ESC vs. ACC/AHA Guidelines for Non-Invasive Imaging in Chronic Coronary Disease: Guideline Discordance, Gaps, and Future Directions

Abstract Aims Chronic coronary disease remains a complex condition for which non-invasive imaging is central to diagnosis, risk stratification, follow-up, and management. An understanding of contemporary clinical practice guidelines is critical to appropriate test selection, avoidance of low-value testing, and individualized care. This review compares the contemporary European Society of Cardiology guidelines and the American College of Cardiology/American Heart Association guidelines regarding non-invasive imaging for chronic coronary disease/syndromes. Methods and Results The European and American guidelines are broadly concordant in supporting clinical likelihood assessment before testing, selective use of coronary computed tomography angiography (CCTA) and functional imaging, and avoidance of routine surveillance testing in clinically stable patients. However, several distinctions emerge. First, the European guideline provides a more prescriptive diagnostic algorithm for suspected chronic coronary syndromes, using pre-test likelihood thresholds to guide deferral of testing, CCTA, functional imaging, and invasive angiography, whereas the American guideline is more focused on established chronic coronary disease, symptom change, functional decline, and whether testing will alter management. Second, the European guideline assigns a stronger early role to CCTA, particularly in low-to-moderate likelihood patients, and provides more high-risk anatomic and ischemic imaging thresholds. Third, the guidelines differ in the positioning of exercise electrocardiography and in the diagnostic evaluation of angina or ischemia with non-obstructive coronary arteries, microvascular angina, and vasospastic angina. Conclusion The latest ESC guideline remains more diagnosis-forward and algorithmic, whereas the ACC/AHA guideline is more management-forward and symptom-driven. These differences may influence imaging selection, repeat testing, and evaluation of non-obstructive coronary syndromes.