How should we manage heart failure treatment before and after revascularisation in case of CCS?

In this discussion, Luigi Biasco and Pasquale Paolisso outline a stepwise strategy for managing chronic coronary syndrome (CCS) in a patient with heart failure and reduced ejection fraction. 

The first priority is optimising heart failure treatment using guideline-directed medical therapy. Once stabilised, myocardial viability should be assessed, preferably with cardiac magnetic resonance imaging (CMR), the gold standard for identifying fibrosis and predicting recovery. If viability is present, functional evaluation of the intermediate coronary lesion with  invasive physiological testing helps guide the need for revascularisation. 

When PCI is indicated, a simplified, single-stent approach is preferred to reduce complexity. Regular follow-up every 3–4 months supports ongoing optimisation and monitoring of LVEF. 

A structured pathway that strengthens clinical decision-making in CCS and heart failure management.