谢昊泰,龚艳君

• 1:北京大学第一医院心内科

摘要(Abstract)：

2024年欧洲心脏病学会时隔5年发布了更新的慢性冠状动脉综合征（CCS）管理指南（以下简称新版指南）。新版指南在2019版指南（以下简称旧版指南）的基础上，结合了该领域最新的循证医学证据和临床经验，对CCS的定义、评估、诊断、治疗和随访等方面提供了全面且最新的推荐意见。本文将结合旧版指南及2024年我国最新发布的CCS管理指南，对重要推荐的更新进行逐一详细解读，以期为当前CCS的临床诊疗实践提供有益指导。

关键词(KeyWords)： 慢性冠状动脉综合征;指南;诊断;管理;治疗

Abstract:

Keywords:

基金项目(Foundation): 北京市自然科学基金资助项目（L246057）

作者(Author): 谢昊泰,龚艳君

参考文献(References)：

• [1] Vrints C,Andreotti F,Koskinas KC,et al.2024 ESC Guidelines for the management of chronic coronary syndromes[J].Eur Heart J,2024,45(36):3415-3537.DOI:10.1093/eurheartj/ehae177.
• [2]Knuuti J,Wijns W,Saraste A,et al.2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes[J].Eur Heart J,2020,41(3):407-477.DOI:10.1093/eurheartj/ehz425.
• [3]中国心血管健康与疾病报告编写组.《中国心血管健康与疾病报告2022》概要[J].中国介入心脏病学杂志,2023,31(7):485-508.DOI:10.3969/j.issn.1004-8812.2023.07.002.
• [4]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.中国慢性冠脉综合征患者诊断及管理指南[J].中华心血管病杂志,2024,52(6):589-614.DOI:10.3760/cma.j.cn112148-20240325-00168.
• [5]Del Buono MG,Montone RA,Camilli M,et al.Coronary microvascular dysfunction across the spectrum of cardiovascular diseases:JACC state-of-the-art review[J].J Am Coll Cardiol,2021,78(13):1352-1371.DOI:10.1016/j.jacc.2021.07.042.
• [6]Winther S,Schmidt SE,Mayrhofer T,et al.Incorporating coronary calcification into pre-test assessment of the likelihood of coronary artery disease[J].J Am Coll Cardiol,2020,76(21):2421-2432.DOI:10.1016/j.jacc.2020.09.585.
• [7]Agha AM,Pacor J,Grandhi GR,et al.The prognostic value of CAC zero among individuals presenting with chest pain:a metaanalysis[J].JACC Cardiovasc Imaging,2022,15(10):1745-1757.DOI:10.1016/j.jcmg.2022.03.031.
• [8]Zhou J,Li C,Cong H,et al.Comparison of different investigation strategies to defer cardiac testing in patients with stable chest pain[J].JACC Cardiovasc Imaging,2022,15(1):91-104.DOI:10.1016/j.jcmg.2021.08.022.
• [9]Douglas PS,Hoffmann U,Patel MR,et al.Outcomes of anatomical versus functional testing for coronary artery disease[J].N Engl J Med,2015,372(14):1291-1300.DOI:10.1056/NEJMoa1415516.
• [10]Newby DE,Adamson PD,Berry C,et al.Coronary CT angiography and 5-year risk of myocardial infarction[J].N Engl J Med,2018,379(10):924-933.DOI:10.1056/NEJMoa1805971.
• [11]Woodward W,Dockerill C,McCourt A,et al.Realworld performance and accuracy of stress echocardiography:the EVAREST observational multi-centre study[J].Eur Heart J Cardiovasc Imaging,2022,23(5):689-698.DOI:10.1093/ehj ci/j eab0 92.
• [12]Rozanski A,Gransar H,Min JK,et al.Long-term mortality following normal exercise myocardial perfusion SPECT according to coronary disease risk factors[J].J Nucl Cardiol,2014,21(2):341-350.DOI:10.1007/s12350-013-9830-z.
• [13]Patel KK,Spertus JA,Chan PS,et al.Myocardial blood flow reserve assessed by positron emission tomography myocardial perfusion imaging identifies patients with a survival benefit from early revascularization[J].Eur Heart J,2020,41(6):759-768.DOI:10.1093/eurheartj/ehz389.
• [14]Bom MJ,van Diemen PA,Driessen RS,et al.Prognostic value of[~(15)O] H_2O positron emission tomography-derived global and regional myocardial perfusion[J].Eur Heart J Cardiovasc Imaging,2020,21(7):777-786.DOI:10.1093/ehjci/jez258.
• [15]Heitner JF,Kim RJ,Kim HW,et al.Prognostic value of vasodilator stress cardiac magnetic resonance imaging:a multicenter study with 48 000 patient-years of follow-up[J].JAMA Cardiol,2019,4(3):256-264.DOI:10.1001/jamacardio.2019.0035.
