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
...e: The numbering of the following tables may...
Table 4. US Heart Disease Prevalence, by Ag...
...S Prevalence of CHD per 100,000, by Age and S...
...2. “Ever Told You Had Angina or CHD?” Age...
...igure 3. Global Age-Adjusted Prevalence...
Diagnosis
...Diagnosis...
...3. Evaluation...
...with CCD and a change in symptoms or functional...
...atients with CCD and a change in symptom...
...In patients with CCD and a change in symptoms or...
4. In patients with CCD and a change in sympt...
...In patients with CCD undergoing stress P...
...In patients with CCD and a change in sympt...
...3.2. Risk St...
...s with CCD, it is recommended that ris...
...with CCD, optimization of GDMT is re...
...atients with CCD with newly reduced LV...
...with CCD, ICA for risk stratification is no...
...Table 5. Poten...
Treatment
...Treatment...
...4. Treatment...
...4.1. Ge...
...patients with CCD, clinical follow-up at...
...In patients with CCD, use of a validat...
...gure 4. Domains to Consider When Seeing a Patient...
...4.1.1. Team-Based Approach...
...ients with CCD, a multidisciplinary team-...
...re 5. Team-Based Approach Reflective of...
...4.1.2. Patient Ed...
...Patients with CCD should receive ongoi...
...with CCD should receive ongoing in...
...4.1.3. Sha...
...tients with CCD and their clinicians...
...patients with CCD and angina on GDMT who are engag...
...4.1.4. Soc...
.... In patients with CCD, routine ass...
Figure 6. Social Determinants of Health a...
...4.2. Gui...
...4.2.1. Nutrition, Incl...
...tients with CCD, a diet emphasizing vegetables,...
...patients with CCD, reducing the percentage...
...with CCD, minimization of sodium (...
...with CCD, limiting refined carbohydrates (eg, con...
...tients with CCD, the intake of trans...
.... In patients with CCD, the use of nonprescripti...
...Recommended Nutrition...
...4.2.2. Mental...
...patients with CCD, targeted discussions and scree...
...ients with CCD, treatment for mental hea...
...6. Suggested Screening Tool to Assess Psyc...
...ed Screening Questions to Assess Psychological H...
...4.2.3. Tobac...
...ts with CCD, tobacco use should be a...
...ts with CCD who regularly smoke tobacco should...
...with CCD who regularly smoke tobacco, behavioral i...
...patients with CCD who regularly smoke tobacco, v...
...ts with CCD who regularly smoke tobacco, the shor...
...nts with CCD should avoid secondhand smoke...
...ioral Resources for Smoking Cessation...
...4.2.4. Alcohol an...
...Patients with CCD should be routinely asked...
...In patients with CCD who consume alcohol, i...
...ients with CCD should not be advised to consume al...
...ces With Abuse Potential and Adverse Cardiov...
...4.2.5. Sexual Health and...
...ients with CCD, it is reasonable to...
...patients with CCD, cardiac rehabilitation a...
.... In patients with CCD, phosphodiesterase type 5 i...
...4.2.6....
...tients with CCD, high-intensity statin the...
...tients in whom high-intensity statin thera...
...tients with CCD, adherence to changes in lifestyle...
...tients with CCD, the use of generic formulations...
...In patients with CCD who are judged to be at...
...with CCD, addition of generic ezetimibe to maxi...
...ts with CCD who are judged to be at very high ri...
...ith CCD who are very high risk, the use of...
.... In patients with CCD on maximally to...
...with CCD who are not at very high...
...tients with CCD on maximally tolerated sta...
...ts with CCD receiving statin therap...
...0. Very High-Risk* of Future ASCVD E...
...8. Lipid Management in Patients With CCD...
Table 11. High-, Moderate-, and Low-Int...
...4.2.7. Blood Pres...
...with CCD, nonpharmacologic strategie...
...with CCD who have hypertension, a BP target of...
...dults with CCD and hypertension (systolic...
...rmacologic Strategies for Blood Press...
...4.2.8. S...
...tients with CCD who have type 2 diabetes, t...
...In patients with CCD and type 2 di...
.... In patients with CCD and type 2 d...
...atients with CCD and heart failure wit...
...ients with CCD and heart failure with LVEF...
...tients with CCD and heart failure with LV...
...In patients with CCD and heart failure with LV...
...4.2.9. Weight Manage...
...patients with CCD, assessment of BM...
...s with CCD and overweight or obesity should r...
...or patients with CCD and overweight o...
...tients with CCD and severe obesity who...
...patients with CCD, use of sympatho...
...4.2.10. Card...
..., PCI, or CABG should be referred to a card...
...ngina or after heart transplant should be referre...
...spontaneous coronary artery dissection eve...
...Table 13. Core Comp...
...4.2.11. Physi...
...ts with CCD who do not have contraindi...
...with CCD who do not have contraindica...
...For patients with CCD who do not have contr...
...4.2.12. Envi...
.... In patients with CCD, minimization o...
.... In patients with CCD, minimization of...
...4.3...
...4.3.1....
...Antiplatele...
...patients with CCD and no indicati...
...s with CCD treated with PCI, dual antiplat...
