Two different goals cannot be glued into one pill. The first is to relieve ischaemia (pain, exercise limitation). The second is to prevent myocardial infarction, stroke, death. ESC 2024 keeps them separate.
Anti-ischaemic therapy. Short-acting nitrates for immediate relief of an attack (I B, ESC CCS 2024, Recommendation Table 16). In most patients with CCS, initial therapy is a beta-blocker and/or a calcium channel blocker to control heart rate and symptoms (I B). The choice is tailored to comorbidities, heart rate, BP and ejection fraction. Ivabradine is not recommended as add-on therapy in CCS with LVEF >40% and without clinical heart failure (ESC CCS 2024, Recommendation Table 16, class III B); it should be considered as add-on therapy in LV systolic dysfunction (EF <40%) and uncontrolled symptoms (IIa B). The course does not build the full third-line ladder (ranolazine, trimetazidine) as a mandatory student skill: that is the level after the first two classes.
Event prevention.
- Lipid-lowering therapy with an LDL-C target <1.4 mmol/L and a ≥50% reduction — I A in patients with CCS (ESC 2024, consistent with ESC/EAS 2019/2025: CCS = ASCVD = very high risk).
- Antiplatelet therapy. The standard in obstructive atherosclerotic CAD without an indication for an anticoagulant is monotherapy: aspirin 75–100 mg or, as a safe and effective alternative, clopidogrel 75 mg (ESC 2024). After MI or PCI, aspirin 75–100 mg lifelong — I A (ESC CCS 2024, long-term single antiplatelet therapy). After elective PCI for CCS — dual antiplatelet therapy (DAPT) with aspirin+clopidogrel to reduce stent thrombosis and MI. ESC 2024 does not consider replacing clopidogrel with ticagrelor in elective PCI "just because" to be justified (ALPHEUS).
- An extended antithrombotic strategy (prolonged DAPT, ticagrelor 60 mg in PEGASUS-TIMI 54, rivaroxaban 2.5 mg twice daily + aspirin in COMPASS) — only in high ischaemic risk without high bleeding risk. This is not a starting student template.
- RAAS blockers, SGLT2 inhibitors, GLP-1 receptor agonists — as indicated (HF, diabetes, CKD), sections 4.3.3–4.3.4 of ESC 2024; the details lie outside the core of the course, but the student should know that "treatment of CCS" is not reduced to a nitrate and a statin.
Revascularisation. Indicated for symptoms refractory to therapy and to improve prognosis in high-risk anatomy (left main, proximal LAD, multivessel disease with impaired LV function, a large ischaemic area ≥10%). The choice of PCI vs CABG depends on anatomy, diabetes, the SYNTAX score (Synergy between PCI with Taxus and Cardiac Surgery: an anatomical index of the severity of coronary disease that the Heart Team — cardiologist, interventionalist and cardiac surgeon — uses when choosing revascularisation) and the Heart Team (ESC 2024, endorsed by EACTS). The course does not teach how to calculate SYNTAX.
Lifestyle. ESC 2024: aerobic exercise 150–300 min/week of moderate or 75–150 min/week of vigorous intensity, limiting sedentary time (I B, ESC CCS 2024). Smoking cessation. Vaccination against influenza and pneumococcus is considered in the counselling section.
The boundary of the lesson. The course does not cover ACS, cardiogenic shock or mechanical complications of myocardial infarction. It does not cover the full pharmacology of ANOCA/INOCA. It does not replace the local formulary of the Republic of Kazakhstan: whether evolocumab or bempedoic acid is available in a particular pharmacy is a question of the reimbursement list, not of ESC guidelines.