• [16]Arai AE,Schulz-Me nger J,Shah D J,et al.Stress perfusion cardiac magnetic resonance vs,SPECT imaging for detection of coronary artery disease[J].J Am Coll Cardiol,2023,82(19):1828-1838.DOI:10.1016/j.jacc.2023.08.046.
• [17]Tonino PA,De Bruyne B,Pijls NH,et al.Fractional flow reserve versus angiography for guiding percutaneous coronary intervention[J].N Engl J Med,2009,360(3):213-224.DOI:10.1056/NEJMoa0807611.
• [18]De Bruyne B,Pijls NH,Kalesan B,et al.Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease[J].N Engl J Med,2012,367(11):991-1001.DOI:10.1056/NEJMoa1205361.
• [19]Lee JM,Choi KH,Koo BK,et al.Comparison of major adverse cardiac events between instantaneous wave-free ratio and fractional flow reserve-guided strategy in patients with or without type 2 diabetes:a secondary analysis of a randomized clinical trial[J].JAMA Cardiol,2019,4(9):857-864.DOI:10.1001/jamacardio.2019.2298.
• [20]G?tberg M,Christiansen EH,Gudmundsdottir IJ,et al.Instantaneous wave-free ratio versus fractional flow reserve to guide PCI[J].N Engl J Med,2017,376(19):1813-1823.DOI:10.1056/NEJMoa1616540.
• [21]Van Belle E,Rioufol G,Pouillot C,et al.Outcome impact of coronary revascularization strategy reclassification with fractional flow reserve at time of diagnostic angiography:insights from a large French multicenter fractional flow reserve registry[J].Circulation,2014,129(2):173-185.DOI:10.1161/CIRCULATIONAHA,113.006646.
• [22]Van Belle E,Baptista SB,Raposo L,et al.Impact of routine fractional flow reserve on management decision and 1-year clinical outcome of patients with acute coronary syndromes:PRIMEFFR(Insights From the POST-IT[Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease] and R3F[French FFR Registry] Integrated Multicenter RegistriesImplementation of FFR[Fractional Flow Reserve] in Routine Practice)[J].Circ Cardiovasc Interv,2017,10(6):e004296.DOI:10.1161/CIRCINTERVENTIONS.116.004296.
• [23]Xu B,Tu S,Qiao S,et al.Diagnostic accuracy of angiographybased quantitative flow ratio measurements for online assessment of coronary stenosis[J].J Am Coll Cardiol,2017,70(25):3077-3087.DOI:10.1016/j.jacc.2017.10.035.
• [24]Song L,Xu B,Tu S,et al.2-year outcomes of angiographic quantitative flow ratio-guided coronary interventions[J].J Am Coll Cardiol,2022,80(22):2089-2101.DOI:10.1016/j.jacc.2022.09.007.
• [25]Xu B,Tu S,Song L,et al.Angiographic quantitative flow ratio-guided coronary intervention(FAVORⅢChina):a multicentre,randomised,sham-controlled trial[J].Lancet,2021,398(10317):2149-2159.DOI:10.1016/S0140-6736(21)02248-0.
• [26]van de Hoef TP,Lee JM,Boerhout CKM,et al.Combined assessment of FFR and CFR for decision making in coronary revascularization:from the multicenter international ILIAS registry[J].JACC Cardiovasc Interv,2022,15(10):1047-1056.DOI:10.1016/j.jcin.2022.03.016.
• [27]Masdjedi K,van Zandvoort LJC,Balbi MM,et al.Validation of a three-dimensional quantitative coronary angiography-based software to calculate fractional flow reserve:the FAST study[J].EuroIntervention,2020,16(7):591-599.DOI:10.4244/EIJ-D-19-00466.
• [28]Koo BK,Kang J,Park KW,et al.Aspirin versus clopidogrel for chronic maintenance monotherapy after percutaneous coronary intervention(HOST-EXAM):an investigator-initiated,prospective,randomised,open-label,multicentre trial[J].Lancet,2021,397(10293):2487-2496.DOI:10.1016/S0140-6736(21)01063-1.
