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
...Introduction...
...e numbering of the following tables may d...
...4. US Heart Disease Prevalence, by Age, Race, Eth...
...Prevalence of CHD per 100,000, by Age and Sex (NHA...
...er Told You Had Angina or CHD?” Age-A...
...e 3. Global Age-Adjusted Prevalence of CCD per 1...
Diagnosis
...D...
...3. Evalu...
...3.1. Di...
1. In patients with CCD and a change in symptoms...
...patients with CCD and a change in symptoms o...
...ith CCD and a change in symptoms or functional c...
...n patients with CCD and a change in symptoms o...
...s with CCD undergoing stress PET MPI or stress CMR...
...patients with CCD and a change in symptoms...
...3.2. Risk Str...
...patients with CCD, it is recommended...
...nts with CCD, optimization of GDMT is recommen...
...with CCD with newly reduced LV systo...
...s with CCD, ICA for risk stratification is not r...
...Table 5....
Treatment
...Treatment
...4....
...4.1. Ge...
1. In patients with CCD, clinical follow-...
...atients with CCD, use of a validate...
...Domains to Consider When Seeing a Pat...
...4.1.1. Te...
...s with CCD, a multidisciplinary team-base...
...Based Approach Reflective of Interconnectedne...
...4.1.2. Patient...
...s with CCD should receive ongoing individua...
...CCD should receive ongoing individu...
...4.1.3. Shared Decisio...
...h CCD and their clinicians should enga...
...nts with CCD and angina on GDMT who are...
...4.1...
...patients with CCD, routine assessment by clinici...
...ocial Determinants of Health and Cardiovas...
...4.2. Guideline-Directe...
...4.2.1. Nutrition,...
...tients with CCD, a diet emphasizing...
...ents with CCD, reducing the percentage of calori...
...with CCD, minimization of sodium (...
...ents with CCD, limiting refined carbohyd...
...with CCD, the intake of trans fat should be av...
...s with CCD, the use of nonprescription...
...re 7. Recommended Nut...
...4.2.2. Mental...
...s with CCD, targeted discussions an...
...tients with CCD, treatment for mental...
...uggested Screening Tool to Assess Psychological...
...7. Suggested Screening Questions to Asses...
...4.2.3. Tobacco Produ...
...atients with CCD, tobacco use should b...
...ients with CCD who regularly smoke...
...with CCD who regularly smoke tobacco, behavio...
...tients with CCD who regularly smok...
...In patients with CCD who regularly smoke tobacc...
6. Patients with CCD should avoid secondhand...
...ioral Resources for Smoking CessationHaving trou...
...4.2.4....
...th CCD should be routinely asked a...
2. In patients with CCD who consume alco...
...CCD should not be advised to cons...
...ubstances With Abuse Potential and...
...4.2.5. Sexual...
...In patients with CCD, it is reason...
...ents with CCD, cardiac rehabilitation and r...
...nts with CCD, phosphodiesterase type 5 inhibi...
...4.2.6. Lipid Ma...
...ts with CCD, high-intensity statin therapy is reco...
...in whom high-intensity statin therapy...
...patients with CCD, adherence to changes in lifesty...
...atients with CCD, the use of generic formulations...
...ents with CCD who are judged to be at ver...
...patients with CCD, addition of generic...
...ents with CCD who are judged to be at very hi...
...ents with CCD who are very high risk, the...
...n patients with CCD on maximally tolerated...
...0. In patients with CCD who are not at v...
...n patients with CCD on maximally tolerated...
...n patients with CCD receiving statin the...
...High-Risk* of Future ASCVD EventsHaving...
...ipid Management in Patients With...
...High-, Moderate-, and Low-Intensity Statin ...
...4.2.7. Blood Pressure...
...ts with CCD, nonpharmacologic strategies a...
...s with CCD who have hypertension, a BP target...
...In adults with CCD and hypertension (systolic B...
...onpharmacologic Strategies for Blood Pressur...
4.2.8. SG...
...ients with CCD who have type 2 diabete...
...with CCD and type 2 diabetes, addition of a GLP...
...ith CCD and type 2 diabetes, addit...
...ents with CCD and heart failure with...
5. In patients with CCD and heart failure...
...patients with CCD and heart failure with...
...In patients with CCD and heart failure wit...
...4....
1. In patients with CCD, assessment of BMI with or...
...ients with CCD and overweight or obesit...
...r patients with CCD and overweight or...
...with CCD and severe obesity who have not...
...atients with CCD, use of sympathom...
...4.2.10. Cardiac...
after recent MI, PCI, or CABG should be ref...
...h stable angina or after heart transpl...
...ntaneous coronary artery dissection ev...
...Table 13...
...4.2.11. Physica...
...ents with CCD who do not have contrain...
...with CCD who do not have contraindications, re...
...r patients with CCD who do not have co...
...4.2.12....
...s with CCD, minimization of exposure to ambient ai...
...s with CCD, minimization of climate-r...
...4.3. Medic...
...4.3.1. Antip...
...Antiplatelet The...
...s with CCD and no indication for OAC...
2. In patients with CCD treated with PCI, dual a...
...ct patients with CCD treated with PCI a...
