ESC Guideline Recommendations for the Management of Coronary Artery Disease

1. Lipid‑Lowering and Antiplatelet Therapy

• High‑intensity statin therapy (maximum tolerated dose) is required for all CAD patients to achieve LDL‑C < 55 mg/dL (1.4 mmol/L) with ≥ 50 % reduction from baseline; this is a Class I recommendation. 1
• If the LDL‑C target is not met on maximal statin therapy, add ezetimibe. 1
• When statin + ezetimibe still fails to reach goal, add a PCSK9 inhibitor (evolocumab or alirocumab). 1
• In statin‑intolerant patients who are not at goal on ezetimibe alone, add bempedoic acid. 1
• Low‑dose aspirin is the cornerstone of antiplatelet therapy for secondary prevention in CAD. 1
• Aspirin should be started post‑operatively after revascularization once bleeding risk is acceptable. 1
• Proton‑pump inhibitor co‑therapy is advised for patients at increased gastrointestinal bleeding risk for the entire duration of combined antithrombotic treatment. 1

2. Management of Key Comorbidities

Diabetes Mellitus

• SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) are mandatory in patients with type 2 diabetes and CAD to lower cardiovascular events, independent of glycaemic control. 1
• GLP‑1 receptor agonists (liraglutide, semaglutide, dulaglutide) are equally recommended for the same population to reduce cardiovascular events. 1

Hypertension and Heart Failure

• ACE inhibitors (or ARBs if ACE‑I intolerant) are required in CAD patients who also have hypertension, diabetes, or heart failure. 1
• In patients with heart‑failure with reduced ejection fraction, replace ACE‑I/ARB with sacubitril/valsartan to decrease heart‑failure hospitalization and mortality. 2

Anti‑inflammatory Therapy

• Low‑dose colchicine (0.5 mg daily) should be considered in atherosclerotic CAD to lower the risk of myocardial infarction, stroke, and repeat revascularization. 2

3. Indications for Revascularization

Patients with LVEF > 35 %

• Left‑main coronary artery disease (functionally significant) mandates revascularization in addition to optimal medical therapy. 1, 3
  
  • CABG is preferred over PCI for lower rates of spontaneous MI and repeat revascularization. 2
  • PCI is acceptable when left‑main disease is low‑complexity (SYNTAX ≤ 22) and complete revascularization can be achieved. 2
• Three‑vessel disease requires revascularization to improve long‑term survival, reduce cardiovascular mortality, and lower spontaneous MI risk. 1, 3
• Proximal LAD involvement (single‑ or two‑vessel disease) warrants revascularization to decrease cardiovascular mortality and spontaneous MI. 3
• Persistent angina despite optimal medical therapy indicates revascularization of functionally significant obstructive CAD to improve symptoms. 3

Patients with LVEF ≤ 35 %

• CABG is recommended over medical therapy alone in surgically eligible patients with multivessel CAD to improve long‑term survival. 3
• PCI may be considered as an alternative to CABG in selected high‑surgical‑risk or inoperable patients with multivessel disease and LVEF ≤ 35 %. 3
• Decision between revascularization and medical therapy alone should involve a Heart Team evaluation that weighs coronary anatomy, the relationship between CAD and LV dysfunction, comorbidities, life expectancy, risk‑benefit ratio, and patient preferences. 2, 3

4. Procedural Planning and Risk Assessment

• SYNTAX score calculation is required in multivessel obstructive CAD to quantify anatomical complexity. 3
• STS score should be used to estimate in‑hospital morbidity and 30‑day mortality after CABG. 3
• Intracoronary imaging (IVUS or OCT) is mandatory for PCI of complex lesions such as left‑main stem, true bifurcations, and long lesions. 2, 3
• Physiological lesion assessment with FFR, iFR, or QFR is required to guide lesion selection in multivessel disease. 3
• Post‑PCI, FFR or iFR should be measured to identify patients at high risk of persistent angina and future adverse events. 3

5. Heart Team and Patient‑Centred Decision‑Making

• For complex cases where CABG and PCI have comparable recommendations, a multidisciplinary Heart Team discussion (interventional cardiology, cardiac surgery, non‑interventional cardiology, and other relevant specialties) is mandatory. 1, 2
• The Heart Team’s recommendation must be communicated in balanced, lay‑language that the patient can understand. 1
• Revascularization decisions must be patient‑centred, incorporating individual preferences, health literacy, cultural context, and social support. 1, 2

6. Common Pitfalls to Avoid

• Do not delay optimal medical therapy in stable CAD; premature revascularization without functional assessment offers no mortality or MI benefit.
• Avoid undertreatment of lipids – many patients remain on moderate‑intensity statins when high‑intensity therapy with combination agents is needed to meet LDL‑C targets. 1
• Do not omit SGLT2 inhibitors or GLP‑1 agonists in diabetic CAD patients, as they confer cardiovascular protection independent of glycaemic effects. 1
• Ensure functional assessment (FFR/iFR) in multivessel disease rather than relying solely on angiographic appearance to guide revascularization decisions. 3