ACC-AHA 2023 2023 AHA/ACC Guideline for the Management of Patients With Chronic Coronary Disease
ACC/AHA｜循環器 / 冠動脈疾患｜111 ページ｜チャンク 1179｜推奨 13 件｜current
推奨表（自動抽出）
PDF の推奨表から機械的に抽出したものです。引用前に必ず該当ページの原文を確認してください。
| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.13 | 1 A | in the composite primary MACE (cardiovascular death, MI, hospitalization for unstable angina, HF, or resuscitated cardiac arrest) endpoint was observed at ∼3.3 years of follow-up. Angina symptoms improved in both the conservative and invasive treatment arms, although improvements were larger in the invasive arm, particularly with more frequent angina at baseline.48 Therefore, in patients with CCD with known anatomy and ongoing angina despite GDMT, early invasive angiography and revascularization should be considered to improve symptoms. Notably, secondary analyses of RCTs have reported no differences in major adverse cardiovascular outcomes in medical versus invasive medical treatment strategies in patient with CCD49 when stratified by ischemia severity on noninvasive testing. 3. The improved diagnostic accuracy of PET MPI is helpful in patients with known CAD. In a randomized trial of 322 symptomatic patients with known CAD, the presence of low- and high-risk stress PET findings was associated with lower and higher rates of ICA when compared with SPECT MPI (P=0.001).29 Downloaded from http://ahajournals.org by on October 7, 2026 4 Observational studies of patients with CAD and stable chest pain have shown that exercise treadmill testing can be useful by evaluating the relation of symptoms to graded stress testing, thereby helping to confirm the diagnosis of angina pectoris; assessing symptom severity; and selecting appropriate management (eg, medical therapy, revascularization, cardiac rehabilitation [CR]).26,30–32 5 Reduced MBFR reflects abnormalities of flow | ||
| p.25 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.29 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.35 | 1 A | Verapamil SR/Trandolapril Study) trial, CCB and ACE inhibitors and beta-blocker/thiazide diuretic therapy had similar cardiovascular morbidity and death outcomes.31 In the EUROPA (Exclusive Endocrine Therapy or Partial Breast Irradiation for Women ≥70 Years Early Stage Breast Cancer) study involving patients with CCD, ACE inhibitor therapy produced a 20% reduction in risk of CVD death, MI, or cardiac arrest compared with placebo.15 Beta blockers are particularly effective in patients with CCD, especially those with recent MI and those with ongoing angina, given their ability to reduce angina, improve anginafree exercise tolerance, reduce exertion-related myocardial ischemia, and reduce risk of CVD events.17,23,27,32,33 Because of the significant benefits from beta blockers and ACE inhibitors and ARB agents in patients with CCD, these medications are recommended as a first-line therapy in the treatment of hypertension in such individuals. GDMT beta blockers for CCD and for lowering BP include carvedilol, metoprolol tartrate, metoprolol succinate, nadolol, bisoprolol, propranolol, | ||
| p.36 | 1 A | CLINICAL STATEMENTS AND GUIDELINES | ||
| p.40 | 1 A | Published evidence suggests favorable cost-effectiveness of CR.34–36 One multicenter, randomized trial of longer-term “maintenance” CR of up to 3 years was associated with moderate but significant improvements in cardiovascular outcomes compared with those who participated in the traditional 12-week course of CR.37 For related information, refer to these Sections: 3.2, “Risk Stratification and Relationship to Treatment Selection”; 4.1.1, “Team-Based Approach”; 4.1.2, “Patient Education,” 4.1.3, “Shared Decision-Making”; 4.2.1, “Nutrition, Including Supplements”; 4.2.2, “Mental Health”; 4.2.6, “Lipid Management”; 4.2.7, “Blood Pressure Management”; 4.2.8, “Sodium Glucose Cotransporter 2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists”; 4.2.9, “Weight Management”; 6.1, “Existing Heart Diseases and Conditions”; 6.9, “Post- Heart Transplant Cardiac Allograft Vasculopathy”; and 2022 ACC/AHA/HFSA heart failure guideline.38 CLINICAL STATEMENTS AND GUIDELINES Recommendation-Specific Supportive Text 1 Patients with CCD with a recent MI, PCI, or CABG | ||
| p.42 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.47 | 1 A | is based on historical data with warfarin as well as data extrapolated from more recent studies evaluating various combination therapies versus monotherapy in patients with a recent ACS.38-44,66–70 15 The COMPASS (Cardiovascular Outcomes for | ||
