New guideline for chronic coronary disease
The 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease has been published.
The top 10 take home messages of this guideline:
1. The importance of patient-centered and multidisciplinary team-based care is emphasized. Communication among caregivers and with the patient is necessary to improve health outcomes and quality of life. Social determinants of health should be assessed by the care team and taken into consideration in the individualized treatment plan and lifestyle recommendations.
2. A healthy diet and exercise are recommended for patients with chronic coronary disease. A healthy diet includes vegetables, fruits, legumes, nuts, whole grains and lean protein. Intake of saturated fat, salt, and refined carbohydrates should be reduced. Trans fat should be avoided.
3. For patients without contraindications, an increase in physical activity and reduction of a sedentary lifestyle is recommended. Cardiac rehabilitation is recommended for eligible patients as it provides cardiovascular benefits.
4. A SGLT2i or a GLP-1RA with proven CV benefit are recommended in patients with CCD and T2D (class 1 recommendation). A SGLT2i is also recommended in patients with CCD and HFrEF (class 1 recommendation) and can be considered in patients with HFmrEF or HFpEF (class 2a recommendation), irrespective of diabetes status.
5. Beta blockers or calcium channel blockers are recommended as first-line antianginal therapy. Long-term beta-blocker therapy is not recommended in patients without previous MI or LVEF ≤50%, or another primary indication for beta-blocker therapy.
6. High-intensity statin therapy is recommended as first-line therapy to reduce LDL-c levels by ≥50% (class 1 recommendation). In patients at very high risk and on maximally tolerated statin therapy with LDL-c ≥70 mg/dL (≥1.8 mmol/L), ezetimibe can be beneficial (class 2a recommendation). In patients at very high risk and who have an LDL-c level ≥70 mg/dL despite statin and ezetimibe therapy, a PCSK9 monoclonal antibody can be considered (class 2a recommendation). Icosapent ethyl may be considered in patients on statin therapy with an LDL-c level <100 mg/dL and fasting triglyceride levels of 150-499 mg/dL (class 2b recommendation). Bempedoic acid or inclisiran may be considered in patients on statin therapy with an LDL-c level ≥70 mg/dL in whom ezetimibe and a PCSK9 monoclonal antibody are insufficient or not tolerated (class 2b recommendation).
7. Recommendations regarding the duration of dual antiplatelet therapy (DAPT) have been updated. In patients with CCD who underwent PCI, DAPT with aspirin and clopidogrel for 6 months post PCI followed by single antiplatelet therapy is recommended (class 1 recommendation). In a select group of patients with CCD who were treated with PCI with a drug-eluting stent (DES) and who have received 1- to 3-months of DAPT, P2Y12 inhibitor monotherapy for at least 12 months can be considered (class 2a recommendation).
8. Nonprescription dietary supplements such as low-dose omega-3 fatty acids or vitamins are not recommended due to the lack of proven benefit in reducing CV events.
9. Routine periodic testing with CCTA or stress testing is not recommended for risk stratification or for therapeutic decision-making in patients with CCD on optimized GDMT without a change in clinical or functional status.
10. Patients who smoke (including e-cigarettes) should be advised to quit smoking at every visit. To increase cessation rates, behavioral interventions together with pharmacotherapy or nicotine replacement therapy are recommended. E-cigarettes are not recommended as first line therapy for smoking cessation because of the risk of sustained use and unknown long-term safety.