Management of Patients with Chronic Coronary Disease
Overview
Overview
Key Points
- Chronic coronary disease (CCD) is heterogeneous group of conditions that includes obstructive and nonobstructive coronary artery disease (CAD) with or without previous myocardial infarction (MI) or revascularization, ischemic heart disease diagnosed only by noninvasive testing, and chronic angina syndromes with varying underlying causes and the risk of future cardiovascular (CV) events is not uniform with symptom relief and improvement in quality of life (QOL) important considerations.
- Approximately 20.1 million persons in the United States live with CCD.
- 11.1 million Americans have chronic stable angina pectoris, and approximately one-quarter (n=200,000) of all MIs in the United States occur among the 8.8 million persons with CCD who have had a previous MI (Table 4).
- Despite an approximate 25% overall relative decline in death from coronary heart disease (CHD) over the past decade, it remains the leading cause of death in the United States and worldwide and is associated with substantial individual, economic, and societal burdens. Within the United States (Figures 1 and 2; Table 4) and worldwide (Figure 3), the prevalence of CCD and chronic stable angina vary by age, sex, race, ethnicity, and geographic region, and the role of social determinants of health (SDOH) in both risk for and outcomes from CCD is increasingly recognized.
- The number and complexity of comorbid conditions and concurrent treatments for those conditions among patients with CCD have increased.
- Thus, this guideline will address established diagnostic, risk stratification, and treatment approaches in a contemporary context, new therapies, and the intersection between CCD and other comorbid diseases in a framework that recognizes the importance of shared decision-making, team-based care, and cost and value.
CCD Definition
- This guideline is intended to apply to the following categories of patients in the outpatient setting:
- Patients discharged after admission for an acute coronary syndrome (ACS) event or after coronary revascularization procedure and after stabilization of all acute cardiovascular issues.
- Patients with left ventricular (LV) systolic dysfunction and known or suspected coronary artery disease (CAD) or those with established cardiomyopathy deemed to be of ischemic origin.
- Patients with stable angina symptoms (or ischemic equivalents such as dyspnea or arm pain with exertion) medically managed with or without positive results of an imaging test.
- Patients with angina symptoms and evidence of coronary vasospasm or microvascular angina.
- Patients diagnosed with CCD based solely on the results of a screening study (stress test, coronary computed tomography angiography [CTA]), and the treating clinician concludes that the patient has coronary disease.
Top 10 Take-Home Messages for Chronic Coronary Disease
- Emphasis is on team-based, patient-centered care that considers social determinants of health along with associated costs while incorporating shared decision-making in risk assessment, testing, and treatment.
- Nonpharmacologic therapies, including healthy dietary habits and exercise, are recommended for all patients with CCD.
- Patients with CCD who are free from contraindications are encouraged to participate in habitual physical activity, including activities to reduce sitting time and to increase aerobic and resistance exercise. Cardiac rehabilitation for eligible patients provides significant cardiovascular benefits, including decreased morbidity and mortality outcomes.
- Use of sodium glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists are recommended for select groups of patients with CCD, including groups without diabetes.
- New recommendations for beta-blocker use in patients with CCD:
(a) Long-term beta-blocker therapy is not recommended to improve outcomes in patients with CCD in the absence of myocardial infarction in the past year, left ventricular ejection fraction ≤50%, or another primary indication for beta-blocker therapy; and (b) Either a calcium channel blocker or beta blocker is recommended as first-line antianginal therapy. - Statins remain first line therapy for lipid lowering in patients with CCD. Several adjunctive therapies (eg, ezetimibe, PCSK9 [proprotein convertase subtilisin/kexin type 9] inhibitors, inclisiran, bempedoic acid) may be used in select populations, although clinical outcomes data are unavailable for novel agents such as inclisiran.
- Shorter durations of dual antiplatelet therapy are safe and effective in many circumstances, particularly when the risk of bleeding is high and the ischemic risk is low to moderate.
