The American Heart Association (AHA) and American College of Cardiology (ACC), as well as several other associations, have issued an updated guideline for managing patients with chronic coronary disease (CCD), as jointly published in Circulation and the Journal of the American College of Cardiology.

The 2023 AHA/ACC/American College of Clinical Pharmacy (ACCP)/American Society for Preventive Cardiology (ASPC)/National Lipid Association (NLA)/Preventive Cardiovascular Nurses Association (PCNA) Guideline for the Management of Patients With Chronic Coronary Disease is intended to provide a patient-centered approach to managing patients with chronic coronary disease that integrates shared decision-making, social determinants of health, and team-based care. The main audience is clinicians in primary care and the cardiology specialty who care for patients with chronic coronary disease in the outpatient setting.

“[The guideline] aims to provide succinct recommendations in the domains of diagnostic evaluation, symptom relief, improvement in quality of life (QOL), and reduction of future atherosclerotic cardiovascular disease-related events and heart failure (HF) in patients with CCD [chronic coronary disease],” stated the writing committee.

The committee was comprised of general cardiologists, interventional cardiologists, cardiovascular surgeons, cardiac imaging experts, advance practice nurses, clinical pharmacists, health economists, and layperson/patient representatives.

The guideline is an update to and replaces the 2012 American College of Cardiology Foundation (ACCF)/AHA/American College of Chest Physicians (ACP)/American Association for Thoracic Surgery (AATS)/PCNA/Society for Cardiovascular Angiography and Interventions (SCAI)/Society of Thoracic Surgeons (STS) Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease and the 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease.

Committee members performed an extensive literature search in MEDLINE, EMBASE, Cochrane Library, the Agency for Healthcare Research and Quality, and other databases for relevant human studies published in English from September 24, 2021, to May 2022. Additional studies published through November 2022 during the writing process also were considered.

Each recommendation was given a class of recommendation (COR) and level of evidence (LOE) grade. A number of the recommendations were published in previous guidelines, and other recommendations have been modified with formatting changes or adapted with substantive changes.

Among the top 10 take-home messages in the guidelines, according to the writing committee, nonpharmacologic therapies such as healthy dietary habits and exercise are recommended for all patients with chronic coronary disease. Lifestyle-related factors that can help lower elevated blood pressure (BP) include weight loss, a heart-healthy diet that is rich in fruits and vegetables, reduced dietary sodium, physical activity, and reduction or abstinence of alcohol.

A strong recommendation (COR 1) was issued for nonpharmacologic strategies as first-line treatment to lower BP in adults with chronic coronary disease and elevated BP (120-129/<80 mm Hg; LOE A). For adults with chronic coronary disease and hypertension, a BP target of less than 130/80 mm Hg is strongly recommended to reduce cardiovascular disease (CVD) events and all-cause death (LOE B-randomized [R]). Also, for adults with chronic coronary disease and hypertension (systolic BP ≥130 and/or diastolic BP ≥80 mmHg), guideline-directed management and therapy (GDMT) angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARB), or beta blockers in addition to nonpharmacologic strategies are strongly recommended as first-line therapy for indications such as recent myocardial infarction (MI) or angina, with additional antihypertensive medications added as needed for optimal BP control (LOE B-R).

Habitual physical activities such as nonexercise lifestyle activities, aerobic exercise training, and resistance (strength) training are associated with improved outcomes in patients with CVD, and a change from sedentary lifestyle habits to at least lower-intensity physical activities can improve metabolic and cardiovascular health. For patients with chronic coronary disease who do not have contraindications, an exercise regimen is strongly recommended, including 150 minutes or more per week of moderate-intensity aerobic activities or 75 minutes or more per week of higher-intensity aerobic activities to improve functional capacity and QOL and to reduce hospital admission and mortality (LOE A). For patients with chronic coronary disease without contraindications, resistance (strength) training exercises are strongly recommended 2 days or more per week to improve muscle strength, functional capacity, and cardiovascular risk factor control (LOE B-R).

Sodium glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists can significantly lower the risk for major adverse cardiovascular events (MACE) in patients with chronic coronary disease and type 2 diabetes, with additional benefits for weight loss and progression of kidney disease. For patients with chronic coronary disease and HF with left ventricular ejection fraction (LVEF) of 40% or less, the committee issued a strong recommendation for use of an SGLT2 inhibitor to reduce the risk of cardiovascular death and HF hospitalization and to improve QOL, regardless of diabetes status (LOE A).

Among patients with chronic coronary disease and without previous MI or LVEF of  50% or less, the committee found no benefit for the use of beta-blockers in reducing MACE, without another primary indication for a beta-blocker (LOE B-not randomized [NR]).

