The new guidelines introduce a streamlined 4-step sequential clinical approach for patients with suspected CCS, replacing the previous 6-step protocol:

A patient-centered approach is recommended to address treatment goals, including patient-reported outcome measures and patient-reported experience measures. Health outcomes improve with effective communication and increased patient involvement, in which shared decision-making is central to future patient care and long-term follow-up. Controlling risk factors is essential for preventing disease progression and enhancing prognosis in patients with CCS. Multidisciplinary interventions that address risk factors and symptom management are increasingly associated with improvements in self-care and lifestyle modifications.

The section on antianginal medications has been shortened, as most information has been relocated to the supplemental data section. These guidelines have removed the classification of antianginal medications into first- and second-line treatments, recommending that physicians choose therapies based on each patient's hemodynamic profile, comorbidities, concomitant medications, and the underlying pathophysiology of myocardial ischemia. However, the authors acknowledge that treatment should be started with a beta-blocker or a calcium channel blocker. To assist physicians in selecting the most suitable antianginal drug and in determining combinations, the authors have included a helpful diamond (figure 1). Lastly, the authors have issued a class III indication (not recommended) for the use of ivabradine as add-on therapy in patients with CCS, a left ventricular ejection fraction (LVEF) >40%, and no clinical heart failure.

Figure 1.

Central illustration. Management of patients with chronic coronary syndromes.

ACS, acute coronary syndrome; ANOCA, angina with no coronary artery disease; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CCTA, coronary computed tomography angiography; CCB, calcium channel blocker; CMR, cardiac magnetic resonance; CVRF, cardiovascular risk factors; ECHO, echocardiography; INOCA, ischemia with no coronary artery disease; LV, left ventricle; PET, positron emission tomography; PCI, percutaneous coronary intervention; SPECT, single photon emission computed tomography.

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Regarding event prevention, the longest section is dedicated to antithrombotic therapy. New evidence indicating that clopidogrel has better efficacy and a lower or similar bleeding risk compared to aspirin has prompted the task force to recommend clopidogrel monotherapy as a safe and effective alternative to aspirin for long-term secondary prevention. Another updated recommendation is for lifelong aspirin treatment in patients without a history of myocardial infarction or revascularization but with evidence of significant obstructive CAD.

The duration of dual antiplatelet therapy following stenting is guided by bleeding and thrombotic risks, with the default recommendation being six months. In patients at high ischemic risk without a high bleeding risk, prolonged dual antiplatelet therapy with aspirin plus either ticagrelor 60mg twice daily (bid), low-dose rivaroxaban, clopidogrel, or prasugrel is equally recommended. The option of ticagrelor 90mg bid monotherapy is also introduced (IIbC).

In terms of lipid-lowering drugs, the guidelines introduce bempedoic acid as an effective treatment for patients intolerant to statins (IB) or as an add-on therapy in those not achieving their goals with statins and ezetimibe (IIaC). Interestingly, the guidelines recommend the use of semaglutide in patients with CCS who are overweight (body mass index >27kg/m2) or obese to reduce cardiovascular events. Additionally, colchicine (0.5mg/d) is recommended to reduce the risk of myocardial infarction, stroke, and the need for revascularization in patients with CAD (IIaA).

The guidelines include several significant updates regarding myocardial revascularization. Prior to considering any invasive strategy, optimizing medical therapy through guideline-directed medical therapy (GDMT) is strongly encouraged. This is especially relevant in light of recent evidence for patients with heart failure (HF) and CAD. Despite initial controversy surrounding the benefits of revascularization following the publication of the ISCHEMIA trial results,5 further analysis of long-term outcomes, meta-analyses, and other clinical trials have supported the role of revascularization in improving survival in patients with extensive coronary artery disease, such as 3-vessel disease (IA), left main CAD (IA), and severe stenosis of 1 or 2 vessels, including the left anterior descending artery (IB).

A key aspect of the new guidelines is the personalized selection of the revascularization strategy. The authors emphasize the need for an individualized approach when deciding between PCI and CABG. Key factors to consider include the extent and complexity of CAD, which can be quantified using the SYNTAX score (IB); the presence of comorbidities, particularly diabetes; the assessment of surgical risk with the Society of Thoracic Surgeons (STS) score (IB), as opposed to EuroSCORE or other scales; ventricular function; and patient preference (IC). If PCI is selected to treat complex lesions—such as left main lesions, bifurcations, or long lesions—the authors recommend the use of intracoronary imaging guidance via intravascular ultrasound or optical coherence tomography (OCT) (IA). As in previous guidelines, it is advised that therapeutic decisions be made by a multidisciplinary team, or Heart Team, to ensure the most appropriate strategy for each individual case (IC).

