Value of lifestyle, symptom relief underscored in new chronic coronary disease guidelines
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Key takeaways:
- The AHA/ACC released updated guidelines for the management of chronic coronary disease.
- The document contains updated recommendations for beta-blocker use, revascularization, routine testing and more.
Updates on beta-blocker use, revascularization and routine testing and recommendations on healthy lifestyle are among the highlights of a new guideline on the management of patients with chronic coronary disease.
The guideline, issued by the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines, provides a general approach to chronic coronary disease treatment with an emphasis on team-based care, patient education and shared decision-making.
The document features healthy lifestyle recommendations for patients with chronic coronary disease, including guidelines for nutrition and dietary supplements, exercise, mental health, alcohol and tobacco use, sexual health and more.
The guideline was developed in collaboration with and/or endorsed by the American College of Clinical Pharmacy, American Society for Preventive Cardiology, National Lipid Association, Preventive Cardiovascular Nurses Association and the Society for Cardiovascular Angiography and Interventions and published in Circulation and the Journal of the American College of Cardiology.
“The last guideline for patients with chronic coronary disease was published in 2012 with an update in 2014. Since that time, our understanding of the disease and how we treat it has evolved considerably,” Salim S. Virani, MD, PhD, FAHA, FACC, vice provost for research at Aga Khan University in Pakistan, cardiologist at the Texas Heart Institute, adjunct professor at Baylor College of Medicine and chair of the AHA/ACC joint guideline writing committee, told Healio. “How we use medications — statins, nonstatin lipid lowering therapies, dual antiplatelet therapy, SGLT2 inhibitors, GLP-1 receptor agonists — revascularization procedures, and how we leverage a team-based approach to treating patients with chronic coronary disease have all evolved since the last publication of the guideline. I would clarify that this is not an update to a prior guideline but rather a guideline on its own, ie, the evidence for every recommendation was reviewed by the writing committee.”
A general approach to management
The joint guideline provides a general approach to clinical decision-making for the management of chronic coronary disease, underscoring a team-based strategy, patient education, shared decision-making and a focus on social determinants of health.
In terms of what is new in the guidance, Virani stated, “Several concepts in terms of the importance of social determinants of health and how we leverage a team-based approach to care for patients with chronic coronary disease. In addition, there are specific recommendations on several new classes of medications. Available evidence on the relationship between environmental exposures in patients with chronic coronary disease are also discussed.”
With a focus on improving symptoms and future CV risk, the document provides updates on the following pharmacologic recommendations:
- Beta-blockers are no longer recommended to be used for more than 1 year in patients who have not had MI within the past year or in those with left ventricular ejection fraction 50% or more. Beta-blockers or calcium channel blockers are recommended as first-line antianginal therapy.
- SGLT2 inhibitors and GLP-1 receptor agonists are recommended for select patients with chronic coronary disease. SGLT2 inhibitors are recommended in patients with diabetes and in those with HF and LVEF 40% or less, and may be considered in patients with HF and LVEF more than 40%. GLP-1 receptor agonists are recommended in patients with diabetes.
- Statin therapy remains a first-line therapy for lipid lowering in chronic coronary disease and certain adjunctive therapies may be used in select patients; however, outcomes data are unavailable for some novel agents such as inclisiran (Leqvio, Novartis).
- Under many circumstances, shorter-duration dual antiplatelet therapy is safe and effective.
The document also features new guidelines for revascularization, including a class 1A recommendation for revascularization to improve symptoms for patients with chronic coronary disease and significant coronary artery stenoses amenable to revascularization who have angina despite guideline-directed medical therapy.
CABG plus medical therapy was also made a class 1B-R recommendation for patients with chronic coronary disease and significant left main or multivessel disease and severe LV dysfunction.
In addition, routine periodic anatomic or ischemic testing with no evidence of change in either clinical or functional status is not recommended for risk stratification in patients with chronic coronary disease nor to guide clinical decision-making, according to the document.
“It is important to note that the prognosis of patients with chronic coronary disease — both in terms of symptom control and improvement in CV outcomes — has improved tremendously as long patients have a healthy lifestyle and they are prescribed and are taking guideline-directed medical therapy,” Virani told Healio. “This is not the same disease it was a couple of decades ago. There is a lot of hope and patients have a lot of options in terms of available therapies. It is extremely important therefore for patients to ask questions of their treating clinician and for patients to be part of shared decision-making for this chronic condition.”
Guideline a ‘living document’
In a related editorial, Sunil V. Rao, MD, FSCAI, FACC, director of interventional cardiology at the NYU Langone Health System and past president of SCAI, and colleagues discussed the updated recommendations and their significance in clinical practice.
“Chronic coronary disease affects millions of people worldwide, and is responsible for significant morbidity, mortality and costs. Chronic coronary disease as defined in the 2023 guideline includes patients who may or may not have classic signs and symptoms of CAD,” the authors wrote. “The 2023 guideline reflects this heterogeneity by including patients stabilized after acute coronary syndrome hospitalization, those with ischemic cardiomyopathy, stable angina or equivalent with or without a positive imaging test, vasospasm or microvascular disease, and positive noninvasive screening test leading to a clinician diagnosis of CAD.
“The three new recommendations regarding revascularization, the role of beta-blockers, and routine functional or anatomic testing highlighted in this frame of reference represent only a fraction of the important content in the document,” they wrote. “Importantly, the guidelines exist to provide guidance, and are meant to complement, not supplant, clinical judgment. As the evidence for the management of chronic coronary disease continues to evolve, the guidelines will need to be a ‘living document’ to ensure that clinicians and patients can achieve their shared therapeutic goals of reducing mortality and improving quality of life.”
For more information:
Salim S. Virani, MD, PhD, FAHA, FACC, can be reached at salim.virani@aku.edu.
References:
- Rao SV, et al. Circulation. 2023;doi:10.1161/CIRCULATIONAHA.123.064623.
- Symptom relief and healthy habits are top goals for treating chronic heart disease. newsroom.heart.org/news/symptom-relief-and-healthy-habits-are-top-goals-for-treating-chronic-heart-disease. Published July 20, 2023. Accessed July 20, 2023.
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