Speakers name: Thomas Cuisset, MD, PhD X I have the following - - PowerPoint PPT Presentation

ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425) www.escardio.org/guidelines

Speaker’s name: Thomas Cuisset, MD, PhD X I have the following potential conflicts of interest to report: Consulting and/or lecture fees: Abbott Vascular, Astra Zeneca, Boston Scientific, Crossroad Institute, Edwards, Europa Organisation, Medtronic, Terumo, Sanofi

2019 ESC Guidelines on the diagnosis and management of chronic coronary syndromes

Thomas CUISSET CHU Timone, Marseille

« Messages clés »

ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425) www.escardio.org/guidelines

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2006 Stable Angina 2013 Stable Coronary artery disease 2019 Chronic coronary syndromes

ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425) www.escardio.org/guidelines

Chronic coronary syndrome Acute Coronary Syndrome

One disease, two presentations

Planned patient Outpatient clinic Non invasive testing Risk = long term mortality Urgent admission Hospitalisation Coronary angiography Risk = short term mortality

ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425) www.escardio.org/guidelines

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Diagnosis of CCS

ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425) www.escardio.org/guidelines

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Pre Test Probability (Age, sex symptom) Risk Factors, ECG, calcium score Clinical likehood of CAD Choice of diagnosis modality

ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425) www.escardio.org/guidelines

Performance of Tests

A Test results

Clinical Likelihood of ICA-significant CAD

0% 50% 100%

+

• +
• +
• +
• +
• +
• Stress ECG

Coronary CTA Stress CMR Stress Echocardiography SPECT PET

15% 85% 85% Clinical Likelihood range where test can rule-in CAD (Post-test probability will rise above 85%)

Ranges of clinical likelihood for rule-in/out CAD

Clinical Likelihood range where test can rule-out CAD (Post-test probability will drop below 15%)

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ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425) www.escardio.org/guidelines

Choice of test for each patient

Offer diagnostic testing No diagnostic testing mandated Coronary CTA f Choice of test based on clinical likelihood, patient characteristics and preference, availability, as well as local expertise d Invasive angiography (with iwFR/FFR)

e

Testing for ischaemia (imaging testing preferred) Clinical likelihood of obstructive CAD Very high Very low 8

Management of Chronic coronary syndrome

Management of Symptom ‘Angina’ Management of CAD ‘Event prevention’

Anti-ischemic drug Revascularisation Prevention Life style Medications

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Anti-ischemic drugs

BB and CCB as first-line tailored to patient Long acting Nitrates as second line Others

Antithrombotic Strategy

DAPT for CCS

ASA lifelong (IA) When to do « less »?

Standard

When to do « more » ?

No Antiplatelet drug if OAC indication OAC + APLT drug in selected pt (IIb) Optimized antithrombotic strategy ASA + Second Drug High Risk patient (IIa) Intermediate risk (IIb)

Or Clopidogrel

If ASA intolerance (Ia) If prior PAD / Stroke (IIb)

DAPT after DES for CCS

ASA + Clopidogrel (IA) When to do « less »?

Longer duration > 6 Mo in High risk patients (IIa)

Standard post PCI

When to do « more » ?

Shorter duration 3 Mo in HBR patients (IIa) 1 Mo in very HBR patients (IIb) Early Potent P2Y12 blockers Ticagrelor or Prasugrel (IIb) In High risk patients / PCI Followed by de-escalation

Duration = 6 Mo (IA)

DAPT after DES for CCS with OAC

ASA + Clopidogrel (I) When to do « less »?

Dual therapy OAC + Tica / Prasu (IIb)

Standard post PCI

When to do « more » ?

Shorter Triple therapy (IIa) Reduced Dose of NOAC (IIa) Dabigatran, Rivaroxaban Longer triple therapy up to 6 Mo (IIa)

Triple therapy Full dose NOAC (I) 1 Month (I)

High ischemic risk High Bleeding risk

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Lipid-lowering drugs

High Dose Statin / New target Add Ezetimibe if needed Consider PCSK9i if needed in High-risk Pt

Poor Secondary Event Prevention

Atheroscerosis CAD Atherothrombotic events ACS / Arrythmias / Sudden Death

Years

Atheroscerosis CAD Atherothrombotic events ACS / Arrythmias / Sudden Death

Years

Good Secondary Event Prevention

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Revascularisation in CCS

No Major change from earlier guidelines Revascularisation based on symptom / ischemia Value of FFR if stenosis < 90% and No ischemia No Major change after ISCHEMIA trial ?

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Messages clés

New title = Chronic coronary syndrome Screening: more CT / Less stress ECG / based on PTP Anti-ischemic drugs: BB and CCB / Nitrates as second line Event prevention Life style recommendations Optimized antithrombotic strategy in high-risk patients Optimized lipid-lowering therapy in high-risk patients Revascularisation for symptom +/- prognosis in high-risk pt Follow-up yearly …. And …

Optimized event prevention in high risk patient

Optimized Antithrombotic strategy (IIaA recommendation) Ticagrelor 60 mg (PEGASUS): No reimbursement Rivaroxaban 2,5 mg (COMPASS): No reimbursement Optimized lipid-lowering therapy (IA recommendation) AntiPCSK9 = class IA in high-risk patient (FOURRIER, ODYSSEY): ASMR 5

How to apply guidelines with local constraint ?

ESC Guidelines on the diagnosis and management of chronic coronary syndromes (European Heart Journal 2019; 10.1093/eurheartj/ehz425) www.escardio.org/guidelines

www.escardio.org/guidelines Full Text ESC Pocket Guidelines App and much more…

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