The 2023 multisociety guideline for the management of patients with chronic coronary disease (CCD) provides a comprehensive framework for addressing this condition. Here, we summarize key perspectives and recommendations outlined in the guideline:

1. Team-Based, Patient-Centered Care:

• The CCD guideline emphasizes a patient-centered approach that takes into account social determinants of health and associated costs. It promotes shared decision-making in risk assessment, testing, and treatment.

2. Lifestyle Modification:

• Lifestyle modification and nonpharmacologic therapies, including healthy dietary habits and exercise, are recommended for all patients with CCD.

3. Physical Activity:

• Patients with CCD who are free from contraindications are encouraged to engage in habitual physical activity. This includes reducing sitting time and incorporating aerobic and resistance exercises.

4. Cardiac Rehabilitation:

• Cardiac rehabilitation is recommended for eligible patients, as it provides significant cardiovascular benefits, including decreased morbidity and mortality outcomes.

5. Medications:

• The use of sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists is recommended for select groups of patients with CCD, even in the absence of diabetes, to improve outcomes.

• Long-term beta-blocker therapy is not recommended to improve outcomes unless specific indications such as recent myocardial infarction, reduced ejection fraction, or another primary indication are present.

• For antianginal therapy, either a calcium channel blocker or beta-blocker is recommended as first-line treatment.

• Statins remain the first-line therapy for lipid lowering in patients with CCD. Adjunctive therapies like ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors may be considered in select populations.

6. Dual Antiplatelet Therapy:

• Shorter durations of dual antiplatelet therapy are considered safe and effective in many cases, especially when the risk of bleeding outweighs the ischemic risk.

7. Dietary Supplements:

• The use of nonprescription or dietary supplements, including fish oil, omega-3 fatty acids, or vitamins, is not recommended for patients with CCD due to the lack of evidence supporting their effectiveness in reducing cardiovascular events.

8. Routine Testing:

• Routine periodic anatomic or ischemic testing without a change in clinical or functional status is not recommended for risk stratification or therapeutic decision-making in patients with CCD.

9. Smoking Cessation:

• While e-cigarettes can increase the likelihood of successful smoking cessation, they are not recommended as first-line therapy due to the lack of long-term safety data and risks associated with sustained use.

10. Revascularization:

• In patients with CCD and lifestyle-limiting angina despite guideline-directed management and therapy, revascularization is recommended to improve symptoms.

• For patients with CCD requiring revascularization for multivessel coronary artery disease (CAD) with complex and diffuse CAD (e.g., SYNTAX score >33), coronary artery bypass grafting is considered a reasonable choice over percutaneous coronary intervention to improve survival.

11. Future Research:

• The guideline highlights the need for further research to assess effective strategies for guideline implementation in clinical practice and the impact of new guidelines at various levels of healthcare delivery.

This guideline offers a comprehensive approach to the management of chronic coronary disease, emphasizing patient-centered care, lifestyle modification, evidence-based medication use, and personalized treatment strategies. It serves as a valuable resource for healthcare professionals and researchers in the field of cardiovascular medicine.

FAQs:

1. What is Chronic Coronary Disease (CCD)?

• Chronic Coronary Disease, often referred to as CCD, is a condition characterized by long-term or persistent narrowing of the coronary arteries, typically due to atherosclerosis. It can lead to reduced blood flow to the heart muscle, causing symptoms such as angina (chest pain) and potentially contributing to heart attacks.

2. How does the guideline approach patient care for CCD?

• The guideline emphasizes team-based, patient-centered care that considers social determinants of health, associated costs, and shared decision-making in risk assessment, testing, and treatment. It promotes a holistic approach to managing CCD.

3. Are lifestyle modifications recommended for CCD patients?

• Yes, lifestyle modifications are strongly recommended for all CCD patients. This includes adopting healthy dietary habits and engaging in regular exercise as part of a comprehensive management strategy.

4. What type of physical activity is encouraged for CCD patients?

• CCD patients are encouraged to participate in habitual physical activity, which includes activities to reduce sitting time and incorporate both aerobic and resistance exercises. Regular physical activity can improve cardiovascular health.

5. What are the benefits of cardiac rehabilitation for CCD patients?

• Cardiac rehabilitation offers significant cardiovascular benefits for eligible CCD patients, including decreased morbidity and mortality outcomes. It provides structured programs to enhance overall heart health.

6. Are medications prescribed for CCD management?

• Yes, medications play a crucial role in CCD management. Sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists may be recommended for select patient groups. However, long-term beta-blocker therapy is generally not recommended unless specific indications are present.

7. What is the recommended approach for antianginal therapy in CCD patients?

• Either a calcium channel blocker or a beta-blocker is recommended as first-line antianginal therapy for CCD patients.

8. What is the primary approach to lipid-lowering in CCD?

• Statins remain the first-line therapy for lipid lowering in CCD patients. Depending on individual circumstances, adjunctive therapies like ezetimibe or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors may be considered.

9. How long should dual antiplatelet therapy be administered for CCD patients?

• The guideline suggests that shorter durations of dual antiplatelet therapy can be safe and effective in many cases, particularly when there is a higher risk of bleeding compared to ischemic risk.

10. Are dietary supplements recommended for CCD patients? - No, the use of nonprescription or dietary supplements, including fish oil, omega-3 fatty acids, or vitamins, is not recommended for CCD patients due to the lack of evidence supporting their effectiveness in reducing cardiovascular events.

11. When is revascularization recommended for CCD patients? - Revascularization is recommended for CCD patients with lifestyle-limiting angina despite guideline-directed management and therapy. It can help improve symptoms and quality of life.

12. In complex cases of multivessel coronary artery disease, which revascularization method is preferred? - In cases of CCD with complex and diffuse coronary artery disease (e.g., SYNTAX score >33), coronary artery bypass grafting (CABG) is considered a reasonable choice over percutaneous coronary intervention (PCI) to improve survival.

13. What areas of research are needed in the management of CCD? - Further research is needed to assess effective strategies for implementing guidelines in clinical practice and to understand the impact of new guidelines at various levels of healthcare delivery. This research will help improve CCD management in the future.

Citation:

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines | Circulation (ahajournals.org)

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Video courtesy:

Raymond Stainback | Non-invasive Imaging in Coronary Syndromes

The Texas Heart Institute