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...
...numbering of the following tables m...
...ble 4. US Heart Disease Prevalence, by Age, R...
...1. US Prevalence of CHD per 100,000, by A...
...e 2. “Ever Told You Had Angina or CHD?â€...
...l Age-Adjusted Prevalence of CCD per 100,0...
Diagnosis
...agnosi...
...ation, Diagnosis, and Risk Stratifica...
....1. Diagnostic Evaluatio...
...ients with CCD and a change in symptoms or functio...
...nts with CCD and a change in symptoms or funct...
...with CCD and a change in symptoms or funct...
...ith CCD and a change in symptoms o...
...n patients with CCD undergoing stress PET MPI...
...tients with CCD and a change in symptoms...
...isk Stratification and Relationship to Tr...
...ts with CCD, it is recommended that risk stratific...
...n patients with CCD, optimization o...
...tients with CCD with newly reduced LV s...
...patients with CCD, ICA for risk stratification is...
.... Potential Features Associated With a Higher Ri...
Treatment
...eatment...
...reatment
...General Approach to Treatment Decisions...
...with CCD, clinical follow-up at least annually is...
...patients with CCD, use of a validated C...
...Domains to Consider When Seeing a Patient...
...Team-Based Approa...
...ients with CCD, a multidisciplinary te...
...ased Approach Reflective of Interconnectedn...
....1.2. Patient Educat...
...nts with CCD should receive ongoing...
...ith CCD should receive ongoing individualized...
....3. Shared Decision-Mak...
...h CCD and their clinicians should engag...
...atients with CCD and angina on GDMT who are...
4.1.4. Social Determinants of Health (SDOH)
...ents with CCD, routine assessment by c...
...Social Determinants of Health and...
.... Guideline-Directed Management and...
....2.1. Nutrition, Including Suppl...
...atients with CCD, a diet emphasizing vege...
...In patients with CCD, reducing th...
...with CCD, minimization of sodium (...
...In patients with CCD, limiting refined...
...s with CCD, the intake of trans fat should...
...In patients with CCD, the use of nonprescri...
...ure 7. Recommended Nu...
...2. Mental Health Condit...
...ts with CCD, targeted discussions and screeni...
...n patients with CCD, treatment for menta...
...ested Screening Tool to Assess Psychological Dist...
...Suggested Screening Questions to Ass...
....3. Tobacco Product...
...n patients with CCD, tobacco use should be assess...
...with CCD who regularly smoke tobacco...
...with CCD who regularly smoke tobacco, b...
...tients with CCD who regularly smoke...
...In patients with CCD who regularly s...
...with CCD should avoid secondhand smoke exposur...
...oral Resources for Smoking CessationHaving tr...
...Alcohol and Substance...
...CCD should be routinely asked and cou...
...ients with CCD who consume alcohol, it is reasonab...
...ith CCD should not be advised to consume...
...ubstances With Abuse Potential and A...
.... Sexual Health and Activi...
...In patients with CCD, it is reasonable to indiv...
...In patients with CCD, cardiac rehabilitati...
...n patients with CCD, phosphodiester...
.... Lipid Managemen...
...tients with CCD, high-intensity statin ther...
...nts in whom high-intensity statin therapy is con...
...ith CCD, adherence to changes in lif...
...patients with CCD, the use of generic...
5. In patients with CCD who are judged to...
...atients with CCD, addition of generic ez...
...ients with CCD who are judged to be at very hi...
...patients with CCD who are very high risk, th...
...ith CCD on maximally tolerated sta...
10. In patients with CCD who are not...
...patients with CCD on maximally tole...
...tients with CCD receiving statin therapy, a...
...ery High-Risk* of Future ASCVD EventsHaving t...
...Lipid Management in Patients Wit...
...igh-, Moderate-, and Low-Intensity Stat...
...od Pressure Management...
...lts with CCD, nonpharmacologic strategies are...
...In adults with CCD who have hyperte...
...h CCD and hypertension (systolic BP ≥130 and/o...
...ble 12. Nonpharmacologic Strategies for Blood Pre...
...hibitors and GLP-1 Receptor Agonists...
...atients with CCD who have type 2 diabetes, the...
...with CCD and type 2 diabetes, addition...
3. In patients with CCD and type 2 diabetes,...
...ients with CCD and heart failure w...
...In patients with CCD and heart failure with LVEF...
.... In patients with CCD and heart failu...
...s with CCD and heart failure with...
...2.9. Weight Managemen...
...n patients with CCD, assessment of BMI with or w...
...with CCD and overweight or obesity s...
...ts with CCD and overweight or obesity in w...
...In patients with CCD and severe obesi...
...with CCD, use of sympathomimetic we...
...rdiac Rehabilitation...
...er recent MI, PCI, or CABG should be referred to...
...angina or after heart transplant shoul...
...recent spontaneous coronary artery di...
...13. Core Components of CR...
...1. Physical Activity...
...ts with CCD who do not have contra...
...For patients with CCD who do not have...
...atients with CCD who do not have contraindica...
4.2.12. Environmental Ex...
...nts with CCD, minimization of expo...
.... In patients with CCD, minimization of...
...Therapy to Prevent Cardiovascular E...
...Antiplatelet Therapy and Oral Anticoag...
...atelet Therapy Without OAC...
...patients with CCD and no indication for...
...ts with CCD treated with PCI, dual anti...
...In select patients with CCD treated with PCI...
...s with CCD who have had a previous MI...
...with CCD and a previous history of MI with...