...In select patients with CCD treated with...
...ents with CCD who have had a previous MI and...
...ients with CCD and a previous history of MI wit...
.... In patients with CCD, the use of D...
7. In patients with CCD without re...
...In patients with CCD and previous s...
...s with CCD and previous stroke, TIA...
...s with CCD, chronic nonsteroidal anti-...
...Antiplatelet...
...nts with CCD who have undergone electiv...
...patients with CCD who have undergone PCI...
...In patients with CCD who require oral ant...
...ts with CCD who require oral anticoagulation, D...
...Antiplatelet...
...s with CCD without an indication f...
...DAPT and Prot...
...ts with CCD on DAPT, the use of a PPI...
...commended Duration of Antiplatelet Therap...
4....
.... In patients with CCD and LVEF ≤40%...
...patients with CCD and LVEF...
...atients with CCD who were initiated on...
...with CCD without previous MI or LVEF ≤50%, the...
...4.3.3. Renin-Angiotensi...
...In patients with CCD who also have hypertension,...
...with CCD without hypertension, diabetes, or...
...4.3.4. Colchicine...
...with CCD, the addition of colchicine for...
...4.3.5...
...In patients with CCD, an annual influen...
...patients with CCD, coronavirus disease 2019 (CO...
...atients with CCD, a pneumococcal vaccine is rea...
...4.3.6. Medical Therapy for...
...ith CCD and angina, antianginal therapy with...
...tients with CCD and angina who remain symptomatic...
...with CCD, ranolazine is recommended in patients w...
.... In patients with CCD, sublingual nitroglycerin...
...atients with CCD and normal LV functi...
...4.3.7. Ma...
...n patients with CCD, refractory angin...
...4.3.8. Chelation Ther...
...currently not approved by the FDA for pre...
Revascularization
...Revascularization...
...5. Revasculari...
...5.1. Revascula...
...Goals of Revascula...
...In patients with CCD and lifestyle-limiti...
...patients with CCD who have signifi...
...s with CCD and multivessel disease with sev...
...ients with CCD and multivessel CAD approp...
...patients with CCD and significant left main...
...Decision-Makin...
...ents with CCD who have angina or an anginal...
...In patients with CCD undergoing cor...
...s with CCD with complex 3-vessel disease or for w...
...5....
...Patients...
...patients with CCD who require revasculariz...
...In patients with CCD who require revascu...
...Patients With C...
...nts with CCD who are appropriate for revascular...
...Patients With CCD and...
...In patients with CCD, diabetes, and m...
.... In patients with CCD and diabetes who have l...
Special Populations
...Special Populations...
...6.1....
...6.1.1. Chronic...
...In patients with CCD who have experienced SCAD,...
.... In patients with CCD who have experienced SCA...
...s with CCD who have experienced SCAD...
...14. Screening Questions for SCAD-Associat...
...6.1.2. Ischemia W...
...In symptomatic patients with nonobstructive CA...
...ical Criteria for Suspecting Microvas...
...16. Diagnostic Criteria for Vasospastic Angina...
...ve Coronary Function Testing Definitio...
...6.1.3. HF Wit...
...most common cause of HF in the United St...
...6....
...D is common in patients with valvular he...
...6.3. Young Adults...
...young adults with CCD, after optimiza...
...8. Traditional and Nontraditional Risk Factor...
...Nonatherosclerotic Causes of CCD in Young Adult...
...n patients with CCD and cancer, a mult...
...6.5. Women, Inc...
...Pregnancy...
...th CCD who are contemplating pregnancy or who are...
...omen with CCD who are contemplating pregnancy or...
...omen with CCD, continuation of statin...
...Women with CCD who are contemplating pregnan...
...Postmeno...
...en with CCD should not receive sys...
...10. Team-Based Cardio-Obstetrics Mo...
...able 20. CARPREG II Risk Prediction...
...RPREG II Risk Prediction Model - CARPREG II S...
...Safety of Cardiovascular Medication...
...6.6. Older A...
...le 22. The Geriatric 5 Ms Mind Ment...
...6.7. Chronic...
.... In patients with CCD and CKD, measures...
...HIV...
...dults with CCD and HIV, antiretroviral therapy...
...s with CCD and HIV, it is reasonable to choose an...
3. In adults with CCD and HIV, lovastatin or...
...Autoimmune Disorders...
...lts with CCD and rheumatoid arthritis,...
...with CCD and autoimmune diseases, treatment wi...
6. In patients with CCD and rheumatoid arthritis,...
...3. Common Antiretroviral Therapy D...
...6.9. Card...
...with cardiac allograft vasculopathy, statins a...
...with cardiac allograft vasculopathy, a...
...atients with severe cardiac allograft vasculopath...
...g-Drug Interactions With Statins and Immuno...
Patient Follow-Up: Monitoring and Managing Symptoms
...Patient Follow-Up: Mo...
...7.1...
.... In stable patients with CCD and wi...
2. In patients with CCD without a change in c...
...n patients with CCD without a chang...
...atients with CCD without a change in clinical o...
Other Important Considerations
...Other...
...8.1. Cost and...
...en discussing treatment and prevention...