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...
...umbering of the following tables may differ from t...
...ble 4. US Heart Disease Prevalence, by Age, Race...
...1. US Prevalence of CHD per 100,000, by Age...
...2. “Ever Told You Had Angina or CHD?”...
...bal Age-Adjusted Prevalence of CCD per 100,...
Diagnosis
...agnosis...
...on, Diagnosis, and Risk Stratification...
...gnostic Evaluation...
...s with CCD and a change in symptoms or...
...In patients with CCD and a change in...
...n patients with CCD and a change in symptoms or f...
...ts with CCD and a change in symptoms...
...In patients with CCD undergoing st...
...atients with CCD and a change in symptoms...
.... Risk Stratification and Relationship...
...ts with CCD, it is recommended that...
...atients with CCD, optimization of GDMT is...
.... In patients with CCD with newly re...
...ents with CCD, ICA for risk stratification is n...
...5. Potential Features Associated With...
Treatment
Treatm...
...reatment
...l Approach to Treatment Decisions...
...ith CCD, clinical follow-up at least annuall...
...patients with CCD, use of a validated C...
...igure 4. Domains to Consider When Seeing...
4.1.1. Team-Based Approa...
...with CCD, a multidisciplinary team-based approa...
...eam-Based Approach Reflective of Interconnectedne...
...atient Education...
...with CCD should receive ongoing individualized...
2. Patients with CCD should receive o...
.... Shared Decision-Making...
...Patients with CCD and their clinicians s...
...r patients with CCD and angina on GDMT w...
...4. Social Determinants of Health (...
1. In patients with CCD, routine assessment by cli...
...ure 6. Social Determinants of Health...
...-Directed Management and Therapy...
.... Nutrition, Including Supplements...
...tients with CCD, a diet emphasizing...
...In patients with CCD, reducing the...
...with CCD, minimization of sodium (...
...ith CCD, limiting refined carbohydrates...
...with CCD, the intake of trans fat should be avoid...
...patients with CCD, the use of nonpres...
...7. Recommended Nutritio...
4.2.2. Mental Health Con...
...ients with CCD, targeted discussions and scr...
...nts with CCD, treatment for mental healt...
...ested Screening Tool to Assess Psy...
...7. Suggested Screening Questions to A...
...3. Tobacco Products...
...ients with CCD, tobacco use should be assessed a...
...ients with CCD who regularly smoke tobacco should...
...ients with CCD who regularly smoke tobacco,...
...ts with CCD who regularly smoke tob...
5. In patients with CCD who regularly smoke toba...
...h CCD should avoid secondhand smoke exposu...
...le 8. Behavioral Resources for Smokin...
.... Alcohol and Substance Use...
...nts with CCD should be routinely asked a...
...tients with CCD who consume alcohol,...
...h CCD should not be advised to consume alcohol f...
...bstances With Abuse Potential and Adverse ...
....2.5. Sexual Health and Activit...
...ients with CCD, it is reasonable to individualize...
...In patients with CCD, cardiac rehabilitation...
...atients with CCD, phosphodiesterase type 5 in...
...2.6. Lipid Management
...s with CCD, high-intensity statin therapy is re...
...in whom high-intensity statin therapy is c...
...ts with CCD, adherence to changes in lifes...
...tients with CCD, the use of generic...
...n patients with CCD who are judged to be at very h...
.... In patients with CCD, addition of...
...s with CCD who are judged to be at very high risk...
...with CCD who are very high risk, the use of P...
.... In patients with CCD on maximally tolerat...
...ients with CCD who are not at very high ris...
...ients with CCD on maximally tolerated statin th...
...patients with CCD receiving statin ther...
...y High-Risk* of Future ASCVD EventsHaving tro...
...ipid Management in Patients With CCD...
...Moderate-, and Low-Intensity Statin Ther...
....7. Blood Pressure Management...
...adults with CCD, nonpharmacologic strategies a...
...ith CCD who have hypertension, a BP tar...
3. In adults with CCD and hypertension (sys...
...e 12. Nonpharmacologic Strategies for Bl...
...LT2 Inhibitors and GLP-1 Receptor Agonists...
...In patients with CCD who have type 2 diabetes,...
...nts with CCD and type 2 diabetes, a...
...atients with CCD and type 2 diabetes, addition...
...ients with CCD and heart failure w...
...ents with CCD and heart failure with LVEF ≤40%,...
.... In patients with CCD and heart failure wi...
...ients with CCD and heart failure with LV...
4.2.9. Weight Ma...
...patients with CCD, assessment of BM...
...with CCD and overweight or obesity shoul...
...ts with CCD and overweight or obesity...
4. In patients with CCD and severe...
...ith CCD, use of sympathomimetic weig...
...2.10. Cardiac Rehabil...
...r recent MI, PCI, or CABG should be referred to...
...ble angina or after heart transplant sho...
...ntaneous coronary artery dissection even...
...Components of CR...
4.2.11. Physical Activity
...tients with CCD who do not have contraindicat...
...ts with CCD who do not have contraindications, r...
...nts with CCD who do not have contraindication...
...Environmental Exposures...
...patients with CCD, minimization of...
...In patients with CCD, minimization of climate-rela...
...rapy to Prevent Cardiovascular Events and Manage S...
...3.1. Antiplatelet Therapy and Oral Anticoag...
...telet Therapy Without O...
.... In patients with CCD and no indication for OA...
...ts with CCD treated with PCI, dual anti...
...In select patients with CCD treated with P...
