Invasive treatment strategies in the ESC guidelines developed in collaboration with EACTS for the management of chronic coronary syndrome: implications for contemporary clinical practice.

Purpose of review: To critically appraise the 2024 ESC Guidelines for chronic coronary syndrome (CCS), developed in collaboration with EACTS, emphasizing invasive-treatment recommendations, their underlying rationale and key areas requiring further clarification for clinical implementation.

Recent findings: The document formally incorporates indications for myocardial revascularization and the criteria for choosing between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) into the single CCS guideline framework. It calls for Heart-Team decisions whenever CABG and PCI are equally recommended and introduces modality-specific criteria based on anatomical complexity, SYNTAX score, and clinically relevant comorbidities. CABG remains the preferred strategy for anatomically complex disease, including left main and multivessel involvement, especially when PCI cannot achieve equivalent completeness of revascularization or in patients with comorbidities associated with a favorable prognosis (e.g., diabetes mellitus, heart failure). PCI is recommended for less complex lesions in which comparable completeness is feasible for patients whose primary goal is symptom relief or those at high surgical risk. Apart from patient selection, the document provides limited procedural detail, offers limited guidance on secondary prevention measures, and lacks explicit recommendations on the optimal timing of intervention.

Summary: The 2024 guideline re-establishes a unified, multidisciplinary European approach to the management of CCS, reaffirming the prognostic value of guideline-directed revascularization and the central role of the Heart Team in selecting the optimal strategy. Supplementary documents are required to fill procedural, secondary prevention and implementation gaps.