Abstract
The European Society of Cardiology (ESC) has recently published new guidelines on the diagnosis and management of chronic coronary syndromes (CCS). Due to variable symptoms, objective tests are often necessary to confirm the diagnosis, exclude alternative diagnoses, and assess the severity of underlying disease. This review provides a summary of the main diagnostic strategies listed in the guidelines for evaluation of patients suspected of having obstructive coronary artery disease (CAD). Based on data from contemporary cohorts of patients referred for diagnostic testing, the pre-test probabilities of obstructive CAD based on age, sex, and symptoms have been adjusted substantially downward compared with the previous guidelines. Further, a new concept of “clinical likelihood of CAD” was introduced accounting for the impact of various risk factors and modifiers on the pre-test probability. Noninvasive functional imaging for myocardial ischemia, coronary computed tomography angiography, or invasive coronary angiography combined with functional evaluation is recommended as the initial strategy to diagnose CAD in symptomatic patients, unless obstructive CAD can be excluded by clinical assessment alone. When available, imaging tests are recommended as noninvasive modalities instead of exercise electrocardiograms.
Highlights
The European Society of Cardiology (ESC) recently published the 2019 ESC guidelines on the diagnosis and management of chronic coronary syndromes (CCS; [1])
The term “chronic coronary syndromes” emphasizes the fact that despite stable symptoms, coronary artery disease (CAD) is a dynamic process of atherosclerotic plaque accumulation and functional alterations of coronary circulation that can be modified by lifestyle, pharmacological therapies, and revascularization, which may result in disease stabilization or regression [1]
A pooled analysis [6] of three contemporary study cohorts including patients evaluated for suspected CAD [7,8,9] indicates that the pre-test probability (PTP) based on age, sex, and nature of symptoms in current patients is approximately one third of that predicted by the model used in the 2013 version of the ESC guidelines [10, 11]
Summary
The European Society of Cardiology (ESC) recently published the 2019 ESC guidelines on the diagnosis and management of chronic coronary syndromes (CCS; [1]). A pooled analysis [6] of three contemporary study cohorts including patients evaluated for suspected CAD [7,8,9] indicates that the PTP based on age, sex, and nature of symptoms in current patients is approximately one third of that predicted by the model used in the 2013 version of the ESC guidelines [10, 11]. Clinical models that incorporate information on risk factors for cardiovascular disease, resting electrocardiogram (ECG) changes (Q-wave and changes in ST-segment or T-wave), LV dysfunction suggestive of CAD, findings of exercise ECG or coronary calcification provide improved identification of patients with obstructive CAD compared with age, sex, and symptoms alone [13,14,15,16].
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