• [29]Kang J,Park KW,Lee H,et al.Aspirin versus clopidogrel for long-term maintenance monotherapy after percutaneous coronary intervention:the HOST-EXAM extended study[J].Circulation,2023,147(2):108-117.DOI:10.1161/CIRCULATIONAHA.122.062770.
• [30]Valgimigli M,Frigoli E,Heg D,et al.Dual antiplatelet therapy after PCI in patients at high bleeding risk[J].N Engl J Med,2021,385(18):1643-1655.DOI:10.1056/NEJMoa2108749.
• [31]Costa F,Montalto C,Branca M,et al.Dual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk:a meta-analysis of randomized trials[J].Eur Heart J,2023,44(11):954-968.DOI:10.1093/eurheartj/ehac706.
• [32]Mach F,Baigent C,Catapano AL,et al.2019 ESC/EAS Guidelines for the management of dyslipidaemias:lipid modification to reduce cardiovascular risk[J].Eur Heart J,2020,41(1):111-188.DOI:10.1093/eurheartj/ehz455.
• [33]Visseren FLJ,Mach F,Smulders YM,et al.20 2 1 E S C Guidelines on cardiovascular disease prevention in clinical practice[J].Eur Heart J,2021,42(34):3227-33 37.DOI:10.10 9 3/eurheartj/ehab484.
• [34]Baigent C,Blackwell L,Emberson J,et al.Efficacy and safety of more intensive lowering of LDL cholesterol:a meta-analysis of data from 170,000 participants in 26 randomised trials[J].Lancet,2010,376(9753):1670-1681.DOI:10.1016/S0140-6736(10)61350-5.
• [35]Nissen SE,Lincoff AM,Brennan D,et al.Bempedoic acid and cardiovascular outcomes in statin-intolerant patients[J].N Engl J Med,2023,388(15):1353-1364.DOI:10.1056/NEJMoa2215024.
• [36]Ray KK,Wright RS,Kallend D,et al.Two phase 3 trials of inclisiran in patients with elevated LDL cholesterol[J].N Engl J Med,2020,382(16):1507-1519.DOI:10.1056/NEJMoa1912387.
• [37]Tardif JC,Kouz S,Waters DD,et al.Efficacy and safety of low-dose colchicine after myocardial infarction[J].N Engl J Med,2019,381(26):2497-2505.DOI:10.1056/NEJMoa19123 88.
• [38]Nidorf SM,Fiolet ATL,Mosterd A,et al.Colchicine in patients with chronic coronary disease[J].N Engl J Med,2020,383(19):1838-1847.DOI:10.1056/NEJMoa2021372.
• [39]Andreis A,Imazio M,Piroli F,et al.Efficacy and safety of colchicine for the prevention of major cardiovascular and cerebrovascular events in patients with coronary artery disease:a systematic review and meta-analysis on 12 869 patients[J].EurJ Prev Cardiol,2022,28(17):1916-1925.DOI:10.1093/eurjpc/zwab04 5.
• [40]Neumann FJ,Sousa-Uva M,Ahlsson A,et al.2018 ESC/EACTS Guidelines on myocardial revascularization[J].Eur Heart J,2019,40(2):87-165.DOI:10.1093/eurheartj/ehy394.
• [41]Sullivan PG,Wallach JD,Ioannidis JP.Meta-analysis comparing established risk prediction models(EuroSCORE II,STS Score,and ACEF Score)for perioperative mortality during cardiac surgery[J].Am J Cardiol,2016,118(10):1574-1582.DOI:10.1016/j.amjcard.2016.08.024.
• [42]Sinha S,Dimagli A,Dixon L,et al.Systematic review and meta-analysis of mortality risk prediction models in adult cardiac surgery[J].Interact Cardiovasc Thorac Surg,2021,33(5):673-686.DOI:10.1093/icvts/ivab151.
• [43]Thuijs DJFM,Habib RH,Head SJ,et al.Prognostic performance of the Society of Thoracic Surgeons risk score in patients with left main coronary artery disease undergoing revascularisation:a post hoc analysis of the EXCEL trial[J].EuroIntervention,2020,16(1):36-43.DOI:10.4244/EIJ-D-19-00417.
• [44]Scudeler TL,Farkouh ME,Hueb W,et al.Coronary atherosclerotic burden assessed by SYNTAX scores and outcomes in surgical,percutaneous or medical strategies:a retrospective cohort study[J].BMJ Open,2022,12(9):e062378.DOI:10.113 6/bmjopen-2022-0623 78.