| p.47 | 1 A | People Using Anticoagulation Strategies) trial evaluated the efficacy and safety of low-dose rivaroxaban 2.5 mg twice daily, with or without low-dose aspirin therapy, in reducing CVD events in patients with stable ASCVD.30 The primary outcome of cardiovascular death, stroke, or MI occurred in 4.1% of the aspirin plus rivaroxaban group, 4.9% of the rivaroxaban alone group, and 5.4% for aspirin monotherapy. The study was terminated early because of the observed benefit of rivaroxaban plus aspirin compared with aspirin alone. Evaluation of high-risk patients (multivessel CAD and at least one of the following: diabetes requiring medication, recurrent MI, peripheral artery disease, HF, or CKD with an eGFR of 15-59 mL/min/m2 69) showed an absolute net clinical benefit with combination therapy, with substantial reductions in ischemic events and all-cause death.31 The high-risk population also derived a larger absolute risk reduction, resulting in an even lower number needed to treat.30–32 The combination of rivaroxaban plus aspirin resulted in a higher risk of major bleeding compared with aspirin monotherapy (3.1% versus 1.9%; hazard ratio, 1.70 [95% CI, 1.40–2.05]; P<0.001]). The use of DAPT was an exclusion criteria. 16. Increased bleeding including gastrointestinal | ||
| p.48 | 1 A | guidelines on patients with stable ischemic heart disease recommended the use of beta-blocker therapy in patients with previous MI and preserved LV systolic function, this recommendation was based on data gathered from the noncontemporary era.33 In the contemporary era of timely reperfusion/revascularization and progressive pharmacotherapy (including antithrombotic and lipid-lowering therapy) among patients with MI, the recommendation for long-term use (>1 year) of beta-blocker therapy in the absence of LV systolic dysfunction has been challenged.13,14 Observational studies from the current era evaluating post-MI patients with preserved LV systolic function showed discrepant results with some studies suggesting clinical benefit while others showed lack of clinical benefit with long-term use of beta-blocker therapy.9-15,34 Long-term use of beta-blocker therapy may also confer potential clinical risks including fatigue, depression, and drug-drug interactions, thereby necessitating future high-quality data to ascertain the need | ||
| p.50 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 | ||
| p.53 | 1 A | combines with biologically active heavy metal polyvalent cations, such as lead and cadmium, to form soluble complexes that can then be excreted.1 Very small trials conducted in patients with intermittent claudication and with CCD failed to show clinically relevant benefits.2–5 The first adequately powered trial of this intervention, TACT (Trial to Assess Chelation Therapy), randomized 1708 patients with previous MI to 40 infusions of chelation or placebo.6 The primary composite endpoint of total mortality, recurrent MI, stroke, coronary revascularization, or hospitalization for angina occurred in 222 (26%) patients in the chelation group and 261 (30%) patients in the placebo group (hazard ratio, 0.82 [95% CI, 0.69–0.99]; P=0.035). Among the 633 TACT patients with diabetes, chelation reduced the primary composite endpoint by 41% reduction (hazard ratio, 0.59 [95% CI, 0.44–0.79]; P=0.02 for interaction).6,7 EDTA is currently not approved by the FDA for preventing or treating cardiovascular disease. TACT2 (Trial to Assess Chelation Therapy 2) has randomized 1000 patients with diabetes and previous MI using the same treatment regimen as TACT and will report results in 2024.8 Downloaded from http://ahajournals.org by on October 7, 2026 5 REVASCULARIZATION The topic of revascularization is evolving. We highlight certain management decisions in the next section. Recommendations are typically based on results of the major trials, meta-analyses, or both, covering varying amounts of the same material. We acknowledge that the trials do not cover the area consistently or address all questions comprehensively. Some trials begin with angiographically proven CAD (and a decision already made to proceed with revascularization), while others begin earlier in the clinical presentation. With this in mind, we have made a concerted effort to stay within the strongest evidence in shaping these recommendations for revascularization in patients with CCD. | ||
| p.56 | 1 A | Downloaded from http://ahajournals.org by on October 7, 2026 |