Management of Patients with Chronic Coronary Disease

Publication Date: July 20, 2023
Last Updated: July 20, 2023

Diagnosis

3. Evaluation, Diagnosis, and Risk Stratification

3.1. Diagnostic Evaluation

1. In patients with CCD and a change in symptoms or functional capacity that persists despite GDMT, stress positron emission tomography/single photon emission CT myocardial perfusion imaging (PET/SPECT MPI), cardiovascular magnetic resonance (CMR) imaging, or stress echocardiography is recommended to detect the presence and extent of myocardial ischemia, estimate risk of major adverse cardiovascular events (MACE), and guide therapeutic decision-making.* ( B-NR , I )
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2. In patients with CCD and a change in symptoms or functional capacity that persists despite GDMT, invasive coronary angiography (ICA) is recommended for guiding therapeutic decision-making with the goal of improving anginal symptoms. ( B-R , I )
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3. In patients with CCD and a change in symptoms or functional capacity that persists despite GDMT, when selected for rest/stress nuclear MPI, PET is reasonable in preference to SPECT, if available, to improve diagnostic accuracy and decrease the rate of nondiagnostic test results. ( B-R , IIa )
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4. In patients with CCD and a change in symptoms or functional capacity that persists despite GDMT, exercise treadmill testing can be useful to determine whether the symptoms are consistent with angina pectoris, assess the severity of symptoms, evaluate functional capacity, and guide management. ( B-NR , IIa )
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5. In patients with CCD undergoing stress PET MPI or stress CMR imaging, the addition of myocardial blood flow reserve (MBFR) can be useful to improve diagnostic accuracy and enhance risk stratification. ( B-NR , IIa )
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6. In patients with CCD and a change in symptoms or functional capacity that persists despite GDMT, and who have had previous coronary revascularization, coronary CT angiography (CCTA) is reasonable to evaluate bypass graft or stent patency (for stents ≥3 mm). ( B-NR , IIa )
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3.2. Risk Stratification and Relationship to Treatment Selection

1. In patients with CCD, it is recommended that risk stratification incorporate all available information, including noninvasive, invasive, or both cardiovascular diagnostic testing results or use validated risk scores to classify patients as low (<1%), intermediate (1%-3%), or high (>3%) yearly risk for cardiovascular death or nonfatal MI. ( B-NR , I )
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2. In patients with CCD, optimization of GDMT is recommended to reduce MACE. ( A , I )
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3. In patients with CCD with newly reduced LV systolic function, clinical heart failure, or both, ICA is recommended to assess coronary anatomy and guide potential revascularization. ( A , I )
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4. In patients with CCD, ICA for risk stratification is not routinely recommended in patients without LV systolic dysfunction, heart failure, stable chest pain refractory to GDMT, and/or noninvasive testing suggestive of significant (>50%) left main disease. ( A , III (no benefit) )
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Treatment

4. Treatment

4.1. General Approach to Treatment Decisions

1. In patients with CCD, clinical follow-up at least annually is recommended to assess for symptoms, change in functional status, adherence to and adequacy of lifestyle and medical interventions, and monitoring for complications of CCD and its treatments. ( C-LD , I )
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2. In patients with CCD, use of a validated CCD-specific patient-reported health status measure may be reasonable to assess symptoms, functional status, and QOL. ( B-NR , IIb )
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4.1.1. Team-Based Approach

1. In patients with CCD, a multidisciplinary team-based approach is recommended to improve health outcomes, facilitate modification of ASCVD risk factors, and improve health service utilization. ( A , I )
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4.1.2. Patient Education

1. Patients with CCD should receive ongoing individualized education on symptom management, lifestyle changes, and SDOH risk factors to improve knowledge and facilitate behavior change. ( C-LD , I )
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2. Patients with CCD should receive ongoing individualized education on medication adherence to improve knowledge and facilitate behavior change. ( C-LD , I )
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4.1.3. Shared Decision-Making

1. Patients with CCD and their clinicians should engage in shared decision-making particularly when evidence is unclear on the optimal diagnostic or treatment strategy, or when a significant risk or benefit tradeoff exists. ( C-LD , I )
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2. For patients with CCD and angina on GDMT who are engaged in shared decision-making regarding revascularization, a validated decision aid may be considered to improve patient understanding and knowledge about treatment options. ( B-R , IIb )
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4.1.4. Social Determinants of Health (SDOH)

