Chronic Coronary Syndrome Management

Antithrombotic Therapy

The European Society of Cardiology recommends aspirin 75-100 mg daily lifelong as the cornerstone of antithrombotic therapy, combined with beta-blockers and/or calcium channel blockers for symptom control, plus high-intensity statin therapy for cardiovascular risk reduction 1, 2
Aspirin 75-100 mg daily is recommended lifelong after an initial period of dual antiplatelet therapy (DAPT) in patients with prior MI or remote PCI 1, 2, 3
Clopidogrel 75 mg daily is a safe and effective alternative to aspirin monotherapy if aspirin is not tolerated in patients with prior MI or remote PCI 1, 2, 4
DAPT with aspirin 75-100 mg plus clopidogrel 75 mg daily for up to 6 months is the default strategy after PCI-stenting, regardless of stent type 1, 2, 4
In high bleeding risk patients (but not high ischemic risk), discontinue DAPT after 1-3 months and continue single antiplatelet therapy 1, 2, 3

Beta-blockers and/or calcium channel blockers (CCBs) are recommended as initial treatment for most patients to control heart rate and symptoms 1, 2
Short-acting nitrates are recommended for immediate relief of angina 1, 2
Long-acting nitrates or ranolazine should be considered as add-on therapy when symptoms are inadequately controlled on beta-blockers and/or CCBs 4

High-intensity statin therapy is essential for all patients with chronic coronary syndrome, with atorvastatin 80 mg daily demonstrating superior outcomes compared to lower doses 5

ACE inhibitors are recommended for all patients with chronic coronary syndrome, especially those with heart failure, hypertension, diabetes, or LV dysfunction 6
ARBs are effective alternatives if ACE inhibitors are not tolerated (e.g., due to cough) 6

Direct oral anticoagulant (DOAC) is preferred over vitamin K antagonist (VKA) in eligible patients 1, 2, 3
OAC alone (without aspirin) is recommended lifelong for patients with chronic coronary syndrome and atrial fibrillation 1, 2

Proton pump inhibitor is recommended in patients at increased risk of gastrointestinal bleeding during antithrombotic therapy 1, 3

Aerobic physical activity of 150-300 minutes per week of moderate intensity or 75-150 minutes per week of vigorous intensity is recommended 1, 2
Multidisciplinary exercise-based programs are recommended to improve cardiovascular risk profile and reduce cardiovascular mortality 1, 2