2026 Focused Update of the Saudi Heart Association Guidelines on Best Practices in the Management of Chronic Coronary Syndromes.

Background: Chronic coronary syndromes (CCS) continue to impose a substantial clinical and economic burden in Saudi Arabia. Since publication of the 2022 Saudi Heart Association (SHA) CCS guidelines, important advances have emerged in diagnosis, pharmacotherapy, cardiometabolic risk reduction, antiplatelet management, and revascularization. This 2026 focused update selectively revises and clarifies key recommendations to reflect these advances within the Saudi context. Methods: A multidisciplinary SHA expert panel conducted a structured review of randomized trials, meta-analyses, and relevant international guidance published since 2022. Updates were restricted to areas with substantive new evidence or evolving clinical practice. Recommendations were formulated through expert consensus in accordance with SHA methodological standards. This document complements the 2022 guideline and does not replace it. Results and conclusions: This focused update advances a more personalized, risk-driven approach to CCS management. Diagnostic algorithms now explicitly integrate pre-test probability, reinforce coronary computed tomography angiography as the preferred initial modality in low-to-intermediate probability, and refine the positioning of functional stress imaging. Residual risk assessment and preventive strategies are also strengthened. Importantly, this update introduces a dedicated diagnostic and management framework for angina and ischemia with non-obstructive coronary arteries (ANOCA/INOCA), emphasizing endotype-specific evaluation and targeted therapy for this historically under-recognized population. Anti-anginal therapy positions beta-blockers and calcium channel blockers as equivalent first-line agents, upgrades long-acting nitrates, and integrates ranolazine, ivabradine, and trimetazidine as evidence-based add-on options. Antiplatelet guidance emphasizes individualized dual antiplatelet therapy duration after percutaneous coronary intervention (PCI), early de-escalation strategies, and selective use of P2Y12 inhibitor monotherapy. Lipid management and cardiovascular risk reduction options are now expanded and revascularization recommendations are restructured. Collectively, these updates strengthen the delivery of contemporary, evidence-based, and patient-centered CCS care and provide a clear framework for implementation across diverse healthcare settings.