...In patients with CCD, the use of DAPT after...
...with CCD without recent ACS or a PC...
...patients with CCD and previous stroke, TIA, or...
...ts with CCD and previous stroke, TIA, or ICH, pra...
...atients with CCD, chronic nonsteroidal anti-i...
...elet Therapy With Direct OAC...
...In patients with CCD who have undergone elect...
...patients with CCD who have undergone PCI and who...
...In patients with CCD who require oral ant...
...ents with CCD who require oral anticoagulation,...
...elet Therapy and Low-Dose DOAC...
...ts with CCD without an indication...
...PT and Proton Pump Inhib...
...with CCD on DAPT, the use of a PPI can...
...igure 9. Recommended Duration of Antipl...
4.3.2. Beta Blocke...
...patients with CCD and LVEF ≤40% with or witho...
...patients with CCD and LVEF...
...nts with CCD who were initiated on beta-blocke...
4. In patients with CCD without pre...
....3.3. Renin-Angiotensin-Aldosterone Inhibitors
...s with CCD who also have hypertension, d...
...atients with CCD without hypertension, diabetes, o...
...3.4. Colchic...
...ith CCD, the addition of colchicine for secondar...
4.3.5. Immuniz...
...In patients with CCD, an annual influenza vaccin...
...atients with CCD, coronavirus disease 2019 (CO...
...patients with CCD, a pneumococcal vaccine is rea...
...edical Therapy for Relief of Angina...
...patients with CCD and angina, antianginal...
...patients with CCD and angina who remain sy...
...n patients with CCD, ranolazine is recommend...
...patients with CCD, sublingual nitroglyce...
...patients with CCD and normal LV function, the...
...3.7. Management of Refractory Angina...
...In patients with CCD, refractory angina, and...
...Chelation Therapy...
...ently not approved by the FDA for preventing o...
Revascularization
...scularization...
5. Revascularizat...
.... Revasculariza...
...f Revascularizatio...
...ts with CCD and lifestyle-limiting angina despite...
...n patients with CCD who have significant left...
...patients with CCD and multivessel disease with s...
...ients with CCD and multivessel CAD ap...
...atients with CCD and significant left main...
...ision-Making for Revascular...
...ents with CCD who have angina or an anginal...
...tients with CCD undergoing coronary angiog...
...ents with CCD with complex 3-vessel di...
...ascularization: PCI Versus CAB...
...atients With CC...
...s with CCD who require revascularizati...
...ents with CCD who require revasculariza...
...tients With CCD at High Surgical...
...In patients with CCD who are appropriate for...
...With CCD and Diabetes...
...In patients with CCD, diabetes, and multives...
...nts with CCD and diabetes who have l...
Special Populations
...l Populations...
6.1. Existing Heart Diseases and...
...Chronic Management After SCAD...
...tients with CCD who have experienced SCAD, coun...
...s with CCD who have experienced SCAD, evaluatio...
...atients with CCD who have experienced SCAD, bet...
...ning Questions for SCAD-Associated...
...emia With Nonobstructive Coronary Arteries...
...ic patients with nonobstructive CAD, a s...
...linical Criteria for Suspecting Microvascular ...
...e 16. Diagnostic Criteria for Vasos...
Table 17. Invasive Coronary Function Testing Defi...
...ith Preserved or Reduced Ejection Fraction...
...e most common cause of HF in the Uni...
...CAD With Valvular Heart Dis...
...is common in patients with valvular heart disease...
...Young Adults...
...ung adults with CCD, after optimization of tradit...
...aditional and Nontraditional Risk...
...atherosclerotic Causes of CCD in Young Adult...
.... Cancer...
...patients with CCD and cancer, a multidiscipli...
...omen, Including Pregnancy and Postmeno...
...regnancy...
...D who are contemplating pregnancy or who ar...
...Women with CCD who are contemplating pregn...
...men with CCD, continuation of statin use d...
...ith CCD who are contemplating pregnancy or...
...pausal Hormone Therap...
...with CCD should not receive syste...
...eam-Based Cardio-Obstetrics Model of Ca...
...ble 20. CARPREG II Risk Prediction Model -Â CA...
.... CARPREG II Risk Prediction Model -Â CAR...
...fety of Cardiovascular Medications During...
...Older Adults...
...eriatric 5 MsHaving trouble viewing table? Exp...
...Chronic Kidney Dis...
...with CCD and CKD, measures should be taken to min...
...and Autoimmune Disorders...
HI...
...h CCD and HIV, antiretroviral thera...
...ith CCD and HIV, it is reasonable to cho...
...with CCD and HIV, lovastatin or simvastatin sho...
...immune Disorders in CCD
...ults with CCD and rheumatoid arthritis, initia...
...dults with CCD and autoimmune diseases,...
...tients with CCD and rheumatoid arthrit...
Table 23. Common Antiretroviral Therapy Dru...
...Cardiac Allograft Vasculopathy in Hear...
...with cardiac allograft vasculopathy,...
...In patients with cardiac allograft vasculopat...
...s with severe cardiac allograft vascu...
...ug-Drug Interactions With Statins and Im...
Patient Follow-Up: Monitoring and Managing Symptoms
...p: Monitoring and Managing Symptom...
...lan and Testing in Stable Patients
.... In stable patients with CCD and wi...
...ith CCD without a change in clinical or...
...atients with CCD without a change in c...
.... In patients with CCD without a ch...
Other Important Considerations
...mportant Considerations...
...Cost and Value Considerati...
1. When discussing treatment and prevention...