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
Introducti...
...he numbering of the following tables may diffe...
Table 4. US Heart Disease Prevalence, by Age...
...ure 1. US Prevalence of CHD per 100,000, by Ag...
...gure 2. “Ever Told You Had Angina o...
...lobal Age-Adjusted Prevalence of CC...
Diagnosis
...iagnosi...
..., Diagnosis, and Risk Stratificatio...
....1. Diagnostic Evaluatio...
...tients with CCD and a change in symptoms o...
...atients with CCD and a change in symptoms or fu...
...ts with CCD and a change in symptoms or fun...
...In patients with CCD and a change in sympt...
...tients with CCD undergoing stress PET MPI...
...ts with CCD and a change in symptoms or functio...
...sk Stratification and Relationship to Trea...
...In patients with CCD, it is recommended...
...ts with CCD, optimization of GDMT is re...
...In patients with CCD with newly reduced LV sys...
...tients with CCD, ICA for risk stratification...
...Potential Features Associated With a Higher Ris...
Treatment
Treatm...
...Treatment
...eral Approach to Treatment Decis...
...nts with CCD, clinical follow-up at...
...patients with CCD, use of a validated CCD-speci...
.... Domains to Consider When Seeing a Patient...
...Team-Based Approach...
...with CCD, a multidisciplinary team-based ap...
...igure 5. Team-Based Approach Reflective...
....2. Patient Education...
...Patients with CCD should receive...
...with CCD should receive ongoing individualized e...
...Shared Decision-Making...
...CCD and their clinicians should engage...
...tients with CCD and angina on GDMT who...
...cial Determinants of Health (...
...In patients with CCD, routine assess...
...6. Social Determinants of Health and Cardiova...
...ne-Directed Management and Therapy...
...rition, Including Supplements...
...with CCD, a diet emphasizing vegeta...
...tients with CCD, reducing the percentage of c...
...s with CCD, minimization of sodium (...
...patients with CCD, limiting refined...
...s with CCD, the intake of trans fat should be a...
.... In patients with CCD, the use of nonp...
...e 7. Recommended Nutrition...
...2. Mental Health Condit...
...ts with CCD, targeted discussions and scre...
...s with CCD, treatment for mental health co...
...le 6. Suggested Screening Tool to Assess...
...7. Suggested Screening Questions...
.... Tobacco Product...
...with CCD, tobacco use should be assessed at...
...s with CCD who regularly smoke tobacco should be...
...ts with CCD who regularly smoke tobacco, be...
4. In patients with CCD who regularly smoke...
...ients with CCD who regularly smoke tobacco, the sh...
...s with CCD should avoid secondhand smoke...
...ehavioral Resources for Smoking CessationH...
...lcohol and Substance Use...
...h CCD should be routinely asked and cou...
...with CCD who consume alcohol, it is...
...tients with CCD should not be advised...
...ances With Abuse Potential and Adverse Car...
...ual Health and Activity...
...tients with CCD, it is reasonable to indivi...
...In patients with CCD, cardiac rehabilita...
...patients with CCD, phosphodiesterase...
...2.6. Lipid Manage...
...ients with CCD, high-intensity statin therap...
2. In patients in whom high-intensity st...
...In patients with CCD, adherence to changes in...
...ents with CCD, the use of generic formulations of...
...In patients with CCD who are judged to be a...
.... In patients with CCD, addition of generic e...
...ts with CCD who are judged to be at ver...
...ents with CCD who are very high risk, the use of...
...ents with CCD on maximally tolerated statin...
...patients with CCD who are not at very high risk...
...atients with CCD on maximally tolerated statin th...
...ts with CCD receiving statin therapy,...
...10. Very High-Risk* of Future ASCVD EventsHavin...
...8. Lipid Management in Patients With...
Table 11. High-, Moderate-, and Low-Intens...
...lood Pressure Management...
.... In adults with CCD, nonpharmacologic strate...
...with CCD who have hypertension, a BP target of...
...In adults with CCD and hypertension (systolic...
Table 12. Nonpharmacologic Strategi...
...2.8. SGLT2 Inhibitors and GLP-1 Receptor Ago...
...ients with CCD who have type 2 diabete...
...ith CCD and type 2 diabetes, addition of a GLP...
...In patients with CCD and type 2 di...
...with CCD and heart failure with LVEF ≤40...
...tients with CCD and heart failure with LVEF â...
...ts with CCD and heart failure with LVEF >4...
...tients with CCD and heart failure with LVE...
.... Weight Management
...with CCD, assessment of BMI with or wit...
...ients with CCD and overweight or obesity...
...nts with CCD and overweight or obesity in who...
...tients with CCD and severe obesity who have not...
...s with CCD, use of sympathomimetic weight loss dr...
.... Cardiac Rehabilitation...
...nt MI, PCI, or CABG should be referred to a cardi...
with stable angina or after heart...
...er recent spontaneous coronary artery d...
...re Components of CR...
....2.11. Physical Activ...
.... For patients with CCD who do not have...
...r patients with CCD who do not have...
...For patients with CCD who do not have contra...
...nvironmental Exposures...
...In patients with CCD, minimization of exposure...
...nts with CCD, minimization of climate-relate...
...l Therapy to Prevent Cardiovascular Event...
4.3.1. Antiplatelet Therapy and Oral Anticoag...
...elet Therapy Without OAC...
...patients with CCD and no indication for OAC...
...with CCD treated with PCI, dual antip...
...elect patients with CCD treated with PC...
...tients with CCD who have had a previous...
