New ACC, AHA, Multi-Society Guideline Addresses Management of Chronic Coronary Disease

The newest clinical guideline developed by the ACC, American Heart Association (AHA) and other specialty societies takes an evidence-based and patient-centered approach to the management of patients with chronic coronary disease. The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" both updates and consolidates ACC/AHA guidelines previously published in 2012 and 2014 for the management of patients with stable ischemic heart disease.

Taking into account the newest published evidence, the new guideline provides an overview of epidemiology, as well as recommendations for evaluation, diagnosis and risk stratification of patients. It also dives into treatment recommendations, stressing the overall importance of a team-based care approach, patient education and the incorporation of shared decision-making principles and social determinants of health in treatment decisions.

Along with general approaches to treatment, the guideline addresses nutrition (including supplements); mental health conditions; tobacco, e-cigarette, alcohol and other substance use; sexual health and activity; lipid and blood pressure management; physical activity; weight management; environmental exposures; and more. Medical therapy to prevent cardiovascular events and manage symptoms is also a focus, with recommendations tied to use of antiplatelet therapy and oral anticoagulants, beta-blockers, renin-angiotensin-aldosterone inhibitors, colchicine, immunizations and chelation therapy. In addition, medical therapy for relief of angina and management of refractory management is also considered, and a separate section of the guideline is dedicated to revascularization.

Guidance is also provided for managing chronic coronary disease in special populations, including both younger and older adults; patients with cancer, existing heart diseases and conditions, chronic kidney disease or HIV and autoimmune disorders; others. Of note, the guideline outlines a cardio-obstetrics model of care involving multiple specialists working together and with the patient to address issues from preconception, through pregnancy and delivery, and the postpartum period. Patient follow-up, including outpatient monitoring and managing symptoms, is also discussed given the elevated risk among patients with chronic coronary disease for future major adverse cardiovascular events.

Similar with other recent guidelines, the chronic coronary disease guideline spends time on other important considerations, including cost and value, evidence gaps and future research needs. "Some new chronic coronary disease therapies are only available as branded formulations, and their high out-of-pocket costs can impede adoption or increase the risk of cost-related nonadherence," the guideline states. "…Therefore, clinicians have a key role in ensuring access and adherence to effective therapies by regularly discussing out-of-pocket costs with their patients with chronic coronary disease as a part of shared decision-making, using lower-cost alternatives when available, and guiding health systems to adopt cost-effective therapies when >1 alternative is appropriate."

In terms of future research, the guideline recognizes the numerous recent advances in diagnosis and treatment. However, the guideline authors note that the definition of patients who have chronic coronary disease is evolving and stress the need for more research into areas like noninvasive imaging technology; personalized medicine approaches; use of substances like marijuana on patient outcomes; and the efficacy of treatments based on gender, race and ethnicity. The authors also advocate for the creation and validation of comprehensive risk scores that take into account patient demographics, medical information, social determinants, and data from noninvasive test results or invasive test results or both.

"Our understanding about the role of social determinants of health, shared decision-making and the need to fully leverage a team-based approach to care has evolved and improved based on new evidence," says Salim S. Virani, MD, PhD, FACC, chair of the guideline writing committee. "The guideline consolidates the new information for the latest evidence-based recommendations to guide care for people with chronic coronary disease."

"Management of chronic coronary disease is a team sport," Virani says. "Clinicians in both primary and specialty care should fully leverage all members of the cardiovascular care team, including physicians, PAs, nurse practitioners, nurses and nursing assistants, pharmacists, dietitians, exercise physiologists, physical, occupational and speech therapists, psychologists and social workers to maximize benefits to patients with chronic coronary disease."

Read more about the guideline, including Top 10 Take-Home Messages, here. Access chronic coronary disease guideline-related resources for clinicians and patients, including CardioSmart infographics addressing medication adherence, active and mindful living, and heart-healthy nutrition; the 2023 Chronic Coronary Disease Guideline-at-a-Glance; the JACC Central Illustration and more on the Chronic Coronary Disease Guideline Hub.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Cardiac Surgery and SIHD, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Interventions and Coronary Artery Disease, Diet, Exercise, Chronic Angina

Keywords: Angiotensins, Colchicine, Renin, Myocardial Ischemia, Heart Diseases, Renal Insufficiency, Chronic, Anticoagulants, Disease Management, Risk Assessment, Coronary Disease, Lipids, Angina, Stable, Adrenergic beta-Antagonists, Angina Pectoris, Calcium Channel Blockers, Coronary Artery Bypass, Cardiac Rehabilitation, Chronic Disease, Coronary Artery Disease, Coronary Stenosis, Diabetes Mellitus, Type 2, Diet, Electronic Nicotine Delivery Systems, Exercise, Glucagon-Like Peptide-1 Receptor, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Life Style, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Patient Care Team, PCSK9 protein, human, Platelet Aggregation, Proprotein Convertase 9, Risk Assessment, Secondary Prevention, Sodium-Glucose Transporter 2 Inhibitors, Stroke Volume, Subtilisins, Ventricular Function, Left, Vitamins

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