Decision support only — not a substitute for the 2024 ESC CCS guideline, NHFA/CSANZ, or eTG. The 2024 reframe: coronary disease is a dynamic spectrum (it can destabilise to ACS) and includes ANOCA/INOCA — angina with non-obstructive arteries. The central discipline is separating the drugs that change prognosis from the ones that only relieve angina. Verify all doses.
1 Prevent the events — therapy that changes prognosis
Foundationbiggest lever
Every patient.
Smoking cessation, cardiac rehab, exercise, diet, weight — the highest-yield intervention, and easy to under-prioritise.
Antiplateletsingle agent long-term
Established CCS.
Aspirin 75–100 mg daily — or clopidogrel 75 mg as a reasonable alternative HOST-EXAM. DAPT duration is tailored after PCI.
Lipidstreat to target
All — this is prognostic.
High-intensity statin → LDL <1.4 mmol/L (and ≥50% reduction); add ezetimibe, then a PCSK9 inhibitor if not at target.
Disease-specific add-onsby comorbidity / residual risk
Selected patients.
ACEi/ARB if HF, LV dysfunction, diabetes, HTN, CKD. SGLT2i or GLP-1 if diabetes. Low-dose colchicine 0.5 mg for residual inflammatory risk LoDoCo2.
These are the agents that reduce death and MI. Keep them mentally separate from the antianginals below — relieving angina and improving prognosis are different goals, achieved by different drugs.
2 Relieve the angina — antianginal ladder
First-lineindividualise
Symptomatic angina.
Beta-blocker and/or a calcium channel blocker — choose by heart rate, blood pressure, LV function and comorbidity (the 2024 guideline drops the rigid "BB-always-first").
Add-onsecond agents
Inadequate control.
Long-acting nitrate, ivabradine (sinus rhythm, HR ≥70 or LVEF <40%), ranolazine, nicorandil, or trimetazidine — combine rationally.
Refractorydespite optimal therapy
Persistent limiting angina on full medical therapy.
Revascularisation for symptom relief; coronary sinus reducer in selected cases; and reconsider an ANOCA/INOCA endotype if arteries are non-obstructive.
Antianginals improve symptoms, not prognosis — the mirror image of §1. In ANOCA/INOCA, tailor the drug to the endotype: microvascular dysfunction → beta-blocker/CCB; vasospastic angina → CCB + nitrate, avoid non-vasodilating beta-blockers.
3 Diagnose — likelihood first, then the right test
The pathway
- LikelihoodEstimate pre-test probability with the Risk-Factor-weighted Clinical Likelihood model — lower than the old estimates, so fewer need testing.
- First-lineCT coronary angiography for low–moderate likelihood (>5–50%) — excellent rule-out + plaque/CT-FFR.
- FunctionalStress imaging (echo, SPECT/PET, CMR) as an alternative, esp. higher likelihood.
- InvasiveICA + physiology (FFR/iFR) when non-invasive testing is uncertain or risk is high.
ANOCA / INOCA — don't dismiss it
- CommonAngina/ischaemia with non-obstructive arteries is common, especially in women, and carries real MACE risk.
- EndotypesCoronary microvascular dysfunction and vasospastic angina — not "non-cardiac chest pain."
- TestRefractory + non-obstructive → invasive coronary functional testing (acetylcholine provocation; CFR/IMR) to define the endotype and target therapy.
4 Revascularisation & the ISCHEMIA lesson
Optimal medical therapy first
- ISCHEMIAIn stable CAD with moderate–severe ischaemia, routine revascularisation did not reduce death or MI vs OMT ISCHEMIA — it improved symptoms/QoL.
- SoRevascularise for refractory symptoms or specific prognostic subsets — not reflexively for "ischaemia on a scan."
- PlaceboEven angina relief from PCI is smaller than it looks against a sham ORBITA.
When & how to revascularise
- PrognosticLeft main, multivessel disease (esp. with LV dysfunction), or large ischaemia burden — functionally significant (FFR-guided).
- CABG vs PCICABG preferred for left main (low surgical risk) and multivessel disease, esp. with diabetes SYNTAX FREEDOM; PCI if low anatomical complexity (SYNTAX ≤22).
- SymptomsRefractory angina despite GDMT → revascularisation for relief.
Sources.
2024 ESC Guidelines for the management of chronic coronary syndromes (Eur Heart J 2024 — dynamic CCS spectrum; RF-weighted clinical likelihood; CTCA first-line for low–moderate likelihood; ANOCA/INOCA & invasive coronary functional testing; antianginal flexibility; LDL <1.4 mmol/L; low-dose colchicine; revascularisation by prognosis vs symptoms; CABG vs PCI). NHFA/CSANZ; eTG; PBS for PCSK9i/colchicine/lipid criteria.
Key trials: ISCHEMIA (revascularisation vs OMT — no death/MI reduction in stable mod–severe ischaemia); ORBITA (PCI vs sham for angina); COURAGE; FAME (FFR-guided PCI); SYNTAX & FREEDOM (CABG vs PCI in multivessel/diabetes); LoDoCo2 & COLCOT (colchicine); HOST-EXAM (clopidogrel vs aspirin monotherapy).
Caveats: CCS is dynamic — reassess, because it can destabilise to ACS (see the ACS sheet). ANOCA/INOCA pharmacotherapy is still largely empirical. PCSK9 inhibitors, colchicine and the incretin/SGLT2i HF-CV indications are PBS-criteria-bound in Australia — confirm access. Verify all doses. Companion to the acute coronary syndromes sheet.