2023 Guideline for the Management of Patients with Chronic Coronary Disease: Top 10 Takeaways

The American College of Cardiology (ACC) and the American Heart Association (AHA) have published a clinical practice guideline for the management of patients with chronic coronary disease (CCD). To update new evidence and consolidate previous guideline statements on the diagnosis and management of patients with stable ischemic heart disease, this new clinical practice guideline:

• Provides an evidence-based, patient-centered approach to management of patients with CCD.
• Incorporates social determinants of health (SDOH).
• Promotes the principles of shared decision-making and team-based care.

What This Update Means for CV Practices

This new guideline is an important step toward eliminating variation in the clinical diagnosis and management of patients with CCD, as well as incorporating important SDOH into treatment plans. CV program leaders should work with clinicians and administrators to update clinical pathways and communicate the new guidelines to care teams. With the new guidance on routine periodic anatomic or ischemic testing, consider the potential impact on diagnostic testing volumes and how your program monitors appropriate use criteria for noninvasive cardiac testing.

Top 10 Takeaways

The AHA and ACC have included a list of the top 10 take-home messages to accompany the guideline. Summarized below, these messages have direct implications and benefits for cardiovascular (CV) providers and programs.

1. Team-Based Care Approach

The new clinical practice guideline places a strong emphasis on team-based, patient-centered care that takes into consideration SDOH and associated costs while incorporating shared decision-making in risk assessment, testing, and treatment. As figure 1 illustrates, team-based, patient-centered care focuses on several domains that promote shared-decision-making and incorporating SDOH, which are defined by the ACC and AHA as:

• Culture and language.
• Economic stability.
• Education and health literacy.
• Gender considerations and/or sexual orientation.
• Healthcare system.
• Physical environment.
• Social support.
• Systemic racism.

_{Figure 1:Domains to Consider When Seeing a Patient with CCD^[1]}

2. Nonpharmacologic Therapies

Nonpharmacologic therapies, including healthy dietary habits and daily exercise, are recommended for all patients with CCD. The guideline recommends patients avoid trans fats and reduce their intake of saturated fats, sodium, processed meats, refined carbohydrates, and sugar-sweetened alcoholic beverages. Instead, patients should follow a heart-healthy diet that centers on fruit, vegetables, legumes, nuts, whole grains, lead proteins, complex carbohydrates, and limited fat.

3. Physical Activity

Patients with CCD who are free from contraindications are encouraged to participate in routine physical activity, including activities to reduce sitting time and increase aerobic and resistance exercise. The guideline also references a key statistic: an approximately 10% reduction in mortality and CV disease is experienced when individuals increase their daily step count by 1,000, according to research. Additionally, cardiac rehabilitation for eligible patients provides significant CV benefits, including decreased morbidity and mortality outcomes. Class 1 indications for a referral to cardiac rehab include the following conditions:

• Recent MI, PCI, CABG
• Recent SCAD
• Stable angina
• Heart transplant

4. Pharmacologic Therapy: Sodium Glucose Cotransporter 2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists

Sodium glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists are recommended for select groups of patients with CCD, including those individuals without diabetes.

5. Pharmacologic Therapy: Beta Blockers

New recommendations for beta-blocker use in patients with CCD:

• 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 of 0%, or another primary indication for beta-blocker therapy.
• Either a calcium channel blocker or beta blocker is recommended as first-line antianginal therapy.

6. Pharmacologic Therapy: Statins

Statins remain first-line therapy for lipid lowering in patients with CCD. Several adjunctive therapies (e.g., ezetimibe, proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors, inclisiran, bempedoic acid) may be used in select populations, although clinical outcomes data is unavailable for novel agents such as inclisiran.

7. Pharmacologic Therapy: Dual Antiplatelet Therapy Duration

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.

8. Nonprescription or Dietary Supplements

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 demonstrated benefit in reducing CV events.

9. Anatomic or Ischemic Testing Intervals

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.

10. Avoidance of E-Cigarettes for Smoking Cessation Therapy

Although e-cigarettes increase the likelihood of successful smoking cessation compared with nicotine replacement therapy, due to the lack of long-term safety data and risks of sustained use, they are not recommended as first-line therapy for smoking cessation. Instead, CV providers should assess tobacco smoking at every health visit and, if the patient smokes, advise them to quit. Treatment should include behavioral interventions, nicotine replacement therapy, and pharmacotherapy (bupropion and varenicline).

About ECG and Our CV Team

ECG, one of the top healthcare consulting firm in the US, specializes in strategic advisory, financial services, and clinical program and operational performance services for healthcare organizations. ECG’s CV consulting team is passionate about improving CV care delivery and since 2010 has conducted nearly 300 engagements across more than 100 parent companies. Our experts focus on providing executive advisory services to the nation’s leading CV programs. For more information, please contact our team.

_{Edited by: Matt Maslin}

Published August 11, 2023