4. In patients with CCD who have had a previous MI...
...ith CCD and a previous history of MI without...
...with CCD, the use of DAPT after CABG may be...
...nts with CCD without recent ACS or a PCI-relat...
...s with CCD and previous stroke, TIA...
...atients with CCD and previous stroke, TIA, or ICH,...
...0. In patients with CCD, chronic nonsteroidal ant...
...Antiplatelet Thera...
.... In patients with CCD who have und...
...n patients with CCD who have undergon...
...ients with CCD who require oral antico...
...tients with CCD who require oral anticoagul...
...Anti...
...with CCD without an indication for th...
...DAPT and Pro...
16. In patients with CCD on DAPT, the...
...ommended Duration of Antiplatelet Therapy*...
...patients with CCD and LVEF ≤40% with or withou...
...n patients with CCD and LVEF...
3. In patients with CCD who were initia...
...ith CCD without previous MI or LVEF ≤50%, the u...
...4.3.3. Renin...
...ts with CCD who also have hypertension, d...
...patients with CCD without hypertension, diabetes...
...In patients with CCD, the addition of...
...4.3.5. Immuniza...
...s with CCD, an annual influenza vacc...
.... In patients with CCD, coronavirus disease 2019...
...patients with CCD, a pneumococcal vaccine...
...4.3.6. Medical...
1. In patients with CCD and angina, ant...
...ith CCD and angina who remain symptomati...
3. In patients with CCD, ranolazine is recom...
4. In patients with CCD, sublingual nitrog...
...ts with CCD and normal LV function, the add...
...4.3.7. Managem...
...ith CCD, refractory angina, and no othe...
...4.3.8. Chelation The...
...is currently not approved by the FDA for preven...
Revascularization
...Revascularizat...
...5. Revasc...
...5.1....
...Goals of Revascularizatio...
...n patients with CCD and lifestyle-limiting...
...In patients with CCD who have significant left...
...In patients with CCD and multivesse...
...atients with CCD and multivessel CA...
.... In selected patients with CCD and significant l...
...Decision...
...In patients with CCD who have angina or an a...
...tients with CCD undergoing coronary angiograp...
8. In patients with CCD with comple...
...5.2. Revasculari...
...Patients With CCD...
...s with CCD who require revascularizatio...
...In patients with CCD who require...
...Patients With CCD...
...In patients with CCD who are appropriate...
...Patients With CCD and Diab...
...In patients with CCD, diabetes, and...
...s with CCD and diabetes who have left mai...
Special Populations
Special Po...
...6.1. Existing H...
...6.1.1. Chronic Ma...
...nts with CCD who have experienced SCAD...
...ts with CCD who have experienced SCAD, evalu...
...ith CCD who have experienced SCAD, b...
...Screening Questions for SCAD-Associated Arterio...
...6.1.2...
...ymptomatic patients with nonobstructive C...
.... Clinical Criteria for Suspecting Micro...
.... Diagnostic Criteria for Vasospastic...
...vasive Coronary Function Testing Definit...
...6....
...AD is the most common cause of HF in the Unite...
...6.2. CAD...
...ncurrent CCD is common in patients...
...6.3. Y...
...g adults with CCD, after optimization...
...Traditional and Nontraditional Ris...
...herosclerotic Causes of CCD in Young...
...ts with CCD and cancer, a multidiscip...
...6.5. Women, Includi...
...Pre...
...n with CCD who are contemplating pr...
...Women with CCD who are contemplating...
.... In women with CCD, continuation of...
...CCD who are contemplating pregnancy or...
...Postmenopausal Ho...
...n with CCD should not receive systemic p...
...m-Based Cardio-Obstetrics Model of CareThe...
...EG II Risk Prediction Model - CARPREG II Pred...
...CARPREG II Risk Prediction Model - CARPREG II S...
...le 21. Safety of Cardiovascular Medicati...
...6.6. Older Adults...
...ble 22. The Geriatric 5 MsHaving t...
...6.7. Chronic Kidney D...
...ients with CCD and CKD, measures should be taken t...
6.8. HIV an...
...In adults with CCD and HIV, antiretrovi...
...with CCD and HIV, it is reasonable to choo...
.... In adults with CCD and HIV, lovastatin o...
...Autoimmun...
...dults with CCD and rheumatoid arthritis,...
...h CCD and autoimmune diseases, treatment with bi...
...nts with CCD and rheumatoid arthritis, hi...
...ommon Antiretroviral Therapy Drugs and Effe...
...6.9. Ca...
...atients with cardiac allograft vasculo...
...nts with cardiac allograft vasculopathy, aspiri...
...In patients with severe cardiac allograft...
...Drug-Drug Interactions With Statins and ...
Patient Follow-Up: Monitoring and Managing Symptoms
...Patient Follow-Up...
...7.1. Follow-U...
...stable patients with CCD and with previous...
.... In patients with CCD without a change in clin...
...ients with CCD without a change in clinical...
...In patients with CCD without a change in cl...
Other Important Considerations
...Other Important Conside...
...8....
...en discussing treatment and prevention w...