- The use of nonprescription or dietary supplements, including fish oil and omega-3 fatty acids or vitamins, is not recommended in patients with CCD given the lack of benefit in reducing cardiovascular events.
- Routine periodic anatomic or ischemic testing without a change in clinical or functional status is not recommended for risk stratification or to guide therapeutic decision-making in patients with CCD.
- Although e-cigarettes increase the likelihood of successful smoking cessation compared with nicotine replacement therapy, because of the lack of long-term safety data and risks of sustained use, e-cigarettes are not recommended as first-line therapy for smoking cessation.
Introduction
...roduction...
...te: The numbering of the following tables...
...4. US Heart Disease Prevalence, by Age, Race, Et...
...revalence of CHD per 100,000, by Ag...
...2. “Ever Told You Had Angina or CHD?â€...
...igure 3. Global Age-Adjusted Prevalence...
Diagnosis
...agnosis
...Diagnosis, and Risk Stratification...
...gnostic Evaluation...
...patients with CCD and a change in symptoms or...
...patients with CCD and a change in symptoms or...
...In patients with CCD and a change in symptoms...
...with CCD and a change in symptoms or func...
...tients with CCD undergoing stress PET MPI or stre...
...In patients with CCD and a change in symptom...
...tification and Relationship to Treatment S...
...atients with CCD, it is recommended tha...
...patients with CCD, optimization of...
...tients with CCD with newly reduced LV systolic fun...
...n patients with CCD, ICA for risk stratifi...
...Potential Features Associated With...
Treatment
...eatment
...reatment...
...General Approach to Treatment Decisio...
...s with CCD, clinical follow-up at least...
...patients with CCD, use of a validated...
...ains to Consider When Seeing a Patient Wit...
.... Team-Based Approach
...In patients with CCD, a multidisciplinary team...
.... Team-Based Approach Reflective of...
...Patient Education...
...ents with CCD should receive ongoing i...
...ith CCD should receive ongoing indiv...
...3. Shared Decision-Making...
.... Patients with CCD and their clinicians...
...r patients with CCD and angina on GDMT who are...
...Social Determinants of Healt...
1. In patients with CCD, routine assessme...
...gure 6. Social Determinants of Health and Card...
...e-Directed Management and Therapy
...tion, Including Supplements...
...patients with CCD, a diet emphasizing vegetabl...
...patients with CCD, reducing the perc...
...tients with CCD, minimization of...
.... In patients with CCD, limiting ref...
...ents with CCD, the intake of trans fat sho...
...nts with CCD, the use of nonprescription or die...
Figure 7. Recommended Nu...
....2.2. Mental Health Con...
...with CCD, targeted discussions and screeni...
...with CCD, treatment for mental health condit...
...able 6. Suggested Screening Tool to Assess Psychol...
...ed Screening Questions to Assess ...
...3. Tobacco Product...
...ents with CCD, tobacco use should be assessed at e...
...ients with CCD who regularly smoke tobacco...
...ts with CCD who regularly smoke tobacco, beha...
...In patients with CCD who regularly...
...patients with CCD who regularly smoke toba...
...s with CCD should avoid secondhand smoke expos...
Table 8. Behavioral Resources for Smoking Cessatio...
...2.4. Alcohol and Substanc...
...Patients with CCD should be routinely asked an...
...tients with CCD who consume alcohol, it is reaso...
.... Patients with CCD should not be advised to con...
...tances With Abuse Potential and Adverse Card...
.... Sexual Health and Activity...
1. In patients with CCD, it is reasonable...
...ith CCD, cardiac rehabilitation and regula...
...atients with CCD, phosphodiesterase type...
...2.6. Lipid Management
...ts with CCD, high-intensity statin...
...atients in whom high-intensity statin therapy i...
...atients with CCD, adherence to changes in lifestyl...
...ith CCD, the use of generic formulation...
...s with CCD who are judged to be at very...
