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
...Introduc...
...e numbering of the following tables may differ...
...e 4. US Heart Disease Prevalence, by Age, Race,...
.... US Prevalence of CHD per 100,000,...
...2. “Ever Told You Had Angina or CHD?” Age-A...
...bal Age-Adjusted Prevalence of CCD per 100,000, by...
Diagnosis
...Dia...
...3. Evaluation...
...3.1. Diagnosti...
...with CCD and a change in symptoms or functi...
...In patients with CCD and a change in symptoms or...
...with CCD and a change in symptoms or...
...tients with CCD and a change in symptoms or fu...
...s with CCD undergoing stress PET MPI or stres...
...atients with CCD and a change in symptoms...
...3.2. Risk Stratification an...
...s with CCD, it is recommended that risk stra...
...with CCD, optimization of GDMT is recommended to r...
...tients with CCD with newly reduced LV systolic...
...s with CCD, ICA for risk stratification is not...
...Table 5. Poten...
Treatment
...Treat...
...4. Treatmen...
...4.1. General Approach...
...In patients with CCD, clinical follow-up...
...ents with CCD, use of a validated CCD-specific p...
...re 4. Domains to Consider When Seeing a...
...4.1.1. Team-Based Appro...
...In patients with CCD, a multidiscip...
Figure 5. Team-Based Approach Refl...
...4.1.2. P...
...h CCD should receive ongoing individualized edu...
2. Patients with CCD should receive ongoing i...
...4.1.3...
...tients with CCD and their clinicians should...
...nts with CCD and angina on GDMT who...
...4.1.4. Social Deter...
...ents with CCD, routine assessment by cl...
...Determinants of Health and Cardiovascular Car...
...4.2. Guideline-Directed...
...4.2.1. Nutrition, Inclu...
...patients with CCD, a diet emphasizing ve...
...In patients with CCD, reducing the per...
...s with CCD, minimization of sodium (...
...s with CCD, limiting refined carbohydr...
...patients with CCD, the intake of trans fa...
...ith CCD, the use of nonprescription or dietary...
Figure 7. Recommended...
...4.2.2. Mental Health...
...tients with CCD, targeted discussions and screeni...
...n patients with CCD, treatment for mental health...
...Suggested Screening Tool to Assess Psycholog...
...ble 7. Suggested Screening Questions...
...4.2.3....
...n patients with CCD, tobacco use should be asses...
.... Patients with CCD who regularly smoke tobacco sh...
...atients with CCD who regularly smo...
...n patients with CCD who regularly smok...
...ith CCD who regularly smoke tobacco, the sho...
...CCD should avoid secondhand smoke...
...havioral Resources for Smoking CessationHaving tro...
...4.2.4. Alcohol and S...
...tients with CCD should be routinely asked a...
...patients with CCD who consume alcohol, it is re...
...ith CCD should not be advised to cons...
...ubstances With Abuse Potential and Adverse Ca...
...4.2.5. Sexua...
.... In patients with CCD, it is reasonable to...
...with CCD, cardiac rehabilitation and regular e...
...s with CCD, phosphodiesterase type 5 inhi...
...4.2.6. Lipid...
1. In patients with CCD, high-intensity...
...s in whom high-intensity statin therapy is co...
...ients with CCD, adherence to changes in...
...s with CCD, the use of generic formulations of m...
...nts with CCD who are judged to be at very high r...
...tients with CCD, addition of generic e...
...patients with CCD who are judged to be at...
...tients with CCD who are very high risk, the...
...with CCD on maximally tolerated statin ther...
...patients with CCD who are not at very hi...
11. In patients with CCD on maximally toler...
...ents with CCD receiving statin therapy, addin...
...High-Risk* of Future ASCVD EventsHaving tr...
...d Management in Patients With CCD...
...gh-, Moderate-, and Low-Intensity St...
...4.2.7....
...s with CCD, nonpharmacologic strate...
...with CCD who have hypertension, a BP target of...
...th CCD and hypertension (systolic BP ≥130 and/o...
...le 12. Nonpharmacologic Strategies for...
...4....
...ts with CCD who have type 2 diabetes, the use of...
...patients with CCD and type 2 diabete...
...patients with CCD and type 2 diabetes, addition...
...n patients with CCD and heart failure with...
.... In patients with CCD and heart failure w...
...ith CCD and heart failure with LVEF...
...n patients with CCD and heart failure with...
...4.2.9. W...
...with CCD, assessment of BMI with or withou...
...tients with CCD and overweight or obesity...
...r patients with CCD and overweight or obesity in...
...atients with CCD and severe obesity who hav...
...patients with CCD, use of sympathomimetic weight...
...4...
...PCI, or CABG should be referred to a cardiac...
...ngina or after heart transplant shoul...
...ontaneous coronary artery dissection event...
...Table 13....
...4.2....
...s with CCD who do not have contraindicati...
...s with CCD who do not have contraindications...
...r patients with CCD who do not have cont...
...4.2.12. Environmenta...
...patients with CCD, minimization of exposure to...
...n patients with CCD, minimization o...
...4.3. Medical...
...4.3.1. Antip...
...Antiplatelet Therapy Wi...
...ts with CCD and no indication for OAC therapy, low...
...s with CCD treated with PCI, dual antiplatelet...
