Management of Patients with Chronic Coronary Disease

Publication Date: July 19, 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

...oduction

...he numbering of the following tables may...


...t Disease Prevalence, by Age, Race, Ethni...


...valence of CHD per 100,000, by Age and Sex (N...


...€śEver Told You Had Angina or CHD?” Age-Adjusted...


...gure 3. Global Age-Adjusted Prevalence of CCD per...


Diagnosis

...agnosis...

...Evaluation, Diagnosis, and Risk Stratificati...

...1. Diagnostic Evaluatio...

...ts with CCD and a change in symptom...

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

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

...ents with CCD and a change in symptoms or f...

...tients with CCD undergoing stress PET MPI or stres...

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

...ratification and Relationship to Treatmen...

...s with CCD, it is recommended that risk stratifi...

...with CCD, optimization of GDMT is recommended to...

...with CCD with newly reduced LV systolic functio...

...atients with CCD, ICA for risk stratification i...

...able 5. Potential Features Associate...


Treatment

...atment...

...Treatment...


....1. General Approach to Treatme...

...n patients with CCD, clinical foll...

...with CCD, use of a validated CCD-specifi...

.... Domains to Consider When Seeing a Pa...

....1. Team-Based Approach

...patients with CCD, a multidisciplinary team-base...

...re 5. Team-Based Approach Reflective of Inte...

...Patient Education

...Patients with CCD should receive on...

...s with CCD should receive ongoing i...

...Shared Decision-Making...

...h CCD and their clinicians should engage in...

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

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

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

...re 6. Social Determinants of Health and Ca...


...e-Directed Management and Therapy...

4.2.1. Nutrition, Including Supplement...

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

...n patients with CCD, reducing the percentag...

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

...nts with CCD, limiting refined carbohydrates (eg...

...with CCD, the intake of trans fat shou...

...n patients with CCD, the use of nonprescriptio...

...ure 7. Recommended Nutri...

...Mental Health Conditi...

...ith CCD, targeted discussions and screening for m...

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

...6. Suggested Screening Tool to Assess Psy...

...able 7. Suggested Screening Questions to Asses...

.... Tobacco Products...

...nts with CCD, tobacco use should b...

...ts with CCD who regularly smoke tob...

...In patients with CCD who regularly smoke tobac...

.... In patients with CCD who regularly sm...

...ts with CCD who regularly smoke tobacc...

.... Patients with CCD should avoid seco...

...vioral Resources for Smoking CessationHaving tr...

....2.4. Alcohol and Substance U...

...Patients with CCD should be routine...

...tients with CCD who consume alcoho...

...CCD should not be advised to consume alcohol...

...e 9. Substances With Abuse Potentia...

...exual Health and Activ...

.... In patients with CCD, it is reasonable to...

...with CCD, cardiac rehabilitation and regular ex...

...In patients with CCD, phosphodiesterase type 5...

...Lipid Management...

...ts with CCD, high-intensity statin the...

...ts in whom high-intensity statin the...

3. In patients with CCD, adherence to changes in...

...nts with CCD, the use of generic formulations o...

...ents with CCD who are judged to be...

...patients with CCD, addition of generic eze...

...ith CCD who are judged to be at very high ris...

.... In patients with CCD who are very h...

...ith CCD on maximally tolerated statin ther...

...0. In patients with CCD who are not at very high r...

.... In patients with CCD on maximally tole...

...s with CCD receiving statin therapy, addin...

...High-Risk* of Future ASCVD EventsHaving troubl...

...d Management in Patients With CCD...

Table 11. High-, Moderate-, and Low-I...

...lood Pressure Management...

...with CCD, nonpharmacologic strategie...

...with CCD who have hypertension, a BP ta...

...adults with CCD and hypertension (systo...

...e 12. Nonpharmacologic Strategies for Blood Pressu...

...LT2 Inhibitors and GLP-1 Receptor Agonists...

...patients with CCD who have type 2 di...

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

3. In patients with CCD and type 2 di...

...tients with CCD and heart failure with LVEF â‰...

...atients with CCD and heart failure with LVEF...

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

...patients with CCD and heart failure wit...

...eight Management...

...with CCD, assessment of BMI with or without wai...

...ith CCD and overweight or obesity should receive...

...r patients with CCD and overweight or...

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

...patients with CCD, use of sympathomimetic we...

...rdiac Rehabilitation...

...cent MI, PCI, or CABG should be referred to a card...

...ngina or after heart transplant should be referre...

...r recent spontaneous coronary artery di...

...able 13. Core Components of CR...

....2.11. Physical Activity...

...with CCD who do not have contraindication...

.... For patients with CCD who do not have co...

...atients with CCD who do not have contr...

...nvironmental Exposures...

...patients with CCD, minimization of exp...

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


...rapy to Prevent Cardiovascular Events and Manag...

...tiplatelet Therapy and Oral Anticoagulants (OAC...

...et Therapy Without OAC...

...s with CCD and no indication for OA...

...patients with CCD treated with PCI,...

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

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

...s with CCD and a previous history o...

.... In patients with CCD, the use of DAPT after C...