...with CCD, addition of generic ezetimibe to ma...
...In patients with CCD who are judged to be a...
...ts with CCD who are very high risk, the use of PCS...
...In patients with CCD on maximally tolerated stat...
...tients with CCD who are not at very...
...ts with CCD on maximally tolerated s...
...n patients with CCD receiving statin...
...Very High-Risk* of Future ASCVD Event...
...re 8. Lipid Management in Patient...
...1. High-, Moderate-, and Low-Intensity...
...Blood Pressure Management
...lts with CCD, nonpharmacologic strategies are reco...
...n adults with CCD who have hypertension,...
3. In adults with CCD and hypertensi...
...onpharmacologic Strategies for Blood Pressur...
....2.8. SGLT2 Inhibitors and GLP-1 Receptor Ago...
...with CCD who have type 2 diabetes, the...
...s with CCD and type 2 diabetes, additio...
...patients with CCD and type 2 diabet...
...In patients with CCD and heart failur...
...ients with CCD and heart failure with LVEF â‰...
...atients with CCD and heart failure with...
...patients with CCD and heart failure with LVEF...
...2.9. Weight Manag...
...In patients with CCD, assessment of B...
...ents with CCD and overweight or obesi...
...with CCD and overweight or obesity in whom...
...patients with CCD and severe obesity who have no...
...with CCD, use of sympathomimetic weight loss...
4.2.10. Cardiac Rehab...
...recent MI, PCI, or CABG should be refe...
...stable angina or after heart transplant shoul...
...recent spontaneous coronary artery d...
...3. Core Components of CR...
...11. Physical Acti...
...s with CCD who do not have contraindication...
...r patients with CCD who do not have contraindicati...
...tients with CCD who do not have contraindication...
...Environmental Exposures...
...ts with CCD, minimization of exposure to ambient...
...ith CCD, minimization of climate-related...
...ical Therapy to Prevent Cardiovascular Eve...
...Antiplatelet Therapy and Oral Antic...
...tiplatelet Therapy Withou...
...tients with CCD and no indication for...
...s with CCD treated with PCI, dual antiplat...
...ct patients with CCD treated with PCI and...
...n patients with CCD who have had a previous MI...
...ents with CCD and a previous history of M...
...patients with CCD, the use of DAPT after CA...
...nts with CCD without recent ACS or a PCI-r...
...In patients with CCD and previous stroke,...
...n patients with CCD and previous stroke...
...n patients with CCD, chronic nonsteroid...
...herapy With Direct OAC (DOAC)...
...nts with CCD who have undergone elective PCI a...
...ients with CCD who have undergone PCI and who r...
...atients with CCD who require oral ant...
...ients with CCD who require oral anticoagulati...
...tiplatelet Therapy and Low-Dose DOAC...
15. In patients with CCD without an indi...
...T and Proton Pump Inhibi...
16. In patients with CCD on DAPT, the use...
...ure 9. Recommended Duration of Antiplatelet Therap...
4.3.2. Beta Bloc...
...patients with CCD and LVEF ≤40% wit...
...ents with CCD and LVEF...
3. In patients with CCD who were initiated...
...ith CCD without previous MI or LVEF ≤50%, t...
4.3.3. Renin-Angiotensin-Aldosterone Inhi...
...ith CCD who also have hypertension,...
...s with CCD without hypertension, diabetes, or CKD...
.... Colchicine...
...ents with CCD, the addition of colchicine for se...
....3.5. Immunizations
...with CCD, an annual influenza vacc...
...ts with CCD, coronavirus disease 2019 (...
...patients with CCD, a pneumococcal vaccine is rea...
.... Medical Therapy for Relief of Angina...
...atients with CCD and angina, antianginal ther...
...n patients with CCD and angina who remain...
...nts with CCD, ranolazine is recommended in pati...
...n patients with CCD, sublingual nitroglyceri...
...tients with CCD and normal LV function, the a...