3. In select patients with CCD treated wit...
4. In patients with CCD who have had a pr...
...ts with CCD and a previous history of MI without...
...tients with CCD, the use of DAPT after...
...ients with CCD without recent ACS...
...atients with CCD and previous stroke, TIA, or...
...atients with CCD and previous stroke,...
...n patients with CCD, chronic nonsteroidal...
...Antiplatel...
...patients with CCD who have undergone electi...
...patients with CCD who have undergone PCI an...
13. In patients with CCD who require oral antic...
...In patients with CCD who require oral anti...
...Antiplatelet T...
...5. In patients with CCD without an indication for...
...DAPT and Proto...
...patients with CCD on DAPT, the use...
...9. Recommended Duration of Antiplatelet Th...
...4.3.2. Beta Blockers...
1. In patients with CCD and LVEF ≤40% with or...
...n patients with CCD and LVEF...
.... In patients with CCD who were initiate...
...nts with CCD without previous MI or LVEF ≤50%,...
4.3.3. Re...
...patients with CCD who also have hyperten...
...with CCD without hypertension, diabetes, or CKD a...
...4.3.4. Colchicin...
...atients with CCD, the addition of colc...
...4.3.5. Immuni...
...atients with CCD, an annual influenza vaccina...
...with CCD, coronavirus disease 2019 (COVID...
...with CCD, a pneumococcal vaccine is reasonable...
...4.3.6....
...ients with CCD and angina, antiangina...
...In patients with CCD and angina w...
...ents with CCD, ranolazine is recommended in pat...
...In patients with CCD, sublingual nitroglycerin...
...n patients with CCD and normal LV...
...4.3.7. Manageme...
1. In patients with CCD, refractory an...
...4.3.8....
EDTA is currently not approved by the FDA for p...
Revascularization
...Revascularization...
...5. Revascularizat...
...5.1. Revasculariza...
...Goals of Revascula...
...n patients with CCD and lifestyle-limiting angina...
...patients with CCD who have signific...
...n patients with CCD and multivessel disease wi...
...s with CCD and multivessel CAD appropriate for...
...patients with CCD and significant left main sten...
...Decision-Ma...
...ents with CCD who have angina or an anginal equ...
...s with CCD undergoing coronary angiography with...
...with CCD with complex 3-vessel diseas...
...5.2. Reva...
...Patients With C...
...patients with CCD who require revascularizatio...
...nts with CCD who require revascula...
...Patients With CCD a...
...s with CCD who are appropriate for rev...
...Patients With...
4. In patients with CCD, diabetes, and...
.... In patients with CCD and diabetes who hav...
Special Populations
Special Po...
...6.1. Existing Heart...
...6....
...In patients with CCD who have experienced SCAD, co...
...ts with CCD who have experienced SCAD, evaluat...
...ts with CCD who have experienced SCAD, b...
...14. Screening Questions for SCAD-Associated...
...6.1.2. Ische...
...n symptomatic patients with nonobs...
...5. Clinical Criteria for Suspecting Micr...
...6. Diagnostic Criteria for Vasospastic...
...Invasive Coronary Function Testin...
...6.1.3. HF With...
...is the most common cause of HF in the United State...
...6.2. C...
...t CCD is common in patients with valvular he...
...6.3. Young Adults...
...g adults with CCD, after optimizati...
...18. Traditional and Nontraditional Risk Factors ...
...e 19. Nonatherosclerotic Causes of CC...
...6.4. Cancer...
...ith CCD and cancer, a multidisciplinary...
...6.5. Women,...
...Pregnancy...
...omen with CCD who are contemplating preg...
...D who are contemplating pregnancy or who are...
...n with CCD, continuation of statin use duri...
4. Women with CCD who are contempla...
...Postmen...
...CCD should not receive systemic postmenop...
...Team-Based Cardio-Obstetrics Model of CareThe c...
...PREG II Risk Prediction Model - CARPR...
...0. CARPREG II Risk Prediction Model - CARPR...
...fety of Cardiovascular Medications During P...
...6.6. Older Adult...
...able 22. The Geriatric 5 MsHaving trouble view...
...6.7. Chronic Kidney Disease...
...with CCD and CKD, measures should be taken t...
...6.8. HIV and Auto...
.... In adults with CCD and HIV, antiretroviral t...
...ts with CCD and HIV, it is reasonable to...
...h CCD and HIV, lovastatin or simva...
...Autoimmune Disor...
...n adults with CCD and rheumatoid arthr...
...adults with CCD and autoimmune diseases,...
...tients with CCD and rheumatoid arthritis, h...
...mmon Antiretroviral Therapy Drugs and Eff...
...6.9. Cardiac...
...ts with cardiac allograft vasculopathy,...
...ents with cardiac allograft vasculop...
...tients with severe cardiac allograft...
...ug-Drug Interactions With Statins and Immunosup...
Patient Follow-Up: Monitoring and Managing Symptoms
...Patient Follow-Up:...
...7.1. Fol...
.... In stable patients with CCD and w...
...tients with CCD without a change in clinical or fu...
.... In patients with CCD without a change in...
...ts with CCD without a change in clinical or funct...
Other Important Considerations
...Other Important Conside...
...8.1. Cost and Valu...
...ng treatment and prevention with patients who...