before diagnosing)
- Rest angina or a crescendo pattern (suspected acute coronary syndrome — refer emergently)
- Angina with hemodynamic instability or syncope
- New heart failure symptoms
- Significant ECG changes suggesting active ischemia
Initial workup
| Test | When to order |
|---|---|
| Resting ECG | In all patients with suspected CCS at initial evaluation. |
| Noninvasive anatomic or functional imaging | First-line diagnostic testing, based on pretest likelihood of obstructive CAD. |
| Fasting lipid panel | At diagnosis, to guide lipid-lowering therapy intensity. |
| Deferral of further testing | Very low pretest likelihood (≤5%) of obstructive CAD. |
Treatment
Lipid management (all patients)
1
High-intensity statin (e.g., atorvastatin)
Strong (Guideline recommendation) — target LDL-C below 1.4 mmol/L (54 mg/dL) with ≥50% reduction from baseline
- Dose
- 40–80 mg once daily, maximum tolerated dose
- Duration
- Ongoing
- Evidence level
- High
- Avoid if
- Active liver disease; history of statin intolerance/myopathy
- If no response ClinicoQ pathway
- Add ezetimibe if the LDL-C target isn't met
2
Add ezetimibe
Strong (Guideline recommendation), if LDL-C target not met on statin alone
- Dose
- 10 mg once daily
- Duration
- Ongoing
- Evidence level
- High
- Avoid if
- —
- If no response ClinicoQ pathway
- Add bempedoic acid or a PCSK9 inhibitor
Antianginal therapy
1
Beta-blocker and/or calcium channel blocker
Strong (Guideline recommendation) — first-line for symptom control
- Dose
- e.g., bisoprolol 2.5–10 mg once daily, or amlodipine 5–10 mg once daily
- Duration
- Ongoing
- Evidence level
- High
- Avoid if
- Severe bradycardia, decompensated heart failure (beta-blockers); significant peripheral edema (CCBs)
- If no response ClinicoQ pathway
- Add a third antianginal agent only if symptoms remain uncontrolled and revascularization is unsuitable or pending
Antithrombotic therapy (secondary prevention)
1
Aspirin
Strong (Guideline recommendation) — for prior MI, PCI, or significant obstructive CAD
- Dose
- 75–100 mg once daily
- Duration
- Lifelong
- Evidence level
- High
- Avoid if
- Active bleeding; aspirin allergy
- If no response ClinicoQ pathway
- Clopidogrel 75 mg once daily as an alternative
⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.