...ts with CCD and a previous history of MI...
...tients with CCD, the use of DAPT afte...
...with CCD without recent ACS or a PCI-rel...
...with CCD and previous stroke, TIA, or ICH, vora...
...In patients with CCD and previous...
...s with CCD, chronic nonsteroidal ant...
...tiplatelet Therapy With Direct OA...
...s with CCD who have undergone elective PCI...
...s with CCD who have undergone PCI and who requ...
...patients with CCD who require oral...
...nts with CCD who require oral anticoagulatio...
...latelet Therapy and Low-Dose...
...nts with CCD without an indication for t...
...T and Proton Pump Inhibi...
...with CCD on DAPT, the use of a PPI can be ef...
...mended Duration of Antiplatelet Therapy*...
.... Beta Blockers...
...ts with CCD and LVEF ≤40% with or without previ...
...ents with CCD and LVEF...
...atients with CCD who were initiated o...
...s with CCD without previous MI or LVEF...
4.3.3. Renin-Angiotensin-Aldosteron...
...ith CCD who also have hypertension, diabetes, LVEF...
...with CCD without hypertension, diabet...
...4. Colchicine...
...In patients with CCD, the addition o...
.... Immunizations...
...ents with CCD, an annual influenza vaccinat...
...with CCD, coronavirus disease 2019 (COV...
...nts with CCD, a pneumococcal vaccine is reas...
...l Therapy for Relief of Angina...
...ents with CCD and angina, antianginal thera...
...ents with CCD and angina who remain symptoma...
...ith CCD, ranolazine is recommended in patien...
...patients with CCD, sublingual nitroglycerin o...
...with CCD and normal LV function, the addition...
...3.7. Management of Refractory Angina...
...ts with CCD, refractory angina, and no other tr...
...3.8. Chelation Th...
...ntly not approved by the FDA for preventing or tre...
Revascularization
...cularization...
...Revascularization...
...Revascularizatio...
...oals of Revasculariza...
...n patients with CCD and lifestyle-limiting an...
...with CCD who have significant left main...
.... In patients with CCD and multivessel di...
...patients with CCD and multivessel CAD appr...
...ted patients with CCD and significant left main st...
...ing for Revascularization...
.... In patients with CCD who have angina or...
...s with CCD undergoing coronary ang...
...ith CCD with complex 3-vessel disease o...
...evascularization: PCI Versus CABG...
...nts With CCD...
...patients with CCD who require reva...
...ients with CCD who require revascula...
...nts With CCD at High Surgi...
...ts with CCD who are appropriate for revascular...
...ith CCD and Diabetes...
...n patients with CCD, diabetes, and m...
...with CCD and diabetes who have left main ste...
Special Populations
...ecial Population...
...g Heart Diseases and Condition...
...Chronic Management Afte...
...patients with CCD who have experienced...
...In patients with CCD who have experienced SCA...
...tients with CCD who have experienced SCAD, beta-b...
...ing Questions for SCAD-Associated Arter...
...Ischemia With Nonobstructive Coronary Arteries...
...omatic patients with nonobstructive C...
...le 15. Clinical Criteria for Suspec...
...iagnostic Criteria for Vasospastic AnginaNitrate-...
...asive Coronary Function Testing Definition...
...F With Preserved or Reduced Ejection F...
...is the most common cause of HF in the Uni...
...With Valvular Heart Disease...
...CD is common in patients with valvu...
...Young Adults
...g adults with CCD, after optimizatio...
...e 18. Traditional and Nontraditional...
...le 19. Nonatherosclerotic Causes of C...
...4. Cancer...
...In patients with CCD and cancer, a multidisciplin...
...ncluding Pregnancy and Postmenopausal Hormone Th...
Pregnancy
...with CCD who are contemplating pregnancy or wh...
...n with CCD who are contemplating pregn...
...with CCD, continuation of statin use du...
...n with CCD who are contemplating pregnancy or w...
...opausal Hormone Therap...
...omen with CCD should not receive systemic p...
...igure 10. Team-Based Cardio-Obstetrics Model of C...
...ble 20. CARPREG II Risk Prediction Mo...
...EG II Risk Prediction Model -Â CAR...
...fety of Cardiovascular Medications Dur...
....6. Older Adults...
...Geriatric 5 MsHaving trouble viewing tab...
.... Chronic Kidney Dise...
...In patients with CCD and CKD, measures should be...
6.8. HIV and Autoimmun...
...IV...
...th CCD and HIV, antiretroviral therapy is...
...In adults with CCD and HIV, it is re...
...s with CCD and HIV, lovastatin or simva...
...oimmune Disorders in CCD...
...h CCD and rheumatoid arthritis, initiation...
...lts with CCD and autoimmune diseases, treatmen...
...with CCD and rheumatoid arthritis, h...
...able 23. Common Antiretroviral Therapy Drugs...
...diac Allograft Vasculopathy in Heart TransplantÂ...
...atients with cardiac allograft vasculopathy, st...
...atients with cardiac allograft vas...
...atients with severe cardiac allograft vasculopathy...
...Drug-Drug Interactions With Statins and ...
Patient Follow-Up: Monitoring and Managing Symptoms
...llow-Up: Monitoring and Managing Symptoms...
...1. Follow-Up Plan and Testing in Stable Patients
...n stable patients with CCD and with previou...
...tients with CCD without a change in clinical or...
...with CCD without a change in clinical or f...
...nts with CCD without a change in clinical or func...
Other Important Considerations
...her Important Consider...
...and Value Considerations...
...sing treatment and prevention with patients...