For patients with chronic coronary disease and angina, antianginal therapy with a beta blocker, calcium channel blocker (CCB), or long-acting nitrate is strongly recommended for relief of angina or similar symptoms (LOE B-R). Among patients with chronic coronary disease and angina who are symptomatic after initial treatment, adding a second antianginal agent from a different therapeutic class (beta blockers, CCB, long-acting nitrates) is strongly recommended for relief of angina or equivalent symptoms (LOE B-R). Also, ranolazine is strongly recommended in patients who are still symptomatic after use of beta blockers, CCB, or long-acting nitrates (LOE B-R).

For lipid management, 3 strong recommendations (all LOE A) were provided. For patients with chronic coronary disease, high-intensity statins are strongly recommended to achieve a 50% or more decrease in low-density lipoprotein cholesterol (LDL-C) levels to lower the risk for MACE. In patients for whom high-intensity statins are contraindicated or not tolerated, moderate-intensity statins are strongly recommended with the goal of a 30% to 49% decrease in LDL-C levels to reduce the risk for MACE. Also, the committee strongly recommends that adherence to changes in lifestyle and effects of lipid-lowering medication should be assessed by measuring fasting lipids 4 to 12 weeks after statin initiation or dose adjustment and every 3 to 12 months afterward according to the need to assess response or adherence to treatment.

In patients with chronic coronary disease who receive percutaneous coronary intervention (PCI), dual antiplatelet therapy with aspirin and clopidogrel for 6 months after PCI followed by single antiplatelet therapy is indicated for reducing MACE and bleeding events (strong recommendation; LOE A). For patients with chronic coronary disease and no indication for oral anticoagulant therapy, low-dose aspirin 81 mg (75-100 mg) is strongly recommended to reduce atherosclerotic events (LOE A).

Among the recommendations for nutrition, the committee concluded that there is no benefit for using nonprescription or dietary supplements, including omega-3 fatty acids, vitamins C, D, and E, beta-carotene, and calcium, to lower the risk for acute CVD events in patients with chronic coronary disease (LOE B-NR). The committee also found that there is harm regarding the intake of trans fat for patients with chronic coronary disease, recommending that trans fat be avoided because it is associated with increased morbidity and mortality (LOE B-NR). The committee noted that the only omega-3 fatty acid formulation that can be recommended in patients with chronic coronary disease is icosapent ethyl (EPA only). A strong recommendation was given for emphasizing a diet that includes vegetables, fruits, legumes, nuts, whole grains, and lean protein to lower the risk for CVD events (LOE B-R).

For patients with chronic coronary disease who do not have a change in clinical or functional status, the committee concluded that routine periodic invasive coronary angiography should not be conducted to guide therapeutic decision-making (harm; LOE B-NR).

Regarding tobacco products, strong recommendations were given for assessing tobacco use at every health care visit for patients with chronic coronary disease, as well as advising those who regularly smoke tobacco to quit at every visit (both LOE A). Also, among patients with chronic coronary disease who regularly smoke tobacco, behavioral interventions are strongly recommended to maximize cessation rates combined with pharmacotherapy, including bupropion, varenicline, or combination long- and short-acting nicotine replacement therapy (LOE A). In addition, for patients who regularly smoke tobacco, the short-term use of nicotine-containing e-cigarettes may be considered to aid smoking cessation, although the risk for continued use and unknown long-term safety may outweigh the benefits (COR 2b; LOE B-R).

Among other topics addressed, the committee issued a strong recommendation that optimization of GDMT is recommended to reduce MACE in patients with chronic coronary disease (LOE A). The committee also gave a strong recommendation for invasive coronary angiography to assess coronary anatomy and guide potential revascularization in patients with chronic coronary disease with newly reduced left ventricular systolic function, clinical heart failure, or both (LOE A).

Among patients with chronic coronary disease who need revascularization for significant left main involvement associated with high-complexity coronary artery disease (CAD), coronary artery bypass grafting (CABG) is strongly recommended vs PCI to improve survival (LOE B-R). Also, among patients with chronic coronary disease who require revascularization for multivessel CAD and complex and diffuse CAD (SYNTAX score >33), CABG is reasonable vs PCI to improve survival (COR 2a; LOE B-R).

The committee also issued a strong recommendation that health care providers discuss out-of-pocket costs for medications when patients are initiating a new medication and at least annually afterward to preempt cost-related nonadherence (LOE B-NR).

Key areas of future research, according to the committee, include topics such as how advances in noninvasive imaging technology may affect detection of patients with chronic coronary disease and their eligibility for preventive therapy, as well as validated comprehensive risk scores for MACE in patients with chronic coronary disease. In addition, high-quality studies are needed to assess the effects of marijuana and other substances on cardiovascular outcomes in patients with chronic coronary disease, as well as the long-term effect of treatment of mental health conditions such as depression.

“The population of patients with CCD [chronic coronary disease] is heterogenous, and the risk of future cardiovascular events is not uniform across this patient population,” stated the committee. “Therefore, clinicians should prioritize therapies based on a patient’s future risk of CVD-related events.”