Real-world implementation of ESC guidelines in chronic coronary syndromes: Insights from the EURECA registry with a focus on Italian practice

Introduction: The EURECA registry showed that 2019 ESC guideline adoption (GA) for management of Chronic Coronary Syndromes is suboptimal regarding the use of diagnostic tests. The present sub-analysis compared Italian cohort (IC) versus non-Italian cohorts (NIC) and explored Italian regional differences. Methods: Patients were grouped into NIC and IC, this further stratified in Northern, Central, and Southern regions. GA was assessed for the choice of first diagnostic test (Endpoint-A) and for the overall diagnostic pathway (Endpoint-B). Quality-of-life, additional diagnostic test and MACE were assessed at 6-month. Results: Among 4262 patients, 38.4% (1636) were enrolled in Italy (May-2019/March-2020). GA was suboptimal in both cohorts but higher in Italy (p < 0.001 for Endpoint-A and B). In IC vs. NIC exercise-ECG and coronary-CT-angiography were used more frequently (39.6% vs. 25.5%, 35.0% vs. 20.2%; p < 0.001) while stress-imaging and invasive coronary angiography (ICA) were less used (39.4% vs. 45.9%, 22.9% vs. 34.5%; p < 0.001 for both). Exercise-ECG and ICA remained the main drivers of non-GA in both cohorts. Final diagnosis of obstructive-CAD was less frequent in IC than NIC (19.9% vs. 26.9%; p < 0.001), with similar rate of ischemia detection (19. % vs. 18.9%; p = 0.74) and revascularization (12.8% vs. 14.0%; p = 0.27). GA, obstructive-CAD, ischemia, treatment changes and revascularizations were low in Italian-southern region. Six-month MACE was low and not associated with GA in both cohorts. Conclusions: The rate of GA was higher in IC as compared with the NIC but still suboptimal, especially in Italian-southern region. Non-GA was mainly driven by exercise-ECG and ICA as first test use.