Management of Patients with Chronic Coronary Disease

Publication Date: July 20, 2023

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

  1. 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.
  2. Nonpharmacologic therapies, including healthy dietary habits and exercise, are recommended for all patients with CCD.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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...

...ing of the following tables may differ fr...


...4. US Heart Disease Prevalence, by Age, Race, E...


...evalence of CHD per 100,000, by Age a...


Figure 2. “Ever Told You Had Angina or CHD?...


...Global Age-Adjusted Prevalence of CCD pe...


Diagnosis

...agnosi...

...on, Diagnosis, and Risk Stratification

.... Diagnostic Evaluation...

...patients with CCD and a change in symptoms or func...

...nts with CCD and a change in symptoms...

.... In patients with CCD and a change in sympt...

.... In patients with CCD and a change in symptoms o...

...ents with CCD undergoing stress PET...

...with CCD and a change in symptoms or functi...

...sk Stratification and Relationship to Treatment...

...atients with CCD, it is recommended that ri...

...patients with CCD, optimization of GDMT is...

...n patients with CCD with newly reduced LV systoli...

...atients with CCD, ICA for risk stratificat...

...5. Potential Features Associated With a Higher...


Treatment

...eatment...

.... Treatmen...


...1. General Approach to Treatment De...

...patients with CCD, clinical follow-up at leas...

...atients with CCD, use of a validated...

...gure 4. Domains to Consider When Se...

...eam-Based Approach

.... In patients with CCD, a multidisciplinary team-b...

...ased Approach Reflective of Interconnectedne...

...atient Education

...ients with CCD should receive ongoing i...

...nts with CCD should receive ongoing in...

...3. Shared Decision-Making...

...ith CCD and their clinicians should engage in sh...

...For patients with CCD and angina on GDMT who...

...Determinants of Health (SDOH)...

...with CCD, routine assessment by cli...

...e 6. Social Determinants of Health and Cardio...


...line-Directed Management and Therapy

...rition, Including Supplemen...

...atients with CCD, a diet emphasizing vegetabl...

...n patients with CCD, reducing the percentage o...

...ients with CCD, minimization of sodium (...

...ts with CCD, limiting refined carbohydrates (e...

...ith CCD, the intake of trans fat s...

...tients with CCD, the use of nonprescri...

...Recommended Nutrition...

....2.2. Mental Health Conditi...

...atients with CCD, targeted discussi...

...with CCD, treatment for mental health condit...

...6. Suggested Screening Tool to Asses...

...sted Screening Questions to Assess...

....2.3. Tobacco Product...

...n patients with CCD, tobacco use sho...

...tients with CCD who regularly smoke tobacco...

...n patients with CCD who regularly smoke...

...n patients with CCD who regularly...

...with CCD who regularly smoke tobacco,...

...nts with CCD should avoid secondhan...

...Behavioral Resources for Smoking Cess...

...4. Alcohol and Substance Use...

...Patients with CCD should be routinely...

...patients with CCD who consume alcohol, it is r...

...Patients with CCD should not be advised...

...e 9. Substances With Abuse Potential and Adverse...

...Sexual Health and Activity

...nts with CCD, it is reasonable to individ...

...patients with CCD, cardiac rehabilita...

...ts with CCD, phosphodiesterase type...

...Lipid Management...

1. In patients with CCD, high-intensity statin the...

...n whom high-intensity statin therapy is contra...

...atients with CCD, adherence to changes...

...ents with CCD, the use of generic...

...patients with CCD who are judged to...

...with CCD, addition of generic ezeti...

...patients with CCD who are judged to...

...ts with CCD who are very high risk...

.... In patients with CCD on maximally tolerate...

...s with CCD who are not at very high risk...

...patients with CCD on maximally tolerated stat...

...with CCD receiving statin therapy, a...

...le 10. Very High-Risk* of Future ASCVD EventsHav...

...Lipid Management in Patients Wi...

...11. High-, Moderate-, and Low-Intens...

...Blood Pressure Management...

.... In adults with CCD, nonpharmacologic strateg...

.... In adults with CCD who have hypertension, a...

...lts with CCD and hypertension (systolic...

.... Nonpharmacologic Strategies for Blood...

...SGLT2 Inhibitors and GLP-1 Receptor Agon...

...ith CCD who have type 2 diabetes, the use of...

...s with CCD and type 2 diabetes, addition...

...ith CCD and type 2 diabetes, addition of an SGLT2...

...In patients with CCD and heart failu...

...ents with CCD and heart failure with LVEF ≤...

...atients with CCD and heart failure with LV...

.... In patients with CCD and heart failure with LVEF...

....2.9. Weight Mana...

...ents with CCD, assessment of BMI with or w...

...with CCD and overweight or obesity should...

...ts with CCD and overweight or obesity in whom pha...

...atients with CCD and severe obesity who have not...

...nts with CCD, use of sympathomimeti...

...2.10. Cardiac Rehabilita...

...recent MI, PCI, or CABG should be referred to a...

...na or after heart transplant should be referred...

...ent spontaneous coronary artery dissecti...

...Components of CR...

.... Physical Activit...

...or patients with CCD who do not have contraind...

...nts with CCD who do not have contraind...

...ts with CCD who do not have contraindications...

...12. Environmental Exposures...

...tients with CCD, minimization of ex...

...atients with CCD, minimization of climate-relate...


...erapy to Prevent Cardiovascular Events and Manage...

.... Antiplatelet Therapy and Oral Anticoagul...

...atelet Therapy Without OAC...

...with CCD and no indication for OAC therapy, low-...

...atients with CCD treated with PCI, dual...