1. In patients with CCD, routine assessment by clinicians and the care team for SDOH is recommended to inform patient-centered treatment decisions and lifestyle change recommendations. ( B-R , I )
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4.2. Guideline-Directed Management and Therapy

4.2.1. Nutrition, Including Supplements

1. In patients with CCD, a diet emphasizing vegetables, fruits, legumes, nuts, whole grains, and lean protein is recommended to reduce the risk of CVD events. ( B-R , I )
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2. In patients with CCD, reducing the percentage of calories from saturated fat (<6% of total calories) and replacing with dietary monounsaturated and polyunsaturated fat, complex carbohydrates, and dietary fiber can be beneficial to reduce the risk of CVD events. ( B-NR , IIa )
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3. In patients with CCD, minimization of sodium (<2,300 mg/d; optimally 1,500 mg/d) and minimization of processed meats (eg, cured bacon, hot dogs) can be beneficial to reduce the risk of CVD events. ( B-NR , IIa )
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4. In patients with CCD, limiting refined carbohydrates (eg, containing <25% whole grain by weight, including refined cold ready-to-eat breakfast cereal, white bread, white rice), and sugar-sweetened beverages (eg, soft drinks, energy drinks, fruit drinks with added sugars) can be beneficial to reduce the risk of CVD events. ( B-NR , IIa )
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5. In patients with CCD, the intake of trans fat should be avoided because trans fat is associated with increased morbidity and mortality rates. ( B-NR , III (harm) )
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6. In patients with CCD, the use of nonprescription or dietary supplements, including omega-3 fatty acid, vitamins C, D, E, beta-carotene, and calcium, is not beneficial to reduce the risk of acute CVD events. ( B-NR , III (no benefit) )
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4.2.2. Mental Health Conditions

1. In patients with CCD, targeted discussions and screening for mental health is reasonable for clinicians to assess and to refer for additional mental health evaluation and management. ( B-R , IIa )
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2. In patients with CCD, treatment for mental health conditions with either pharmacologic or nonpharmacologic therapies, or both, is reasonable to improve cardiovascular outcomes. ( B-R , IIa )
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4.2.3. Tobacco Products

1. In patients with CCD, tobacco use should be assessed at every health care visit to facilitate identification of those who may benefit from behavioral or pharmacologic interventions. ( A , I )
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2. Patients with CCD who regularly smoke tobacco should be advised to quit at every visit. ( A , I )
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3. In patients with CCD who regularly smoke tobacco, behavioral interventions are recommended to maximize cessation rates in combination with pharmacotherapy, including bupropion, varenicline, or combination long- and short-acting nicotine replacement therapy (NRT). ( A , I )
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4. In patients with CCD who regularly smoke tobacco, varenicline may be considered versus bupropion or NRT to increase cessation rates. ( B-R , IIb )
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5. In patients with CCD who regularly smoke tobacco, the short-term use of nicotine-containing e-cigarettes may be considered to aid smoking cessation, although the risk of sustained use and unknown long-term safety may outweigh the benefits. ( B-R , IIb )
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6. Patients with CCD should avoid secondhand smoke exposure to reduce risk of cardiovascular events. ( B-NR , III (harm) )
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4.2.4. Alcohol and Substance Use

1. Patients with CCD should be routinely asked and counseled about substance use to reduce ASCVD events. ( C-LD , I )
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2. In patients with CCD who consume alcohol, it is reasonable to limit alcohol intake (≤1 drink/d for women, ≤2 drinks/d for men) to reduce cardiovascular and all-cause death. ( B-NR , IIa )
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3. Patients with CCD should not be advised to consume alcohol for the purpose of cardiovascular protection. ( B-NR , III (no benefit) )
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4.2.5. Sexual Health and Activity

1. In patients with CCD, it is reasonable to individualize resumption of sexual activity based on type of sexual activity, exercise capacity, and postprocedural healing. ( B-NR , IIa )
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2. In patients with CCD, cardiac rehabilitation and regular exercise can be useful to reduce the risk of cardiovascular complications with sexual activity. ( B-NR , IIa )
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3. In patients with CCD, phosphodiesterase type 5 inhibitors should not be used concomitantly with nitrate medications because of risk for severe hypotension. ( B-NR , III (harm) )
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4.2.6. Lipid Management

