p.14 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

August 29, 2023 Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168

Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline

some functional and anatomic testing modalities, but observational studies and secondary analyses from randomized trials consistently report that the addition of clinical and ancillary imaging variables are associated with improved risk prediction (Table 5).3,4,15–44 A meta-analysis of 165 studies reported that in patients with a normal functional test for CCD, a negative study did not uniformly predict a <1% annual risk of cardiovascular death or nonfatal MI, suggesting that population and patient differences may be associated with prognosis.13 The lone exception is a normal CCTA.45,46 Previous AHA/ACC guidelines have recommended stratifying patients with CCD as low (<1% annual risk), intermediate (1%-3% annual risk), or high (>3% annual risk) risk for MACE.47,48 Although these cutoffs are somewhat arbitrary and may be grounded in historical Bethesda Conference recommendations based on Duke Treadmill Score risk tertiles, we suggest maintaining these categorizations for annual cardiovascular death or nonfatal MI.47,49,50

2 The 2021 AHA/ACC chest pain guideline recom-

mends the optimization of anti-ischemic and preventive therapies with the goal to reduce the patient’s angina burden and improve clinical outcomes.12 Three major RCTs including COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation), ISCHEMIA, and BARI-2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) have shown that there is no reduction in MACE with routine cardiovascular revascularization.5–7 The COURAGE trial, which included patients with stabilized Canadian Cardiovascular Society class IV angina and at least a 70% stenosis in at least 1 coronary artery with evidence of ischemia, reported no difference in all-cause death or nonfatal MI between revascularization with PCI and optimal medical therapy. The BARI-2D trial randomized patients with type 2 diabetes and CCD (≥70% stenosis of a major coronary artery and angina or ≥50% stenosis of a major coronary artery with a positive stress test) to revascularization or medical therapy and reported no difference in survival. 3.	 The STICH (Surgical Treatment for Ischemic Heart

Failure) trial randomized 1212 patients with an ejection fraction ≤35% with coronary disease amenable to coronary artery bypass grafting (CABG) to either medical therapy alone or medical therapy and CABG. After a median follow-up of 56 months, no significant difference was observed in the primary outcomes of all-cause death (41% versus 36%; P=0.12), but cardiovascular death (33% versus 28%; P=0.05) and all-cause death or cardiovascular hospitalization (68% versus 58%; P<0.001) were lower in the CABG arm.9 In a secondary analysis of the ISCHEMIA trial, 398 participants had HF or an LVEF <45%. Both the 4-year primary composite endpoint (17.2% versus 29.3%; event rate difference, −12.1% [95% CI, −22.6 to −1.6]) and cardiovascular death or MI (14.6% versus 25.9%; event rate difference

Table 5.  Potential Features Associated With a Higher Risk of MACE Among Patients With Established CCD Demographics and Socioeconomic Status (also see Section 4.1.4, “Social Determinants of Health”) Age Male sex Poor social support Poverty or lack of health care access Past or Concurrent Medical, Mental Health Conditions Elevated body mass index Previous MI, PCI, or CABG HF Atrial fibrillation or flutter Diabetes Dyslipidemia Chronic kidney disease Current or former smoker Peripheral artery disease Depression Poor adherence with goal-directed pharmacotherapy Ancillary Cardiac Testing or Imaging Inability to exercise Angina with stress ECG: left bundle branch block, left ventricular hypertrophy, higher resting heart rate Echocardiography: reduced left ventricular ejection fraction, left ventricular hypertrophy EST: higher DTS, higher resting heart rate, achieved heart rate <85% predicted Exercise or dobutamine stress echocardiography: higher DTS, lower exercise workload, peak rate-pressure product <15 000, coronary flow reserve <2, no change or increase in left ventricular end-systolic volume, reduced ejection fraction, ischemic electrocardiographic changes with stress SPECT or PET: Percentage fixed myocardium on SPECT, transient ischemic dilation with stress, reduced coronary flow reserve, ischemic electrocardiographic changes with stress Higher calcium score: alone and in addition to functional imaging CCTA: total plaque burden, high-risk plaque (positive remodeling [remodeling index >1.1], low attenuation [mean CT number <30 HU], or napkin-ring sign), reduced CT-fractional flow reserve CMR: reduced left and/or right ventricular ejection fraction, left ventricular hypertrophy, scar or infarct, reduced myocardial perfusion reserve, myocardial blood flow at stress Biomarkers High-sensitivity troponin, B-type natriuretic peptide CABG indicates coronary artery bypass graft; CCD, chronic coronary disease; CCTA, coronary computed tomography angiography; CMR, cardiovascular magnetic resonance imaging; CT, computed tomography; DTS, Duke Treadmill Score; ECG, electrocardiogram; EST, exercise stress test; HF, heart failure; HU, Hounsfield units; MACE, major adverse cardiovascular events; MI, myocardial infarction; PCI, percutaneous coronary intervention; PET, positron emission tomography; and SPECT, single-photon emission computed tomography.

Downloaded from http://ahajournals.org by on October 7, 2026