...with CCD who have had a previous MI and...
...ts with CCD and a previous history of MI withou...
6. In patients with CCD, the use of DAPT aft...
7. In patients with CCD without recent AC...
...tients with CCD and previous stroke, TIA, or ICH,...
.... In patients with CCD and previous stro...
...ients with CCD, chronic nonsteroidal anti-inflamma...
...let Therapy With Direct OAC (DOAC...
...s with CCD who have undergone elective PCI and who...
...2. In patients with CCD who have undergone P...
...tients with CCD who require oral anticoagulati...
14. In patients with CCD who require oral a...
...telet Therapy and Low-Dose...
...ts with CCD without an indication for therapeutic...
...ton Pump Inhibitor (PPI)...
...patients with CCD on DAPT, the use...
...commended Duration of Antiplatelet...
....2. Beta Blockers...
...with CCD and LVEF ≤40% with or without...
...In patients with CCD an...
...In patients with CCD who were initi...
...ith CCD without previous MI or LVEF ...
...3. Renin-Angiotensin-Aldosterone Inhibito...
...patients with CCD who also have hyperten...
...s with CCD without hypertension, diabetes...
....3.4. Colchici...
...with CCD, the addition of colchicine for secondar...
4.3.5. Immuniz...
...patients with CCD, an annual influenza vaccin...
...atients with CCD, coronavirus disease 2...
...tients with CCD, a pneumococcal vacc...
...l Therapy for Relief of Angina...
...tients with CCD and angina, antianginal thera...
.... In patients with CCD and angina who remain sym...
...In patients with CCD, ranolazine is recomme...
...In patients with CCD, sublingual nit...
...atients with CCD and normal LV function, th...
4.3.7. Management of Refrac...
...ients with CCD, refractory angina, a...
.... Chelation Therapy...
...s currently not approved by the FDA...
Revascularization
...cularization...
...vascularization...
...evascularization...
...Revascularization...
...patients with CCD and lifestyle-limiting angin...
...patients with CCD who have signifi...
...patients with CCD and multivessel dise...
...In patients with CCD and multivessel CAD approp...
...lected patients with CCD and signi...
...ecision-Making for Revasc...
...s with CCD who have angina or an angina...
...ith CCD undergoing coronary angiograph...
...nts with CCD with complex 3-vessel disease...
...scularization: PCI Versus C...
Patients Wit...
1. In patients with CCD who require reva...
...nts with CCD who require revascularization fo...
...th CCD at High Surgical Risk...
...with CCD who are appropriate for rev...
...s With CCD and Diabetes...
...nts with CCD, diabetes, and multives...
...tients with CCD and diabetes who have left ma...
Special Populations
Special Populati...
...1. Existing Heart Diseases and Condition...
...1. Chronic Management Aft...
...with CCD who have experienced SCAD, counseling sh...
2. In patients with CCD who have experi...
...ts with CCD who have experienced SCA...
...14. Screening Questions for SCAD-Associated Arte...
...schemia With Nonobstructive Coronary Arteries...
...In symptomatic patients with nonobstructive CAD,...
...15. Clinical Criteria for Suspecting Microva...
...Diagnostic Criteria for Vasospastic AnginaNitra...
.... Invasive Coronary Function Testing Definiti...
...reserved or Reduced Ejection Fraction...
...common cause of HF in the United States and...
...With Valvular Heart Disease...
...ncurrent CCD is common in patients wi...
....3. Young Adu...
...In young adults with CCD, after optimization of t...
...18. Traditional and Nontraditional...
...Nonatherosclerotic Causes of CCD in Young Adults...
....4. Cance...
...s with CCD and cancer, a multidiscipli...
...5. Women, Including Pregnancy and Postmen...
...egnancy...
...with CCD who are contemplating pregnancy or...
2. Women with CCD who are contemplating pregnancy...
...with CCD, continuation of statin use during p...
...CD who are contemplating pregnancy or who are pre...
...nopausal Hormone Therapy...
...D should not receive systemic postmenopau...
...Team-Based Cardio-Obstetrics Model of CareThe ca...
...REG II Risk Prediction Model - CARPREG II Predic...
.... CARPREG II Risk Prediction Model - CARPREG...
...1. Safety of Cardiovascular Medications During P...
...Older Adults...
...ble 22. The Geriatric 5 MsHaving troub...
...onic Kidney Disease...
...In patients with CCD and CKD, measures should be...
...IV and Autoimmune Disorders...
...IV...
...s with CCD and HIV, antiretroviral therapy i...
...ts with CCD and HIV, it is reasonable...
...h CCD and HIV, lovastatin or simvastatin s...
...mune Disorders in CCD...
...In adults with CCD and rheumatoid a...
...lts with CCD and autoimmune diseases, treatmen...
...atients with CCD and rheumatoid ar...
Table 23. Common Antiretroviral Therap...
...Cardiac Allograft Vasculopathy in He...
...nts with cardiac allograft vasculopathy,...
...patients with cardiac allograft vasc...
...nts with severe cardiac allograft v...
...24. Drug-Drug Interactions With S...
Patient Follow-Up: Monitoring and Managing Symptoms
...low-Up: Monitoring and Managing Symptoms...
...Plan and Testing in Stable Patient...
...patients with CCD and with previous AC...
2. In patients with CCD without a change i...
...with CCD without a change in clinical or functi...
.... In patients with CCD without a change in...
Other Important Considerations
...mportant Considerations...
...1. Cost and Value Consi...
...ing treatment and prevention with patients who h...