1. In patients with CCD, high-intensity statin therapy is recommended with the aim of achieving a ≥50% reduction in LDL-C levels to reduce the risk of MACE. ( A , I )
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2. In patients in whom high-intensity statin therapy is contraindicated or not tolerated, moderate-intensity statin therapy is recommended with the aim of achieving a 30% to 49% reduction in LDL-C levels to reduce the risk of MACE. ( A , I )
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3. In patients with CCD, adherence to changes in lifestyle and effects of lipid-lowering medication should be assessed by measurement of fasting lipids in 4 to 12 weeks after statin initiation or dose adjustment and then every 3 to 12 months thereafter based on need to assess response or adherence to therapy. ( A , I )
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4. In patients with CCD, the use of generic formulations of maximally tolerated statin therapy is projected to be cost saving. ( B-NR , )
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5. In patients with CCD who are judged to be at very high risk (Table 10) and on maximally tolerated statin therapy with an LDL-C level ≥70 mg/dL (≥1.8 mmol/L), ezetimibe can be beneficial to further reduce the risk of MACE. ( B-R , IIa )
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6. In patients with CCD, addition of generic ezetimibe to maximally tolerated statin therapy in appropriately selected patients is projected to be of high economic value at US prices. ( B-NR , )
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7. In patients with CCD who are judged to be at very high risk (Table 10) and who have an LDL-C level ≥70 mg/dL (≥1.8 mmol/L), or a non–high-density lipoprotein cholesterol level ≥100 mg/dL (≥2.6 mmol/L), on maximally tolerated statin and ezetimibe, a PCSK9 monoclonal antibody can be beneficial to further reduce the risk of MACE. ( A , IIa )
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8. In patients with CCD who are very high risk, the use of PCSK9 monoclonal antibodies is projected to be of uncertain economic value at US prices. ( B-NR , )
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9. In patients with CCD on maximally tolerated statin therapy with an LDL-C level <100 mg/dL (<2.6 mmol/L) and a persistent fasting triglyceride level of 150 to 499 mg/dL (1.7–5.6 mmol/L) after addressing secondary causes, icosapent ethyl may be considered to further reduce the risk of MACE and cardiovascular death. ( B-R , IIb )
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10. In patients with CCD who are not at very high risk and on maximally tolerated statin therapy with an LDL-C level ≥70 mg/dL (≥1.8 mmol/L), it may be reasonable to add ezetimibe to further reduce the risk of MACE. ( B-R , IIb )
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11. In patients with CCD on maximally tolerated statin therapy who have an LDL-C level ≥70 mg/dL (≥1.8 mmol/L), and in whom ezetimibe and PCSK9 monoclonal antibody are deemed insufficient or not tolerated, it may be reasonable to add bempedoic acid or inclisiran (in place of PCSK9 monoclonal antibody) to further reduce LDL-C levels. ( B-R , IIb )
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12. In patients with CCD receiving statin therapy, adding niacin, or fenofibrate or dietary supplements containing omega-3 fatty acids, are not beneficial in reducing cardiovascular risk. ( B-R , III (no benefit) )
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4.2.7. Blood Pressure Management

1. In adults with CCD, nonpharmacologic strategies are recommended as first-line therapy to lower BP in those with elevated BP (120–129/<80 mm Hg) (see Table 12). ( A , I )
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2. In adults with CCD who have hypertension, a BP target of <130/<80 mm Hg is recommended to reduce CVD events and all-cause death. ( B-R , I )
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3. In adults with CCD and hypertension (systolic BP ≥130 and/or diastolic BP ≥80 mm Hg), in addition to nonpharmacological strategies, GDMT angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARB), or beta blockers are recommended as first-line therapy for compelling indications (eg, recent MI or angina), with additional antihypertensive medications (eg, dihydropyridine calcium channel blockers [CCB], long-acting thiazide diuretics, and/or mineralocorticoid receptor antagonists) added as needed to optimize BP control. ( B-R , I )
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4.2.8. SGLT2 Inhibitors and GLP-1 Receptor Agonists

1. In patients with CCD who have type 2 diabetes, the use of either an SGLT2 inhibitor or a GLP-1 receptor agonist with proven cardiovascular benefit is recommended to reduce the risk of MACE. ( A , I )
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2. In patients with CCD and type 2 diabetes, addition of a GLP-1 receptor agonist at US prices is projected to be of high value compared with standard of care. ( B-NR , )
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3. In patients with CCD and type 2 diabetes, addition of an SGLT2 inhibitor at US prices is projected to be of intermediate value compared with standard of care. ( B-NR , )
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4. In patients with CCD and heart failure with LVEF ≤40%, use of an SGLT2 inhibitor is recommended to reduce the risk of cardiovascular death and heart failure hospitalization and to improve QOL, irrespective of diabetes status. ( A , I )
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5. In patients with CCD and heart failure with LVEF ≤40%, addition of an SGLT2 inhibitor to GDMT, irrespective of diabetes status, is projected to be of intermediate value at US prices. ( B-NR , )
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6. In patients with CCD and heart failure with LVEF >40%, use of an SGLT2 inhibitor can be beneficial in decreasing heart failure hospitalizations and to improve QOL, irrespective of diabetes status. ( B-R , IIa )
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7. In patients with CCD and heart failure with LVEF >40%, addition of an SGLT2 inhibitor to GDMT, irrespective of diabetes status, is projected to be of uncertain value at US prices. ( B-NR , )
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4.2.9. Weight Management

