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
...troductio...
...bering of the following tables may differ fr...
...US Heart Disease Prevalence, by Age, Race...
...gure 1. US Prevalence of CHD per 100,000, by A...
...e 2. “Ever Told You Had Angina or CHD?...
...e 3. Global Age-Adjusted Prevalence of CCD per 10...
Diagnosis
Diagnosi...
...on, Diagnosis, and Risk Stratification
...gnostic Evaluation...
...with CCD and a change in symptoms or funct...
...nts with CCD and a change in symptoms or funct...
...with CCD and a change in symptoms or...
...patients with CCD and a change in s...
...ts with CCD undergoing stress PET MPI o...
...tients with CCD and a change in symptoms or functi...
...k Stratification and Relationship to Treatment...
...with CCD, it is recommended that risk stra...
...with CCD, optimization of GDMT is recommended...
...ts with CCD with newly reduced LV systolic functio...
4. In patients with CCD, ICA for risk stratif...
...5. Potential Features Associated With a High...
Treatment
...eatmen...
.... Treatme...
...ral Approach to Treatment Deci...
.... In patients with CCD, clinical follow-up...
...ts with CCD, use of a validated CCD-specif...
...4. Domains to Consider When Seeing a...
...Team-Based Approach...
...with CCD, a multidisciplinary team-based approac...
...Team-Based Approach Reflective of Interco...
...atient Education...
...atients with CCD should receive ongoing...
...tients with CCD should receive ongoi...
...Shared Decision-Making...
...Patients with CCD and their clinicians should...
...with CCD and angina on GDMT who are engaged in sh...
...Social Determinants of Health...
...ts with CCD, routine assessment by clini...
...e 6. Social Determinants of Health...
...uideline-Directed Management and Th...
...utrition, Including Supplem...
...ents with CCD, a diet emphasizing vegetables, f...
...In patients with CCD, reducing the perce...
3. In patients with CCD, minimization of sodium (
...ith CCD, limiting refined carbohydrates (eg, cont...
...nts with CCD, the intake of trans fa...
...n patients with CCD, the use of nonprescription o...
...gure 7. Recommended Nu...
.... Mental Health Conditi...
...tients with CCD, targeted discussions and...
...In patients with CCD, treatment for m...
...sted Screening Tool to Assess Psychological Distr...
...ested Screening Questions to Assess Psych...
.... Tobacco Products...
...nts with CCD, tobacco use should be asses...
...h CCD who regularly smoke tobacco should be a...
...s with CCD who regularly smoke tobacco, behavior...
...with CCD who regularly smoke tobacco, vareni...
...atients with CCD who regularly smoke toba...
...h CCD should avoid secondhand smok...
...le 8. Behavioral Resources for Smoking C...
...4. Alcohol and Substance...
...s with CCD should be routinely asked and counsele...
...with CCD who consume alcohol, it is reason...
...atients with CCD should not be advi...
...tances With Abuse Potential and Adverse ...
.... Sexual Health and Ac...
...In patients with CCD, it is reasona...
...patients with CCD, cardiac rehabilitatio...
...nts with CCD, phosphodiesterase type 5 in...
....6. Lipid Management...
...nts with CCD, high-intensity statin therapy is re...
...ts in whom high-intensity statin therapy i...
...ts with CCD, adherence to changes in lif...
...s with CCD, the use of generic formulat...
...s with CCD who are judged to be at very high r...
...s with CCD, addition of generic ezetimib...
.... In patients with CCD who are judged to be at...
...ents with CCD who are very high risk, the...
...In patients with CCD on maximally tolerated stat...
...patients with CCD who are not at very hi...
...s with CCD on maximally tolerated...
...atients with CCD receiving statin th...
...High-Risk* of Future ASCVD EventsHav...
...e 8. Lipid Management in Patients...
Table 11. High-, Moderate-, and Low...
...7. Blood Pressure Management...
...In adults with CCD, nonpharmacologic...
...with CCD who have hypertension, a BP target of...
...ts with CCD and hypertension (systolic BP ≥...
...harmacologic Strategies for Blood Pressu...
...2.8. SGLT2 Inhibitors and GLP-1 Receptor...
...In patients with CCD who have type 2 diabe...
...In patients with CCD and type 2 diabetes, additi...
...with CCD and type 2 diabetes, addition of an...
...nts with CCD and heart failure with LVEF â‰...
...ith CCD and heart failure with LVEF ≤40%,...
...nts with CCD and heart failure with LVEF >...
...patients with CCD and heart failure with LVE...
....2.9. Weight Manageme...
...tients with CCD, assessment of BMI with or without...
...atients with CCD and overweight or obesity s...
...patients with CCD and overweight or obesity in wh...
...In patients with CCD and severe obe...
5. In patients with CCD, use of sympathomimetic...
.... Cardiac Rehabilitatio...
...recent MI, PCI, or CABG should be referred t...
...h stable angina or after heart transpla...
...ontaneous coronary artery dissectio...
...Components of CR...
.... Physical Activity...
...s with CCD who do not have contraindications,...
...or patients with CCD who do not have contrai...
...nts with CCD who do not have contraindi...
...2.12. Environmental Exposure...
...s with CCD, minimization of exposu...
...s with CCD, minimization of climate-related exp...
...Therapy to Prevent Cardiovascular Even...
...platelet Therapy and Oral Anticoag...
...let Therapy Without OAC...
...tients with CCD and no indication for OAC th...
...n patients with CCD treated with PCI, dua...
...select patients with CCD treated with PC...
...patients with CCD who have had a previous MI a...