The new guidelines provide more clinically oriented and practical recommendations on the best revascularization strategy compared with medical therapy alone in different scenarios:

About half of HF patients have ischemic etiology, with an increasing proportion of ischemic HF with preserved EF (HFpEF) seen in the last years, with a relevant role of microvascular angina due to coronary microvascular disfunction. The evaluation of inducible ischemia is important in patients with HF, and as clinical assessment alone may underestimate the presence of CAD, functional imaging, especially in HFpEF patients, should be considered to detect potential benefits from revascularization. CCTA is also recommended in patients with a low-to-intermediate pretest likelihood of obstructive CAD, and those with equivocal noninvasive stress tests. In HF patients with LVEF ≤35% in whom obstructive CAD is suspected, direct invasive coronary angiography is recommended (IB). In selected patients with HF with reduced EF (HFrEF) undergoing high-risk PCI, the use of a microaxial flow pump may be considered (IIbC).

In patients with refractory angina that significantly impacts quality of life and suspected or confirmed ANOCA/INOCA (ie, anginal symptoms with normal coronary arteries, nonobstructive lesions on noninvasive imaging, or intermediate stenoses with normal FFR/iFR during coronary angiography), invasive coronary functional testing is recommended to define the underlying endotypes and guide appropriate treatment, considering patient preferences (IB). In symptomatic patients with ANOCA/INOCA, medical therapy tailored to the results of coronary functional tests should be considered to improve symptoms and quality of life (IIaA). In addition, in individuals with suspected vasospastic angina and frequent symptoms, ambulatory ST-segment monitoring should be considered to detect ST-segment deviations during anginal episodes (IIaB).

Health outcomes improve with proper communication and greater patient involvement, in which shared decision-making is central to future patient care and long-term follow-up. This long-term follow-up, in patients with CCS who have established CAD (prior acute myocardial infarction, revascularization, or known CAD—or nonobstructive CAD), includes monitoring for disease progression. Risk stratification is also recommended in patients with new or worsening symptoms, preferably using stress imaging.

Detailed medical history and physical exams require primary care physicians to dedicate time to patient care. Current recommendations, upgrading the use of CCTA as a first-line test, conflict with its underuse in our setting, mainly due to limited availability. Similarly, stress CMR and other functional tests, such as PET, also face significant availability issues, which hampers the proper implementation of diagnostic recommendations. The guidelines emphasize the need for both appropriate technology and professional training to ensure standard care. As a well-trained imaging team is a prerequisite for CCTA, it is essential to focus our efforts on providing professionals with specific training in cardiac imaging and standardizing the acquisition and reporting of these studies.

The new guidelines mark a significant advancement in risk stratification for CAD by introducing an algorithm based on symptoms and risk factors. This algorithm highlights the importance of complementary tests such as ECG, noninvasive functional assessment, and CCTA in patients with moderate-to-high risk profiles. Following these recommendations, there should be a substantial increase in the use of CCTA, which currently shows significant variability in implementation among different regions and health care centers in the country.6

Regarding invasive testing, the guidelines clearly establish the indication for pressure wire assessment of intermediate stenoses (40%-90% diameter stenosis for nonleft main stenosis and 40%-70% diameter stenoses for left main lesions). This is particularly important, as the degree of reclassification of the significance of stenosis after pressure wire assessment is highly notable in our setting.7 Although the use of pressure wire has steadily increased in recent years, its use still lags behind that of neighboring countries.6

An increasing number of centers in Spain are implementing multidisciplinary teams to assess patients comprehensively and involve them in therapeutic decisions. However, there is no single effective model, and limited evidence exists evaluating the efficiency and outcomes for patients. The uneven implementation of educational programs in patients with CAD could be improved through tele-rehabilitation, which is an effective alternative to reach a larger number of patients. Furthermore, the Spanish health care system does not refund GLP-1 medications for weight loss in nondiabetic patients, and there are restrictions on smoking cessation drugs, hindering their widespread availability to all patients. Additionally, the lack of commercialization of some recommended treatments, such as nicorandil or low-dose rivaroxaban, and the absence of an approved indication for the use of colchicine in CCS patients are further limitations to the implementation of these guidelines in our setting.

Implementing these new clinical guidelines is crucial, considering certain regional factors specific to Spain. The guidelines recommend decision-making based on Heart Teams, focusing on patient health outcomes, and align with the Cardiovascular Health Strategy of the Spanish Ministry of Health,8 facilitating their deployment and implementation. Spain continues to have one of the lowest rates of revascularization (PCI or CABG).9 The recommendations outlined in these guidelines should be promoted beyond the field of cardiology, involving the health administration to overcome barriers to patient access to these invasive therapies.

Another significant aspect of the guidelines is the evaluation of patients with ANOCA/INOCA. The guidelines emphasize the need for invasive assessment when these conditions are suspected, aiming to identify the patient's phenotype (endothelial dysfunction, epicardial spasm, microvascular spasm, or microvascular dysfunction) to guide targeted pharmacological treatment or to exclude a coronary cause of the symptoms. Given the high prevalence of these conditions, a considerable increase in the number of invasive studies in this area is expected.6

Despite robust evidence of benefits in terms of mortality and morbidity, adherence to guideline-directed medications remains suboptimal. Behavioral and mobile health interventions, including apps and wearable devices, are recommended to improve patient adherence to healthy lifestyles and medical therapy during long-term follow-up. Simplifying medication regimens (eg, using fixed-dose drug combinations) along with multiprofessional and family involvement is also recommended to enhance patient adherence to medications and promote patient education and involvement.