1. In patients with CCD, assessment of BMI with or without waist circumference is recommended during routine clinical follow-up. ( C-EO , I )
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2. Patients with CCD and overweight or obesity should receive counseling on diet, lifestyle, and goals for weight loss. ( B-NR , I )
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3. For patients with CCD and overweight or obesity in whom pharmacologic therapy is warranted for further weight reduction, a GLP-1 receptor agonist can be beneficial in addition to counseling for diet and physical activity, and it is reasonable to choose semaglutide over liraglutide. ( B-R , IIa )
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4. In patients with CCD and severe obesity who have not met weight loss goals with lifestyle and pharmacologic intervention, and who have acceptable surgical risk, referral for consideration of a bariatric procedure is reasonable for weight loss and cardiovascular risk factor reduction. ( B-NR , IIa )
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5. In patients with CCD, use of sympathomimetic weight loss drugs is potentially harmful. ( B-R , III (harm) )
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4.2.10. Cardiac Rehabilitation

1. All patients with CCD and appropriate indications
after recent MI, PCI, or CABG should be referred to a cardiac rehabilitation program to improve outcomes. ( A , I )
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with stable angina or after heart transplant should be referred to a cardiac rehabilitation program to improve outcomes. ( B-R , I )
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after recent spontaneous coronary artery dissection event should be referred to a cardiac rehabilitation program to improve outcomes. ( C-LD , I )
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4.2.11. Physical Activity

1. For patients with CCD who do not have contraindications, an exercise regimen is recommended, including ≥150 minutes/wk of moderate-intensity aerobic activities or ≥75 minutes/wk of higher-intensity aerobic activities to improve functional capacity and QOL, and to reduce hospital admission and mortality rates. ( A , I )
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2. For patients with CCD who do not have contraindications, resistance (strength) training exercises are recommended on ≥2 days/wk to improve muscle strength, functional capacity, and cardiovascular risk factor control. ( B-R , I )
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3. For patients with CCD who do not have contraindications, lower-intensity lifestyle activities (eg, walking breaks at work) to reduce sedentary behavior (ie, sitting time) are reasonable to improve functional capacity and reduce cardiovascular risk, especially in individuals with low levels of habitual leisure time physical activity. ( B-NR , IIa )
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4.2.12. Environmental Exposures

1. In patients with CCD, minimization of exposure to ambient air pollution is reasonable to reduce the risk of cardiovascular events. ( B-NR , IIa )
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2. In patients with CCD, minimization of climate-related exposures (eg, extreme temperatures, wildfire smoke) may be reasonable to reduce the risk of cardiovascular events. ( B-NR , IIb )
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4.3. Medical Therapy to Prevent Cardiovascular Events and Manage Symptoms

