European Society of Cardiology Chronic Coronary Syndromes Guidelines Review

New guidelines for the diagnosis and management of chronic coronary syndromes (CCS)1were released during the 2019 European Society of Cardiology (ESC) Congress. The new guidelines were discussed in multiple sessions with different formats across the congress; this review summarises some of the discussion among experts at the congress around what the new guidelines mean for the way they manage their patients with respect to antithrombotic treatment. A significant change in the new guidelines versus previous guidelines published in 20132is an update in nomenclature from ‘stable’ coronary artery disease (CAD) to chronic coronary syndromes, to reflect the fact that patients with CCS are at continuous risk of heart attacks, strokes, and death. This highlights the need for effective preventive therapy to protect against these thrombotic events and maintain a state of relative stability in patients with CCS. To this end, a new recommendation in the 2019 guidelines is to consider intensification of antithrombotic therapy, using aspirin plus another antithrombotic agent, to provide enhanced long-term protection for patients with CCS at high risk of ischaemic events. This review places the new guideline recommendations in clinical perspective, including thorough presentations of case studies to illustrate how patients at greatest risk of ischaemic events can be identified, and treatment stratified accordingly. These case studies highlight the role of dual pathway inhibition (DPI) in managing CCS patients with the greatest need for cardiovascular protection, who are likely to derive the greatest benefit from this treatment strategy.