Review Article| Volume 72, P5-8, February 2020

The ESC 2019 CCS guidelines: Have we left our patients and scientific evidence behind?

Published:December 24, 2019DOI:


      The ESC CCS 2019 guidelines recognize that successful management of anginal symptoms relies on effective therapy tailored to individual patient characteristics but do not provide any specific advice or clarity on how to utilize pharmacotherapy in order to achieve these goals. In this review, we are going to summarize and discuss the main points of disagreement.


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        • Beltrame J.F.
        • Weekes A.J.
        • Morgan C.
        • Tavella R.
        • Spertus J.A
        The prevalence of weekly angina among patients with chronic stable angina in primary care practices: the coronary artery disease in general practice (CADENCE) study.
        Arch Intern Med. 2009; 169 (Sep 14): 1491-1499
        • Borrás X.
        • Garcia-Moll X.
        • Gómez-Doblas J.J.
        • Zapata A.
        • Artigas R.
        • AVANCE study researchers
        Stable angina in Spain and its impact on quality of life. The AVANCE registry.
        Rev Esp Cardiol (Engl Ed). 2012; 65: 734-741
        • Ambrosio G.
        • Collins P.
        • Dechend R.
        • Lopez-Sendon J.
        • Manolis A.J.
        • Camm A.J
        Stable angina: perception of needs, quality of life and management of patients (BRIDGE study)-a multinational European physician survey.
        Angiology. 2019; 70: 397-406
      1. Knuuti J., Wijns W., Saraste A., Capodanno D., Barbato E., Funck-Brentano C., ESC Scientific Document Group et al. 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2019 31. pii: ehz425. 10.1093/eurheartj/ehz425.