4.3.1. Antiplatelet Therapy and Oral Anticoagulants (OAC)

Antiplatelet Therapy Without OAC
1. In patients with CCD and no indication for OAC therapy, low-dose aspirin 81 mg (75–100 mg) is recommended to reduce atherosclerotic events. ( A , I )
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2. In patients with CCD treated with PCI, dual antiplatelet therapy (DAPT) consisting of aspirin and clopidogrel for 6 months post PCI followed by single antiplatelet therapy (SAPT) is indicated to reduce MACE and bleeding events. ( A , I )
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3. In select patients with CCD treated with PCI and a drug-eluting stent (DES) who have completed a 1- to 3-month course of DAPT, P2Y12 inhibitor monotherapy for at least 12 months is reasonable to reduce bleeding risk. ( A , IIa )
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4. In patients with CCD who have had a previous MI and are at low bleeding risk, extended DAPT beyond 12 months for a period of up to 3 years may be reasonable to reduce MACE. ( A , IIb )
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5. In patients with CCD and a previous history of MI without a history of stroke, TIA, or ICH, vorapaxar may be added to aspirin therapy to reduce MACE. ( B-R , IIb )
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6. In patients with CCD, the use of DAPT after CABG may be useful to reduce the incidence of saphenous vein graft occlusion. ( B-R , IIb )
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7. In patients with CCD without recent ACS or a PCI-related indication for DAPT, the addition of clopidogrel to aspirin therapy is not useful to reduce MACE. ( A , III (no benefit) )
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8. In patients with CCD and previous stroke, TIA, or ICH, vorapaxar should not be added to DAPT because of increased risk of major bleeding and ICH. ( A , III (harm) )
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9. In patients with CCD and previous stroke, TIA, or ICH, prasugrel should not be used because of risk of significant or fatal bleeding. ( B-R , III (harm) )
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10. In patients with CCD, chronic nonsteroidal anti-inflammatory drugs should not be used because of increased cardiovascular and bleeding complications. ( B-R , III (harm) )
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Antiplatelet Therapy With Direct OAC (DOAC)
11. In patients with CCD who have undergone elective PCI and who require oral anticoagulant therapy, DAPT for 1 to 4 weeks followed by clopidogrel alone for 6 months should be administered in addition to DOAC. ( B-R , I )
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12. In patients with CCD who have undergone PCI and who require oral anticoagulant therapy, continuing aspirin in addition to clopidogrel for up to 1 month is reasonable if the patient has a high thrombotic risk and low bleeding risk. ( B-R , IIa )
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13. In patients with CCD who require oral anticoagulation and have a low atherothrombotic risk, discontinuation of aspirin therapy with continuation of DOAC alone may be considered 1 year after PCI to reduce bleeding risk. ( B-R , IIb )
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14. In patients with CCD who require oral anticoagulation, DOAC monotherapy may be considered if there is no acute indication for concomitant antiplatelet therapy. ( C-LD , IIb )
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Antiplatelet Therapy and Low-Dose DOAC
15. In patients with CCD without an indication for therapeutic DOAC or DAPT and who are at high risk of recurrent ischemic events but low-to-moderate bleeding risk, the addition of low-dose rivaroxaban 2.5 mg twice daily to aspirin 81 mg daily is reasonable for long-term reduction of risk for MACE. ( B-R , IIa )
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DAPT and Proton Pump Inhibitor (PPI)
16. In patients with CCD on DAPT, the use of a PPI can be effective in reducing gastrointestinal bleeding risk. ( B-R , IIa )
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4.3.2. Beta Blockers

1. In patients with CCD and LVEF ≤40% with or without previous MI, the use of beta-blocker therapy is recommended to reduce the risk of future MACE, including cardiovascular death. ( A , I )
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2. In patients with CCD and LVEF <50%, the use of sustained release metoprolol succinate, carvedilol, or bisoprolol with titration to target doses is recommended in preference to other beta blockers. ( A , I )
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3. In patients with CCD who were initiated on beta-blocker therapy for previous MI without a history of or current LVEF ≤50%, angina, arrhythmias, or uncontrolled hypertension, it may be reasonable to reassess the indication for long-term (>1 year) use of beta-blocker therapy for reducing MACE. ( B-NR , IIb )
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4. In patients with CCD without previous MI or LVEF ≤50%, the use of beta-blocker therapy is not beneficial in reducing MACE, in the absence of another primary indication for beta-blocker therapy. ( B-NR , III (no benefit) )
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4.3.3. Renin-Angiotensin-Aldosterone Inhibitors

1. In patients with CCD who also have hypertension, diabetes, LVEF ≤40%, or CKD, the use of ACE inhibitors, or ARBs if ACE inhibitor–intolerant, is recommended to reduce cardiovascular events. ( A , I )
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2. In patients with CCD without hypertension, diabetes, or CKD and LVEF >40%, the use of ACE inhibitors or ARBs may be considered to reduce cardiovascular events. ( B-R , IIb )
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4.3.4. Colchicine

1. In patients with CCD, the addition of colchicine for secondary prevention may be considered to reduce recurrent ASCVD events. ( B-R , IIb )
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4.3.5. Immunizations

1. In patients with CCD, an annual influenza vaccination is recommended to reduce cardiovascular morbidity, cardiovascular death, and all-cause death. ( A , I )
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2. In patients with CCD, coronavirus disease 2019 (COVID-19) vaccination is recommended per public health guidelines to reduce COVID-19 complications. ( C-EO , I )
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3. In patients with CCD, a pneumococcal vaccine is reasonable to reduce cardiovascular morbidity and mortality and all-cause death. ( B-NR , IIa )
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4.3.6. Medical Therapy for Relief of Angina