.... In select patients with CCD treated with PC...

...with CCD who have had a previous MI...

...ith CCD and a previous history of MI without a hi...

...with CCD, the use of DAPT after CABG may...

...s with CCD without recent ACS or a PCI...

...nts with CCD and previous stroke, TIA...

...atients with CCD and previous stroke, TIA, or IC...

...tients with CCD, chronic nonsteroidal anti-...

...ntiplatelet Therapy With Direct OAC (DO...

11. In patients with CCD who have undergon...

...2. In patients with CCD who have undergone PCI...

...patients with CCD who require oral...

...ts with CCD who require oral anticoagula...

Antiplatelet Therapy and Low-Dose D...

...In patients with CCD without an ind...

...and Proton Pump Inhibitor (PPI)...

...ents with CCD on DAPT, the use of a PPI can...

...e 9. Recommended Duration of Antiplate...

...Beta Blockers...

1. In patients with CCD and LVEF ≤40% with o...

...n patients with CCD and LVEF...

...ith CCD who were initiated on beta-blocker th...

...with CCD without previous MI or LVEF ≤50%, th...

4.3.3. Renin-Angiotensin-Aldostero...

...tients with CCD who also have hypertension, diab...

...In patients with CCD without hypertension, dia...

...4. Colchicine...

1. In patients with CCD, the addition of colchic...

...3.5. Immunizations

...In patients with CCD, an annual influenza vaccina...

...ts with CCD, coronavirus disease 2019 (COV...

3. In patients with CCD, a pneumococcal v...

....3.6. Medical Therapy for Relief of Ang...

...nts with CCD and angina, antiangina...

...with CCD and angina who remain symptomatic after...

...nts with CCD, ranolazine is recommended in...

...with CCD, sublingual nitroglycerin or nitroglycer...

5. In patients with CCD and normal LV funct...

...Management of Refractory Angina...

...with CCD, refractory angina, and no other...

....3.8. Chelation Therap...

...ly not approved by the FDA for prevent...


Revascularization

...ascularization...

...Revascularizat...


.... Revascularizatio...

...ls of Revasculariza...

...ients with CCD and lifestyle-limiting angina de...

...ents with CCD who have significant left main d...

...n patients with CCD and multivessel disease with...

...tients with CCD and multivessel CA...

...patients with CCD and significant left m...

...ision-Making for Revascularization

...atients with CCD who have angina or a...

...n patients with CCD undergoing coronary angiog...

...In patients with CCD with complex 3-vessel dis...


...arization: PCI Versus CABG...

...tients With CCD...

...patients with CCD who require revas...

...ith CCD who require revascularization for mult...

...h CCD at High Surgical Risk...

...n patients with CCD who are appropria...

...ients With CCD and Diabe...

...atients with CCD, diabetes, and multivessel...

...atients with CCD and diabetes who have lef...


Special Populations

...ecial Populations

....1. Existing Heart Diseases and Co...

...hronic Management After SCAD...

...tients with CCD who have experienced S...

...atients with CCD who have experienced S...

...patients with CCD who have experienced...

.... Screening Questions for SCAD-Associated A...

...With Nonobstructive Coronary Arteries...

...In symptomatic patients with nonob...

...Clinical Criteria for Suspecting Microvascul...

Table 16. Diagnostic Criteria for Vasospastic...

...17. Invasive Coronary Function Testing Definit...

...With Preserved or Reduced Ejection Fraction...

...ost common cause of HF in the United States...


.... CAD With Valvular Heart Disease...

...ncurrent CCD is common in patients...


....3. Young Adult...

.... In young adults with CCD, after optim...

...8. Traditional and Nontraditional Risk Factors A...

...e 19. Nonatherosclerotic Causes of CCD in...


...4. Cancer...

...In patients with CCD and cancer, a mult...


...en, Including Pregnancy and Postmenopausal Ho...

...regnan...

...with CCD who are contemplating pregnancy or wh...

...n with CCD who are contemplating pregnancy or w...

...omen with CCD, continuation of stati...

.... Women with CCD who are contemplating...

...opausal Hormone Therap...

...CCD should not receive systemic post...

...ure 10. Team-Based Cardio-Obstetrics...

...le 20. CARPREG II Risk Prediction...

...ble 20. CARPREG II Risk Prediction Mode...

...ety of Cardiovascular Medications Durin...


6.6. Older Adu...

...able 22. The Geriatric 5 MsHaving troub...


...Chronic Kidney Disease...

...with CCD and CKD, measures should be...


...HIV and Autoimmune Di...

...IV

...In adults with CCD and HIV, antiret...

...In adults with CCD and HIV, it is r...

...adults with CCD and HIV, lovastatin...

...mmune Disorders in CC...

4. In adults with CCD and rheumato...

...ith CCD and autoimmune diseases, tr...

...s with CCD and rheumatoid arthritis, hig...

...e 23. Common Antiretroviral Therapy...


...9. Cardiac Allograft Vasculopathy in...

...nts with cardiac allograft vasculopathy, statins...

2. In patients with cardiac allograft...

...In patients with severe cardiac allograf...

...Drug-Drug Interactions With Statins and Immun...


Patient Follow-Up: Monitoring and Managing Symptoms

...atient Follow-Up: Monitoring and Managing Sympto...

...ow-Up Plan and Testing in Stable Patient...

...In stable patients with CCD and wi...

.... In patients with CCD without a cha...

...atients with CCD without a change in...

...ith CCD without a change in clinical or fun...


Other Important Considerations

...rtant Considerations...

...ost and Value Considerations...

...cussing treatment and prevention w...