• [45]Cavalcante R,Sotomi Y,Mancone M,et al.Impact of the SYNTAX scoresⅠandⅡin patients with diabetes and multivessel coronary disease:a pooled analysis of patient level data from the SYNTAX,PRECOMBAT,and BEST trials[J].Eur Heart J,2017,38(25):1969-1977.DOI:10.1093/eurheartj/ehx138.
• [46]Takahashi K,Serruys PW,Fuster V,et al.Redevelopment and validation of the SYNTAX scoreⅡto individualise decision making between percutaneous and surgical revascularisation in patients with complex coronary artery disease:secondary analysis of the multicentre randomised controlled SYNTAXES trial with external cohort validation[J].Lancet,2020,396(10260):1399-1412.DOI:10.1016/S0140-6736(20)32114-0.
• [47]Lee JM,Choi KH,Song YB,et al.Intravascular imagingguided or angiography-guided complex PCI[J].N Engl J Med,2023,388(18):1668-1679.DOI:10.1056/NEJMoa2216607.
• [48]Holm NR,Andreasen LN,Neghabat O,et al.OCT or angiography guidance for PCI in complex bifurcation lesions[J].N Engl J Med,2023,389(16):1477-1487.DOI:10.1056/NEJMoa2307770.
• [49]Ali ZA,Landmesser U,Maehara A,et al.Optical coherence tomography-guided versus angiography-guided PCI[J].N Engl J Med,2023,389(16):1466-1476.DOI:10.1056/NEJMoa2305861.
• [50]Head SJ,Milojevic M,Daemen J,et al.Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease:a pooled analysis of individual patient data[J].Lancet,2018,391(10124):939-948.DOI:10.1016/S0140-6736(18)30423-9.
• [51]Thuijs DJFM,Kappetein AP,Serruys PW,et al.Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease:10-year follow-up of the multicentre randomised controlledSYNTAX trial[J].Lancet,2019,394(10206):1325-1334.DOI:10.1016/S0140-6736(19)31997-X.
• [52]Aziz O,Rao C,Panesar SS,et al.Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery[J].BMJ,2007,334(7594):617.DOI:10.1136/bmj.39106.476215.BE.
• [53]Deppe AC,Liakopoulos OJ,Kuhn EW,et al.Minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for single-vessel disease:a meta-analysis of 2885 patients[J].Eur J Cardiothorac Surg,2015,47(3):397-406;discussion 406.DOI:10.1093/ejcts/ezu285.
• [54]Gaudino M,Andreotti F,Kimura T.Current concepts in coronary artery revascularisation[J].Lancet,2023,401(10388):1611-1628.DOI:10.1016/S0140-6736(23)00459-2.
• [55]Kunadian V,Chieffo A,Camici PG,et al.An EAPCI expert consensus document on ischaemia with non-obstructive coronary arteries in collaboration with European Society of Cardiology Working Group on coronary pathophysiologyµcirculation endorsed by coronary vasomotor disorders international study group[J].Eur Heart J,2020,41(37):3504-3520.DOI:10.1093/eurheartj/ehaa503.
• [56]Pesola A,Lauro A,Gallo R,et al.Efficacy of diltiazem in variant angina.Results of a double-blind crossover study in CCU by Holter monitoring.The possible occurrence of a withdrawal syndrome[J].G Ital Cardiol,1987,17(4):329-339.
• [57]Chahine RA,Feldman RL,Giles TD,et al.Randomized placebo-controlled trial of amlodipine in vasospastic angina.Amlodipine Study 160 Group[J].J Am Coll Cardiol,1993,21(6):1365-1370.DOI:10.1016/0735-1097(93)90310-w.
• [58]Oikawa Y,Matsuno S,Yajima J,et al.Effects of treatment with once-daily nifedipine CR and twice-daily benidipine on prevention of symptomatic attacks in patients with coronary spastic angina pectoris-Adalat Trial vs Coniel in Tokyo against Coronary Spastic Angina(ATTACK CSA)[J].J Cardiol,2010,55(2):238-247.DOI:10.1016/j.jjcc.2009.11.005.