1. In patients with CCD and angina, antianginal therapy with either a beta blocker, CCB, or long-acting nitrate is recommended for relief of angina or equivalent symptoms. ( B-R , I )
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2. In patients with CCD and angina who remain symptomatic after initial treatment, addition of a second antianginal agent from a different therapeutic class (beta blockers, CCB, long-acting nitrates) is recommended for relief of angina or equivalent symptoms. ( B-R , I )
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3. In patients with CCD, ranolazine is recommended in patients who remain symptomatic despite treatment with beta blockers, CCB, or long-acting nitrate therapies. ( B-R , I )
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4. In patients with CCD, sublingual nitroglycerin or nitroglycerin spray is recommended for immediate short-term relief of angina or equivalent symptoms. ( B-NR , I )
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5. In patients with CCD and normal LV function, the addition of ivabradine to standard anti-anginal therapy is potentially harmful. ( B-R , III (harm) )
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4.3.7. Management of Refractory Angina

1. In patients with CCD, refractory angina, and no other treatment options, enhanced external counterpulsation may be considered for relief of symptoms. ( B-R , IIb )
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4.3.8. Chelation Therapy

EDTA is currently not approved by the FDA for preventing or treating cardiovascular disease.

Revascularization

5. Revascularization

5.1. Revascularization

Goals of Revascularization

1. In patients with CCD and lifestyle-limiting angina despite GDMT and with significant coronary artery stenoses amenable to revascularization, revascularization is recommended to improve symptoms. ( A , I )
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2. In patients with CCD who have significant left main disease or multivessel disease with severe LV dysfunction (LVEF ≤ 35%), CABG in addition to medical therapy is recommended over medical therapy alone to improve survival. ( B-R , I )
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3. In patients with CCD and multivessel disease with severe LV dysfunction, CABG added to optimal medical therapy is of intermediate economic value compared with medical therapy alone. ( B-NR , )
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4. In patients with CCD and multivessel CAD appropriate for either CABG or PCI, revascularization in addition to GDMT is reasonable to lower the risk of cardiovascular events such as spontaneous MI, unplanned urgent revascularizations, or cardiac death. ( B-R , IIa )
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5. In selected patients with CCD and significant left main stenosis for whom PCI can provide equivalent revascularization to that possible with CABG, PCI is reasonable to improve survival. ( B-NR , IIa )
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Decision-Making for Revascularization

6. In patients with CCD who have angina or an anginal equivalent, no previous evaluation for ischemia, and angiographically intermediate stenoses, the use of FFR or other proven nonhyperemic pressure ratios (eg, iFR) is recommended before proceeding with PCI. ( A , I )
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7. In patients with CCD undergoing coronary angiography without previous stress testing, the use of invasive FFR to evaluate angiographically intermediate coronary stenoses before proceeding with PCI is a high economic value intervention. ( B-NR , )
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8. In patients with CCD with complex 3-vessel disease or for whom the optimal treatment strategy is unclear, a Heart Team approach that includes representatives from interventional cardiology and cardiac surgery is recommended to improve patient outcomes. ( B-NR , I )
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5.2. Revascularization: PCI Versus CABG

Patients With CCD

1. In patients with CCD who require revascularization for significant left main involvement associated with high-complexity CAD, CABG is recommended in preference to PCI to improve survival. ( B-R , I )
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2. In patients with CCD who require revascularization for multivessel CAD with complex and diffuse CAD (eg, SYNTAX score >33), it is reasonable to choose CABG over PCI to improve survival. ( B-R , IIa )
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Patients With CCD at High Surgical Risk

3. In patients with CCD who are appropriate for revascularization but poor candidates for surgery, it is reasonable to choose PCI over CABG to improve symptoms and reduce MACE. ( B-NR , IIa )
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Patients With CCD and Diabetes

4. In patients with CCD, diabetes, and multivessel CAD with involvement of the left anterior descending artery who are appropriate candidates for CABG, CABG (with a left internal mammary artery to the left anterior descending artery) is recommended in preference to PCI to reduce mortality and repeat revascularizations. ( A , I )
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5. In patients with CCD and diabetes who have left main stenosis and low- or intermediate-complexity CAD (eg, SYNTAX score ≤33), PCI may be considered as an alternative to CABG to reduce MACE. ( B-R , IIb )
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Special Populations

