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2019 ESC Guidelines for the Diagnosis and Management Of ESC GUIDELINES European Heart Journal (2020) 41, 407À477 doi:10.1093/eurheartj/ehz425 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC) Downloaded from https://academic.oup.com/eurheartj/article/41/3/407/5556137 by guest on 03 September 2020 Authors/Task Force Members: Juhani Knuuti* (Finland) (Chairperson), William Wijns* (Ireland) (Chairperson), Antti Saraste (Finland), Davide Capodanno (Italy), Emanuele Barbato (Italy), Christian Funck-Brentano (France), Eva Prescott (Denmark), Robert F. Storey (United Kingdom), Christi Deaton (United Kingdom), Thomas Cuisset (France), Stefan Agewall (Norway), Kenneth Dickstein (Norway), Thor Edvardsen (Norway), Javier Escaned (Spain), Bernard J. Gersh (United States of America), Pavel Svitil (Czech Republic), Martine Gilard (France), David Hasdai (Israel), Robert Hatala (Slovak Republic), Felix Mahfoud (Germany), Josep Masip (Spain), Claudio Muneretto (Italy), Marco Valgimigli (Switzerland), Stephan Achenbach (Germany), and Jeroen J. Bax (Netherlands) Document Reviewers: Franz-Josef Neumann (Germany) (CPG Review Coordinator), Udo Sechtem (Germany) (CPG Review Coordinator), Adrian Paul Banning (United Kingdom), Nikolaos Bonaros (Austria), He´ ctor Bueno (Spain), Raffaele Bugiardini (Italy), Alaide Chieffo (Italy), Filippo Crea (Italy), Martin Czerny (Germany), Victoria Delgado (Netherlands), Paul Dendale (Belgium), * Corresponding authors: Juhani Knuuti, Department of Clinical Physiology, Nuclear Medicine and PET and Turku PET Centre, Turku University Hospital, Kiinamyllynkatu 4-8, FI- 20520 Turku, Finland. Tel: þ358 500 592 998, Email: juhani.knuuti@tyks.fi. William Wijns, The Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway, University Road, Galway, H91 TK33, Ireland. Tel: þ353 91 524411, Email: [email protected]. Author/Task Force Member Affiliations: listed in the Appendix. ESC Committee for Practice Guidelines (CPG) and National Cardiac Societies document reviewers: listed in the Appendix. ESC entities having participated in the development of this document: Associations: Acute Cardiovascular Care Association (ACCA), Association of Cardiovascular Nursing & Allied Professions (ACNAP), European Association of Cardiovascular Imaging (EACVI), European Association of Preventive Cardiology (EAPC), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA). Councils: Council for Cardiology Practice. Working Groups: Atherosclerosis and Vascular Biology, Cardiovascular Pharmacotherapy, Cardiovascular Surgery, Coronary Pathophysiology and Microcirculation, Thrombosis. The content of these ESC Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be trans- lated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC ([email protected]). Disclaimer. The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge, and the evidence available at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy, and/or ambiguity between the ESC Guidelines and any other official recom- mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour- aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic, or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. VC The European Society of Cardiology 2019. All rights reserved. For permissions please email: [email protected]. 408 ESC Guidelines Frank Arnold Flachskampf (Sweden), Helmut Gohlke (Germany), Erik Lerkevang Grove (Denmark), Stefan James (Sweden), Demosthenes Katritsis (Greece), Ulf Landmesser (Germany), Maddalena Lettino (Italy), Christian M. Matter (Switzerland), Hendrik Nathoe (Netherlands), Alexander Niessner (Austria), Carlo Patrono (Italy), Anna Sonia Petronio (Italy), Steffen E. Pettersen (United Kingdom), Raffaele Piccolo (Italy), Massimo Francesco Piepoli (Italy), Bogdan A. Popescu (Romania), Lorenz Raber€ (Switzerland), Dimitrios J. Richter (Greece), Marco Roffi (Switzerland), Franz X. Roithinger (Austria), Evgeny Shlyakhto (Russian Federation), Dirk Sibbing (Germany), Sigmund Silber (Germany), Iain A. Simpson (United Kingdom), Miguel Sousa-Uva (Portugal), Panos Vardas (Greece), Adam Witkowski (Poland), Jose Luis Zamorano (Spain) The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines Downloaded from https://academic.oup.com/eurheartj/article/41/3/407/5556137 by guest on 03 September 2020 For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the Guidelines see https://academic.oup.com/eurheartj/article-lookup/doi/ 10.1093/eurheartj/ehz425#supplementary-data Online publish-ahead-of-print 31 August 2019 ................................................................................................................................................................................................... Keywords Guidelines • chronic coronary syndromes • angina pectoris • myocardial ischaemia • coronary artery disease • diagnostic testing • imaging • risk assessment • lifestyle modifications • anti-ischaemic drugs • antithrombotic therapy • lipid-lowering drugs • myocardial revascularization • microvascular angina • vasospastic angina • screening . 3.1.6.1Definitionoflevelsofrisk .......................... 428 Table of contents . 3.2Lifestylemanagement....................................... 429 1.Preamble ...................................................... 411 . 3.2.1 General management of patients with coronary artery . 2.Introduction ................................................... 413 . disease...................................................... 429 2.1Whatisnewinthe2019Guidelines? ........................ 414 . 3.2.2 Lifestyle modification and control of risk factors . 429 . 3. Patients with angina and/or dyspnoea, and suspected . 3.2.2.1Smoking .......................................... 429 coronaryarterydisease........................................... 416 . 3.2.2.2Dietandalcohol................................... 430 . 3.1 Basic assessment, diagnosis, and risk assessment . 416 . 3.2.2.3Weightmanagement .............................. 430 . 3.1.1Step1:symptomsandsigns ............................. 417 . 3.2.2.4Physicalactivity.................................... 430 3.1.1.1Stablevs.unstableangina........................... 418 . 3.2.2.5Cardiacrehabilitation.............................. 430 . 3.1.1.2 Distinction between symptoms caused by . 3.2.2.6Psychosocialfactors ............................... 430 epicardial vs. microvascular/vasospastic disease . 419 . 3.2.2.7Environmentalfactors ............................. 431 . 3.1.2 Step 2: comorbidities and other causes of symptoms . 419 . 3.2.2.8Sexualactivity ..................................... 431 3.1.3Step3:basictesting..................................... 419 . 3.2.2.9Adherenceandsustainability ....................... 431 . 3.1.3.1Biochemicaltests .................................. 419 . 3.2.2.10Influenzavaccination.............................. 431 3.1.3.2 Resting electrocardiogram and ambulatory . 3.3Pharmacologicalmanagement............................... 432 . monitoring............................................... 420 . 3.3.1Anti-ischaemicdrugs ................................... 432 3.1.3.3 Echocardiography and magnetic resonance . 3.3.1.1Generalstrategy................................... 432 . imagingatrest............................................ 420 . 3.3.1.2Availabledrugs .................................... 432 3.1.3.4ChestX-ray....................................... 421 . 3.3.1.3Patientswithlowbloodpressure................... 435 . 3.1.4 Step 4: assess pre-test probability and clinical likelihood . 3.3.1.4Patientswithlowheartrate ........................ 435 ofcoronaryarterydisease ................................... 421
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