...Management of Refractory Angina...
...with CCD, refractory angina, and no other treatme...
...3.8. Chelation Th...
...tly not approved by the FDA for preventing or...
Revascularization
...scularization...
.... Revascularizatio...
.... Revascularization...
...of Revascularization
...patients with CCD and lifestyle-limiting angina de...
...tients with CCD who have significant left main...
...nts with CCD and multivessel disease with se...
...In patients with CCD and multivessel CAD a...
...selected patients with CCD and significa...
...king for Revascularization...
...tients with CCD who have angina or an anginal equi...
...atients with CCD undergoing coronary...
...s with CCD with complex 3-vessel d...
...larization: PCI Versus CABG...
...tients With CCD
...atients with CCD who require revascularization...
...ients with CCD who require revascular...
...ith CCD at High Surgical Risk...
...ith CCD who are appropriate for revascul...
...nts With CCD and Diabetes...
...tients with CCD, diabetes, and multivessel CAD...
...patients with CCD and diabetes who have left main...
Special Populations
...al Populations...
...ting Heart Diseases and Conditions
....1. Chronic Management A...
...nts with CCD who have experienced SCAD, coun...
...atients with CCD who have experienced...
...ents with CCD who have experienced SCAD,...
...Screening Questions for SCAD-Associa...
...ia With Nonobstructive Coronary Arte...
...n symptomatic patients with nonobstructive C...
.... Clinical Criteria for Suspecting Microvascula...
...gnostic Criteria for Vasospastic AnginaNitrate-re...
...17. Invasive Coronary Function Testing Definiti...
...Preserved or Reduced Ejection Fraction...
...AD is the most common cause of HF in the United...
...D With Valvular Heart Disease...
...t CCD is common in patients with valvular heart...
.... Young Adults...
...adults with CCD, after optimization of...
...Traditional and Nontraditional Ris...
...9. Nonatherosclerotic Causes of CCD...
...4. Cancer...
...patients with CCD and cancer, a mult...
...en, Including Pregnancy and Postmenopaus...
...egnancy
...h CCD who are contemplating pregnancy o...
...with CCD who are contemplating pregnancy o...
...ith CCD, continuation of statin use durin...
...th CCD who are contemplating pregnancy or who a...
...nopausal Hormone Therapy...
...D should not receive systemic postmenopausa...
...Team-Based Cardio-Obstetrics Model of CareThe c...
...CARPREG II Risk Prediction Model -Â CARPREG II...
...le 20. CARPREG II Risk Prediction Model -Â CA...
...ety of Cardiovascular Medications During Pr...
6.6. Older Ad...
...22. The Geriatric 5 MsHaving trouble viewing...
...7. Chronic Kidney Dise...
...ts with CCD and CKD, measures should be tak...
...and Autoimmune Disorders
...IV
...s with CCD and HIV, antiretroviral ther...
...adults with CCD and HIV, it is reas...
...s with CCD and HIV, lovastatin or simvastatin s...
...mmune Disorders in CCD...
...th CCD and rheumatoid arthritis, init...
...lts with CCD and autoimmune diseases, treatment...
...atients with CCD and rheumatoid arth...
...3. Common Antiretroviral Therapy Drugs and...
....9. Cardiac Allograft Vasculopathy in Heart Tra...
...nts with cardiac allograft vasculopathy, s...
...with cardiac allograft vasculopath...
...ts with severe cardiac allograft vasculopathy,...
...able 24. Drug-Drug Interactions With Stat...
Patient Follow-Up: Monitoring and Managing Symptoms
...low-Up: Monitoring and Managing Symptoms...
...w-Up Plan and Testing in Stable Patients...
...In stable patients with CCD and with previous ACS...
...ents with CCD without a change in...
...In patients with CCD without a change in...
...In patients with CCD without a chang...
Other Important Considerations
...ther Important Consider...
...and Value Considerations...
...ussing treatment and prevention with...