6.1. Existing Heart Diseases and Conditions

6.1.1. Chronic Management After SCAD

1. In patients with CCD who have experienced SCAD, counseling should be provided regarding potential triggers and risk of SCAD recurrence. ( C-LD , I )
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2. In patients with CCD who have experienced SCAD, evaluation for underlying vasculopathies is reasonable to identify abnormalities in other vascular beds. ( C-LD , IIa )
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3. In patients with CCD who have experienced SCAD, beta-blocker therapy may be reasonable to reduce the incidence of recurrent SCAD. ( C-LD , IIb )
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6.1.2. Ischemia With Nonobstructive Coronary Arteries

1. In symptomatic patients with nonobstructive CAD, a strategy of stratified medical therapy* guided by invasive coronary physiologic testing can be useful for improving angina severity and QOL. ( B-R , IIa )
* See recommendation-specific supportive text for details.
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6.1.3. HF With Preserved or Reduced Ejection Fraction

CAD is the most common cause of HF in the United States and has a pivotal role in the development and progression of both HF with preserved ejection fraction and HF with reduced ejection fraction. Management of patients with CCD and HF with preserved ejection fraction and HF with reduced ejection fraction should follow associated guideline recommendations for revascularization and HF, as well as sections in this guideline: Section 4.2, “Guideline-Directed Medical Therapy,” Section 4.3, “Medical Therapy to Prevent Cardiovascular Events and Manage Symptoms,” and Section 5, “Revascularization.”

6.2. CAD With Valvular Heart Disease

Concurrent CCD is common in patients with valvular heart disease. The evaluation and management of CCD at the time of valve intervention is discussed in the “2021 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.” After valve intervention, patients with valvular heart disease and concomitant CCD should be managed according to current recommendations for secondary prevention as outlined in this guideline. Patients with severe aortic stenosis and concomitant CCD who undergo PCI and transcatheter aortic valve implantation should be treated with DAPT according to the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.

6.3. Young Adults

1. In young adults with CCD, after optimization of traditional cardiovascular risk factors, a comprehensive evaluation and treatment of nontraditional cardiovascular risk factors can be beneficial in reducing the risk of cardiovascular events. ( C-LD , IIa )
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6.4. Cancer

1. In patients with CCD and cancer, a multidisciplinary team including cardiology and oncology expertise is recommended to improve long-term CVD outcomes. ( C-LD , I )
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6.5. Women, Including Pregnancy and Postmenopausal Hormone Therapy

Pregnancy

1. Women with CCD who are contemplating pregnancy or who are pregnant should be risk-stratified and counseled regarding risks of adverse maternal, obstetric, and fetal outcomes. ( C-LD , I )
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2. Women with CCD who are contemplating pregnancy or who are pregnant should receive care from a multidisciplinary cardio-obstetric care team beginning before conception and continuing throughout pregnancy, delivery, and postpartum to improve maternal and fetal outcomes. ( C-LD , I )
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3. In women with CCD, continuation of statin use during pregnancy may be considered. ( C-LD , IIb )
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4. Women with CCD who are contemplating pregnancy or who are pregnant should not use ACE inhibitors, ARBs, direct renin inhibitors, angiotensin receptor-neprilysin inhibitors, or aldosterone antagonists during pregnancy to prevent harm to the fetus. ( C-LD , III (harm) )
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Postmenopausal Hormone Therapy

5. Women with CCD should not receive systemic postmenopausal hormone therapy because of a lack of benefit on MACE and mortality, and an increased risk of venous thromboembolism. ( A , III (harm) )
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6.6. Older Adults

Table 22. The Geriatric 5 Ms

Having trouble viewing table?
Mind Mentation, dementia, delirium, depression
Mobility Impaired gait and balance, fall injury prevention
Medications Polypharmacy, deprescribing, optimal prescribing
Adverse medication effects and medication burden
Multicomplexity Multimorbidity
Complex biopsychosocial situations
Matters most Each individual’s own meaningful health outcome goals and care preferences
Adapted with permission from Molnar F, et al. Can Fam Physician. 2019;65:39. Copyright 2017 Canadian Geriatrics Society
and from Molnar F, et al. Copyright 2019 The College of Family Physicians of Canada. The GERIATRIC 5Ms, Copyright © 2017 Frank Molnar,
Allen Huang, Mary Tinetti. 2017.

The Geriatric 5Ms may be used for educational purposes with full attribution and no alterations.
This work is bound by the Creative Commons license CC-BY-NC-ND 4.0 (https://creativecommons.org/licenses/by-nc-nd/4.0/).

