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The most recent guidelines on the management of stable angina have been published by the European Society of Cardiology in 2019 [4] in which the term chronic coronary syndromes is used to include patients with stable angina due to obstructive disease as well as coronary spasm and microvascular dysfunction. Earlier guidelines include those by the American College of Cardiology (ACC) and the American Heart Association (AHA) in 2012 [5]. Additional relevant guidelines include the 2018 ESC/EACTS Guidelines on myocardial revascularization (Tables 11.2 and 11.3) [6], and the ACCF/AHA/ SCAI 2011 Guideline for Percutaneous Coronary Intervention [7]. These guidelines are evidence based and should be the basis for clinical practice. However, there are several fundamental limitations of the trial data available on the management of stable angina. First, as with many clinical trials, the rigorous inclusion and exclusion criteria have resulted in a relatively small number of the screened patients being enrolled into the studies. This significantly limits the ability to generalize the findings to the larger population in daily practice. Moreover, clinical trials have generally excluded high risk patients with severe angina, severe atherosclerosis, severely reduced left ventricular (LV) systolic function, or multiple comorbid conditions. Second, the findings of clinical trials comparing treatment strategies often become outdated quickly because of the rapid evolution in clinical practice.

Table 11.2 ESC Guideline indications for revascularization in patients with stable angina or silent ischemia.

Extent of CAD (anatomical and/or functional)	Classa	Levelb
For prognosis	Left main disease with stenosis >50%c	I	A
	Proximal LAD stenosis >50%c	I	A
	Two‐vessel or three‐vessel disease with stenosis >50%a with impaired LV function (LVEF ≤35%)c	I	A
	Large area of ischemia (>10% of LV) or abnormal FFRd	I	B
	Single remaining patent with coronary artery stenosis >50%c	I	C
For symptoms	Hemodynamically significant coronary stenosis in the presence of limiting angina or angina equivalent, with insufficient response to optimized medical therapy.e	I	A

CAD, coronary artery disease; FFR, fractional flow reserve; iFR, instantaneous wave‐free ratio; LAD, left anterior descending coronary artery; LV, left ventricular;

LVEF, left ventricular ejection fraction.

^a Class of recommendation.

^b Level of evidence.

^c With documented ischaemia or a hemodynamically relevant lesion defined by FFR <_0.80 or iFR <_0.89, or >90% stenosis in a major coronary vessel.

^d Based on FFR <0.75 indicating a prognostically relevant lesion (see section 3.2.1.1).

^e In consideration of patient compliance and wishes in relation to the intensity of anti‐anginal therapy.

Source: Neumann et al. 2019 [6]. Reproduced by permission of Oxford University Press.

Table 11.3 ESC guidelines for the type of revascularization (CABG or PCI) in patients with stable CAD with suitable coronary anatomy for both procedures and low predicted surgical mortality.^d

Source: Data from Neumann et al. 2019 [6].

Recommendations according to the extent of CAD	CABG	PCI
Classa	Levelb	Classa	Levelb
One‐ or two‐vessel disease without proximal LAD stenosis	IIb	C	I	C
One‐vessel disease with proximal LAD stenosis	I	A	I	A
Two‐vessel disease with proximal LAD stenosis	I	B	I	C
Left main disease with a SYNTAX score ≤ 22	I	A	I	A
Left main disease with a SYNTAX score 23–32	I	A	IIa	A
Left main disease with a SYNTAX score > 32c	I	A	III	B
Three‐vessel disease with a SYNTAX score ≤ 22	I	A	I	A
Three‐vessel disease with a SYNTAX score >22c	I	A	III	A
Three‐vessel disease with diabetes and SYNTAX score ≤ 22	I	A	IIb	A
Three‐vessel disease with diabetes and SYNTAX score >22c	I	A	III	A

^a Class of recommendation.

^b Level of evidence.

^c PCI should be considered if the Heart Team is concerned about the surgical risk or if the patient refuses CABG after adequate counselling by the Heart Team.

^d For example, absence of previous cardiac surgery, severe morbidities, frailty, or immobility precluding CABG.