• [59]Angraal S,Khera R,Wang Y,et al.Sex and race differences in the utilization and outcomes of coronary artery bypass grafting among medicare beneficiaries,1999-2014[J].J Am Heart Assoc,2018,7(14):e009014.DOI:10.1161/JAHA.118.009014.
• [60]Costa E,van Klaveren D,James S,et al.Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy(PRECISE-DAPT)score:a pooled analysis of individual-patient datasets from clinical trials[J].Lancet,2017,389(10073):1025-1034.DOI:10.1016/S0140-6736(17)30397-5,
• [61]Urban P,Mehran R,Colleran R,et al.Defining high bleeding risk in patients undergoing percutaneous coronary intervention:a consensus document from the Academic Research Consortium for High Bleeding Risk[J].Eur Heart J,2019,40(31):2632-265 3.DOI:10.10 9 3/eurheartj/ehz372.
• [62]Foster HME,Celis-Morales CA,Nicholl BI,et al.The effect of socioeconomic deprivation on the association between an extended measurement of unhealthy lifestyle factors and health outcomes:a prospective analysis of the UK Biobank cohort[J].Lancet Public Health,2018,3(12):e576-e585.DOI:10.1016/S2468-2667(18)30200-7.
• [63]Stringhini S,Carmeli C,Jokela M,et al.Socioeconomic status and the 25 x 25 risk factors as determinants of premature mortality:a multicohort study and meta-analysis of 1.7 million men and women[J].Lancet,2017,389(10075):1229-1237.DOI:10.1016/S0140-6736(16)32380-7.
• [64]Sidhu GS,Ward C,Ferdinand KC.Racial disparity in atherosclerotic cardiovascular disease in hospitalized patients with diabetes 2005-2015:potential warning signs for future U.S.public health[J].Am J Prey Cardiol,2020,4:100095.DOI:10.1016/j.ajpc.2020.100095.
• [65]Hosseini F,Malhi N,Sellers SL,et al.The morphology of coronary artery disease in South Asians vs.White Caucasians and its implications[J].Can J Cardiol,2022,38(10):1570-1579.DOI:10.1016/j.cjca.2022.05.005.
• [66]SCORE2 working group and ESC Cardiovascular risk collaboration.SCORE2 risk prediction algorithms:new models to estimate 10-year risk of cardiovascular disease in Europe[J].Eur Heart J,2021,42(25):2439-2454.DOI:10.1093/eurheartj/ehab309.
• [67]SCORE2-OP working group and ESC Cardiovascular risk collaboration.SCORE2-OP risk prediction algorithms:estimating incident cardiovascular event risk in older persons in four geographical risk regions[J].Eur Heart J,2021,42(25):2455-2467.DOI:10.1093/eurheartj/ehab312.
• [68]Lindholt JS,S?gaard R,Rasmussen LM,et al.Five-year outcomes of the danish cardiovascular screening(DANCAVAS)trial[J].N Engl J Med,2022,387(15):1385-1394.DOI:10.1056/NEJMoa2208681.
• [69]Arad Y,Spadaro LA,Roth M,et al.Treatment of asymptomatic adults with elevated coronary calcium scores with atorvastatin,vitamin C,and vitamin E:the St.Francis Heart Study randomized clinical trial[J].J Am Coll Cardiol,2005,46(1):166-172.DOI:10.1016/j.jacc.2005.02.089.
• [70]Ajufo E,Ayers CR,Vigen R,et al.Value of coronary artery calcium scanning in association with the net benefit of aspirin in primary prevention of atherosclerotic cardiovascular disease[J].JAMA Cardiol,2021,6(2):179-187.DOI:10.1001/jamacardio.2020.4939.
• [71]Hochstadt A,Itach T,Merdler I,et al.Effectiveness of coronary sinus reducer for treatment of refractory angina:a meta-analysis[J].Can J Cardiol,2022,38(3):376-383.DOI:10.1016/j.cjca.2021.12.009.
• [72]Caceres J,Atal P,Arora R,et al.Enhanced external counterpulsation:a unique treatment for the"No-Option"refractory angina patient[J].J Clin Pharm Ther,2021,46(2):295-303.DOI:10.1111/jcpt.13330.