6.7. Chronic Kidney Disease

1. In patients with CCD and CKD, measures should be taken to minimize the risk of treatment-related acute kidney injury. ( C-LD , I )
706

6.8. HIV and Autoimmune Disorders

HIV

1. In adults with CCD and HIV, antiretroviral therapy is beneficial to decrease the risk of cardiovascular events. ( B-R , I )
706
2. In adults with CCD and HIV, it is reasonable to choose antiretroviral therapy regimens associated with more favorable lipid and cardiovascular risk profiles with consideration of drug-drug interactions. ( B-R , IIa )
706
3. In adults with CCD and HIV, lovastatin or simvastatin should not be administered with protease inhibitors as this may cause harm. ( C-LD , III (harm) )
706

Autoimmune Disorders in CCD

4. In adults with CCD and rheumatoid arthritis, initiation and maintenance of disease modifying anti-rheumatoid drugs is beneficial to decrease the risk of cardiovascular events. ( C-LD , IIa )
706
5. In adults with CCD and autoimmune diseases, treatment with biologics and other immune modulating therapies that reduce disease activity may be considered to decrease the risk of cardiovascular events. ( C-LD , IIb )
706
6. In patients with CCD and rheumatoid arthritis, high-dose glucocorticoids should not be used long term if alternative therapies are available because of increased cardiovascular risk. ( C-LD , III (harm) )
706

6.9. Cardiac Allograft Vasculopathy in Heart Transplant Recipients

1. In patients with cardiac allograft vasculopathy, statins are recommended for secondary prevention to reduce MACE. ( C-LD , I )
706
2. In patients with cardiac allograft vasculopathy, aspirin can be beneficial for secondary prevention to reduce MACE. ( C-LD , IIa )
706
3. In patients with severe cardiac allograft vasculopathy, revascularization is reasonable in those with suitable anatomy to potentially mitigate the adverse long-term consequences of cardiac allograft vasculopathy. ( C-LD , IIa )
706

Patient Follow-Up: Monitoring and Managing Symptoms

7.1. Follow-Up Plan and Testing in Stable Patients

1. In stable patients with CCD and with previous ACS or coronary revascularization, referral to telehealth programs, community-based programs, or both for lifestyle interventions may be reasonable as an adjunct to usual care to improve management of cardiovascular risk factors. ( B-R , IIb )
706
2. In patients with CCD without a change in clinical or functional status on optimized GDMT, routine periodic testing with coronary CTA or stress testing with or without imaging is not recommended to guide therapeutic decision-making. ( B-R , III (no benefit) )
706
3. In patients with CCD without a change in clinical or functional status, routine periodic reassessment of LV function is not recommended to guide therapeutic decision-making. ( B-R , III (no benefit) )
706
4. In patients with CCD without a change in clinical or functional status, routine periodic invasive coronary angiography should not be performed to guide therapeutic decision-making. ( B-NR , III (harm) )
706

Other Important Considerations

8.1. Cost and Value Considerations

1. When discussing treatment and prevention with patients who have CCD, it is recommended that the health care team discuss out-of-pocket costs for medications at the time of initiating a new medication and at least annually thereafter to preempt cost-related nonadherence. ( B-NR , I )
706

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Management of Patients with Chronic Coronary Disease

Authoring Organizations

Publication Month/Year

July 20, 2023

Last Updated Month/Year

February 14, 2024

Document Type

Guideline

Country of Publication

US

Document Objectives

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. 

Target Patient Population

Patients diagnosed with chronic coronary disease.

Target Provider Population

Clinicians working with patients with chronic coronary disease in outpatient settings.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Outpatient

Intended Users

Nurse, nurse practitioner, community pharmacist, health systems pharmacist, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D003327 - Coronary Disease

Keywords

social determinants of health, myocardial infarction (MI), coronary artery disease, Ischemic Heart Disease, CAD, Coronary Artery Revascularization, chronic coronary disease, CCD, SDOH, chronic angina

Source Citation

Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF,  Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mark DB, Mahtta D, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC Guideline for the Management of Patients with Chronic Coronary Disease: a report of the American Heart Association/American College of Cardiolog y Joint Committee on Clinical Practice Guidelines. [published online ahead of print July 20, 2023]. J Am Coll Cardiol. doi: 10.1016/j.jacc.2023.04.003.

Copublished in Circulation. doi: 10.1161/CIR.0000000000001168.

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
1321
Literature Search Start Date
September 1, 2021
Literature Search End Date
May 1, 2022