...tients with CCD and a previous history of...
...In patients with CCD, the use of DAPT...
...patients with CCD without recent ACS or a PCI-re...
...ith CCD and previous stroke, TIA, or ICH...
.... In patients with CCD and previou...
...tients with CCD, chronic nonsteroi...
...Therapy With Direct OAC (DOAC)...
.... In patients with CCD who have und...
...ts with CCD who have undergone PCI and who requir...
...ts with CCD who require oral anticoagulation an...
...nts with CCD who require oral anticoag...
...telet Therapy and Low-Dose DOA...
...nts with CCD without an indication...
...and Proton Pump Inhibitor (PPI)...
...with CCD on DAPT, the use of a PPI can be effecti...
...re 9. Recommended Duration of Antiplatelet Th...
....2. Beta Blockers...
...ts with CCD and LVEF ≤40% with or without...
.... In patients with CCD and LVE...
...ts with CCD who were initiated on beta-blo...
...n patients with CCD without previous MI or LVEF...
...-Angiotensin-Aldosterone Inhibitors...
...n patients with CCD who also have hyperte...
...patients with CCD without hypertension, diabetes,...
....3.4. Colchici...
...with CCD, the addition of colchicine for second...
...Immunizations...
...s with CCD, an annual influenza va...
.... In patients with CCD, coronavirus disease 2019...
...with CCD, a pneumococcal vaccine is reaso...
...6. Medical Therapy for Relief of Ang...
...ents with CCD and angina, antianginal...
2. In patients with CCD and angina who remain s...
...ith CCD, ranolazine is recommended in...
4. In patients with CCD, sublingual nitroglycerin...
...atients with CCD and normal LV function,...
...Management of Refractory Angina...
...In patients with CCD, refractory angina, and no o...
...3.8. Chelation Therapy...
...rrently not approved by the FDA for pr...
Revascularization
Revascularizati...
...Revascularizat...
.... Revascularization...
Goals of Revascularizati...
...patients with CCD and lifestyle-limiting angina d...
...patients with CCD who have signific...
...nts with CCD and multivessel disease wi...
...ts with CCD and multivessel CAD appro...
...patients with CCD and significant left main st...
...sion-Making for Revascularization...
6. In patients with CCD who have ang...
...patients with CCD undergoing corona...
...with CCD with complex 3-vessel disease or f...
...vascularization: PCI Versus CABG...
...tients With CCD
...tients with CCD who require revasculariza...
...tients with CCD who require revascularization...
...With CCD at High Surgical...
...patients with CCD who are appropriate for revascul...
...nts With CCD and Diabete...
...atients with CCD, diabetes, and multivessel...
...with CCD and diabetes who have left main stenosis...
Special Populations
...pecial Population...
...ng Heart Diseases and Conditions
...Chronic Management After SCAD...
...tients with CCD who have experienced SCA...
...n patients with CCD who have experienced SCAD,...
3. In patients with CCD who have experienced SCA...
...ing Questions for SCAD-Associated ...
...Ischemia With Nonobstructive Coronary A...
...n symptomatic patients with nonobstructive CA...
...ble 15. Clinical Criteria for Suspe...
...16. Diagnostic Criteria for Vasospastic An...
...Invasive Coronary Function Testing Definition a...
...F With Preserved or Reduced Ejection...
...st common cause of HF in the United States...
...h Valvular Heart Disease...
...rrent CCD is common in patients with valvular...
.... Young Adult...
1. In young adults with CCD, after optimization...
...itional and Nontraditional Risk Fa...
...erosclerotic Causes of CCD in Young Adults:Â ...
...4. Cancer
...nts with CCD and cancer, a multidi...
..., Including Pregnancy and Postmenopausal Hormone...
...egnancy...
...Women with CCD who are contemplating pregnan...
2. Women with CCD who are contempla...
...with CCD, continuation of statin...
...ith CCD who are contemplating pregnancy or w...
...opausal Hormone Therapy...
...ith CCD should not receive systemic postmenop...
...10. Team-Based Cardio-Obstetrics Model...
...20. CARPREG II Risk Prediction Model -Â CARPREG II...
Table 20. CARPREG II Risk Prediction Model -...
...ety of Cardiovascular Medications Duri...
.... Older Adults...
...able 22. The Geriatric 5 MsHaving tro...
...hronic Kidney Disease...
...with CCD and CKD, measures should b...
...8. HIV and Autoimmune Disorder...
...IV...
...ith CCD and HIV, antiretroviral therapy...
2. In adults with CCD and HIV, it is reasonable t...
...In adults with CCD and HIV, lovastatin or...
...mmune Disorders in CCD...
...s with CCD and rheumatoid arthritis, initiati...
...s with CCD and autoimmune diseases, tre...
...with CCD and rheumatoid arthritis, high-dose...
...Common Antiretroviral Therapy Drugs and...
...ardiac Allograft Vasculopathy in Heart...
...atients with cardiac allograft vascu...
.... In patients with cardiac allograft vas...
...tients with severe cardiac allograft vascu...
...-Drug Interactions With Statins and Immunosup...
Patient Follow-Up: Monitoring and Managing Symptoms
...llow-Up: Monitoring and Managing Symptoms...
...ow-Up Plan and Testing in Stable Patients...
...tients with CCD and with previous ACS or coro...
.... In patients with CCD without a change...
...with CCD without a change in clinica...
...ents with CCD without a change in clinical or fu...
Other Important Considerations
...r Important Consider...
....1. Cost and Value Consider...
.... When discussing treatment and preve...