        • Montalescot G.
        • Sechtem U.
        • Achenbach S.
        • Andreotti F.
        • Arden C.
        • Budaj A.
        • et al.
        2013 ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery disease of the European society of cardiology.
        Eur Heart J. 2013; 34: 2949-3003
        • Wight L.J.
        • VandenBurg M.J.
        • Potter C.E.
        • Freeth C.J
        A large scale comparative study in general practice with nitroglycerin spray and tablet formulations in elderly patients with angina pectoris.
        Eur J Clin Pharmacol. 1992; 42: 341-342
        • Heidenreich P.A.
        • McDonald K.M.
        • Hastie T.
        • Fadel B.
        • Hagan V.
        • Lee B.K.
        • et al.
        Meta-analysis of trials comparing beta-blockers, calcium antagonists, and nitrates for stable angina.
        JAMA. 1999; 281: 1927-1936
        • Wei J.
        • Wu T.
        • Yang Q.
        • Chen M.
        • Ni J.
        • Huang D
        Nitrates for stable angina: a systematic review and meta-analysis of randomized clinical trials.
        Int J Cardiol. 2011; 146: 4-12
        • Manolis A.J.
        • Poulimenos L.E.
        • Ambrosio G.
        • Kallistratos M.S.
        • Lopez-Sendon J.
        • Dechend R.
        • et al.
        Medical treatment of stable angina: a tailored therapeutic approach.
        Int J Cardiol. 2016; 220: 445-453
        • Ferrari R.
        • Camici P.G.
        • Crea F.
        • Danchin N.
        • Fox K.
        • Maggioni A.P.
        • et al.
        Expert consensus document: a 'diamond' approach to personalized treatment of angina.
        Nat Rev Cardiol. 2018; 15: 120-132
        • Ferrari R.
        • Pavasini R.
        • Camici P.G.
        • Crea F.
        • Danchin N.
        • Pinto F.
        • et al.
        Anti-anginal drugs-beliefs and evidence: systematic review covering 50 years of medical treatment.
        Eur Heart J. 2019; 40: 190-194
        • Heidenreich P.A.
        • McDonald K.M.
        • Hastie T.
        • Fadel B.
        • Hagan V.
        • Lee B.K.
        • et al.
        Meta-analysis of trials comparing beta-blockers, calcium antagonists, and nitrates for stable angina.
        JAMA. 1999; 281: 1927-1936
        • Fox K.M.
        • Mulcahy D.
        • Findlay I.
        • Ford I.
        • Dargie H.J
        The total ischaemic burden European trial (TIBET). Effects of atenolol, nifedipine SR and their combination on the exercise test and the total ischaemic burden in 608 patients with stable angina. The Tibet Study Group.
        Eur Heart J. 1996; 17: 96-103
        • Wallace W.A.
        • Wellington K.L.
        • Chess M.A.
        • Liang C.S
        Comparison of nifedipine gastrointestinal therapeutic system and atenolol on antianginal efficacies and exercise hemodynamic responses in stable angina pectoris.
        Am J Cardiol. 1994; 73: 23-28
        • Bangalore S.
        • Makani H.
        • Radford M.
        • Thakur K.
        • Toklu B.
        • Katz S.D.
        • et al.
        Clinical outcomes with β-blockers for myocardial infarction: a meta-analysis of randomized trials.
        Am J Med. 2014; 127: 939-953
        • Rehnqvist N.
        • Hjemdahl P.
        • Billing E.
        • Bjorkander I.
        • Eriksson S.V.
        • Forslund L.
        • et al.
        Effects of metoprolol vs. verapamil in patients with stable angina pectoris. The Angina Prognosis Study in Stockholm (APSIS).
        Eur Heart J. 1996; 17: 76-81
        • Pepine C.J.
        • Handberg E.M.
        • Cooper-DeHoff R.M.
        • Marks R.G.
        • Kowey P.
        • Messerli F.H.
        • et al.
        INVEST Investigators. A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial.
        JAMA. 2003; 290: 2805-2816
        • Poole-Wilson P.A.
        • Lubsen J.
        • Kirwan B.A.
        • van Dalen F.J.
        • Wagener G.
        • Danchin N.
        • et al.
        Coronary disease trial investigating outcome with nifedipine gastrointestinal therapeutic system investigators. Effect of long-acting nifedipine on mortality and cardiovascular morbidity in patients with stable angina requiring treatment (ACTION trial): randomized controlled trial.
        Lancet. 2004; 364: 849-857
        • Nissen S.E.
        • Tuzcu E.M.
        • Libby P.
        • Thompson P.D.
        • Ghali M.
        • Garza D.
        • et al.
        CAMELOT Investigators. Effect of antihypertensive agents on cardiovascular events in patients with coronary disease and normal blood pressure: the Camelot study: a randomized controlled trial.
        JAMA. 2004; 292: 2217-2225
        • Frishman W.H.
        • Glasser S.
        • Stone P.
        • Deedwania P.C.
        • Johnson M.
        • Fakouhi T.D
        Comparison of controlled-onset, extended-release verapamil with amlodipine and amlodipine plus atenolol on exercise performance and ambulatory ischemia in patients with chronic stable angina pectoris.
        Am J Cardiol. 1999; 83: 507-514
        • Williams B.
        • Mancia G.
        • Spiering W.
        • Agabiti Rosei E.
        • Azizi M.
        • Burnier M.
        • et al.
        2018 Practice Guidelines for the management of arterial hypertension of the European Society of Hypertension and the European Society of Cardiology: ESH/ESC Task Force for the Management of Arterial Hypertension.
        J Hypertens. 2018; 36: 2284-2309
        • Manolis A.J.
        • Kallistratos M.S.
        • Poulimenos L.E
        Angina and hypertension.
        Eur Heart J Suppl. 2019; 21 (Apr): C15-C16
        • Tsika E.P.
        • Poulimenos L.E.
        • Boudoulas K.D.
        • Manolis A.J
        The J-curve in arterial hypertension: fact or fallacy?.
        Cardiology. 2014; 129: 126-135

        • Ambrosio G.
        • Tamargo J.
        • Grant P.J
        Non-haemodynamic anti-anginal agents in the management of patients with stable coronary artery disease and diabetes: a review of the evidence.
        Diab Vasc Dis Res. 2016; 13 (Mar): 98-112
        • Cosentino F.
        • Grant P.J.
        • Aboyans V.
        • Bailey C.J.
        • Ceriello A.
        • Delgado V.
        • et al.
        2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD.
        Eur Heart J. 2019; (Aug 31. pii: ehz486)