.... In patients with CCD without recent ACS or a PC...

.... In patients with CCD and previou...

.... In patients with CCD and previous stroke, TI...

10. In patients with CCD, chronic no...

...telet Therapy With Direct OAC (DOAC)...

...tients with CCD who have undergone elective...

...s with CCD who have undergone PCI and who re...

...ients with CCD who require oral anticoag...

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

...et Therapy and Low-Dose DOAC...

...ients with CCD without an indication...

...APT and Proton Pump Inhibitor...

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

...ure 9. Recommended Duration of Antipla...

4.3.2. Beta Blockers

...ents with CCD and LVEF ≤40% with o...

...In patients with CCD and LVEF...

...tients with CCD who were initiated on beta-bl...

...In patients with CCD without previous MI or L...

4.3.3. Renin-Angiotensin-Aldosterone Inhibi...

...nts with CCD who also have hypertension, diabetes...

.... In patients with CCD without hypertensio...

....4. Colchicine...

...patients with CCD, the addition of col...

...Immunizations...

...ts with CCD, an annual influenza vaccinat...

...atients with CCD, coronavirus disease 2019 (COVID...

...In patients with CCD, a pneumococca...

....3.6. Medical Therapy for Relief o...

...atients with CCD and angina, antianginal ther...

.... In patients with CCD and angina who re...

...ients with CCD, ranolazine is recommended...

...In patients with CCD, sublingual nitroglycerin...

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

....3.7. Management of Refractory An...

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

...3.8. Chelation T...

...rently not approved by the FDA for preventi...


Revascularization

...evascularizati...

.... Revascularization...


...1. Revasculariz...

...of Revascularization

...ts with CCD and lifestyle-limiting angina...

...In patients with CCD who have significant le...

...ients with CCD and multivessel disease with seve...

...nts with CCD and multivessel CAD appropriate for e...

...patients with CCD and significant left main...

...-Making for Revascularization...

.... In patients with CCD who have angina or a...

...ents with CCD undergoing coronary angiograp...

...patients with CCD with complex 3-vessel disease o...


5.2. Revascularization: PCI Versus CA...

...tients With C...

...s with CCD who require revascularization for sign...

...patients with CCD who require revasc...

Patients With CCD at High Surg...

...nts with CCD who are appropriate for r...

...ts With CCD and Diabetes...

...In patients with CCD, diabetes, and mul...

...tients with CCD and diabetes who ha...


Special Populations

Special Populations

....1. Existing Heart Diseases and Con...

...Chronic Management After SCAD...

...tients with CCD who have experienced SCAD, c...

...with CCD who have experienced SCAD, evalu...

.... In patients with CCD who have experien...

...4. Screening Questions for SCAD-Associate...

...schemia With Nonobstructive Coronary...

...ic patients with nonobstructive CAD, a strat...

...ble 15. Clinical Criteria for Suspecting...

...6. Diagnostic Criteria for Vasospast...

.... Invasive Coronary Function Testing Definition...

...3. HF With Preserved or Reduced Ejection Fraction...

...he most common cause of HF in the United States a...


...CAD With Valvular Heart Disease...

...is common in patients with valvular heart dis...


....3. Young Ad...

...n young adults with CCD, after opti...

...Traditional and Nontraditional Risk...

...erosclerotic Causes of CCD in Young Adult...


6.4. Cance...

...tients with CCD and cancer, a multidisci...


...en, Including Pregnancy and Postme...

Pregnancy

...D who are contemplating pregnancy or who are p...

...with CCD who are contemplating pregnancy...

...men with CCD, continuation of statin u...

4. Women with CCD who are contemplatin...

...nopausal Hormone Therapy

...CCD should not receive systemic postmenopausal hor...

...10. Team-Based Cardio-Obstetrics Mod...

...CARPREG II Risk Prediction Model - CARP...

...0. CARPREG II Risk Prediction Model -Â...

...ble 21. Safety of Cardiovascular Medications Du...


6.6. Older A...

...riatric 5 MsHaving trouble viewing table? Expan...


...Chronic Kidney Dise...

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


...V and Autoimmune Disorder...

...IV

...with CCD and HIV, antiretroviral the...

...ith CCD and HIV, it is reasonable to choose antire...

...ith CCD and HIV, lovastatin or simvastat...

...e Disorders in CCD...

...th CCD and rheumatoid arthritis, initiation an...

...s with CCD and autoimmune diseases, treatm...

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

...23. Common Antiretroviral Therapy Drugs and Effec...


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

...ts with cardiac allograft vasculopathy, statin...

...In patients with cardiac allograft vasculopa...

...with severe cardiac allograft vasculopathy, revasc...

...24. Drug-Drug Interactions With Statins an...


Patient Follow-Up: Monitoring and Managing Symptoms

...low-Up: Monitoring and Managing Sympt...

....1. Follow-Up Plan and Testing in Stable Pa...

...le patients with CCD and with previous ACS or c...

.... In patients with CCD without a change in clinica...

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

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


Other Important Considerations

...rtant Considerations...

...t and Value Considerations

...cussing treatment and prevention wi...