Chronic coronary syndromes: Latest ESC recommendations and current insights from the literature

Heart, Vessels and Transplantation · Published 2026-03-26 · DOI 10.24969/hvt.2026.638

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Abstract

The European Society of Cardiology (ESC) 2024 guidelines on chronic coronary syndromes (CCS) defines this condition slightly differently compared to what was defined in previous guidelines. As per the ESC 2019 guidelines, CCS were defined as the stable phases of the coronary artery disease (CAD), either preceding an acute coronary syndrome (ACS) or following an ACS. The definition in ESC 2024 guidelines not only includes the disease of the major arteries of the coronary circulation but also considers the microcirculation. Another important differentiation is that it takes into account not only the structural alterations in the arteries as defined by the ESC 2019 guidelines, but includes the functional alterations in the microvasculature, which may cause different manifestations such as angina, dyspnea mostly precipitated by stress and may even progress to cause the ACS, coronary microvascular dysfunction (CMD) that is increasingly recognized as a common contributor to the entire spectrum of CCS. Functional and structural abnormalities in the coronary microcirculation can lead to angina and ischemia, even in patients who do not have significant blockages in their larger coronary arteries. This condition is classified as angina with non-obstructive coronary arteries (ANOCA) or ischemia with non-obstructive coronary arteries (INOCA). These microvascular issues are important in explaining symptoms in patients without major artery obstruction. The aim of our review is to discuss the main updates in the management of the CCS and their rationale, and to compare the differences in various aspects of between ESC 2019 and ESC 2024 guidelines. Moreover, we present a review of the current knowledge of the topic.

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Year
2026

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