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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 manifestations of coronary disease concluded that education had no effect on total mortality, recurrent MI, or hospitalizations.5 Yet, Swedish registry data suggest that the education component of CR is strongly linked to cardiovascular and total mortality.7 Published studies of educational interventions for patients with CCD, whether provided in person or by Internet, are heterogeneous, often incompletely described, many are short-term, and outcomes assessment varies. At this time, there are insufficient comparative data to provide clinicians and their care teams assistance when choosing among interventions, a gap that should be addressed in future research studies. Recommendation-Specific Supportive Text 1 A systematic review of the effect of patient edu- cation reported improvement in knowledge about medications and appropriate responses to symptoms,1 as well as improvements in physical activity, dietary habits, and smoking cessation rates, but no convincing evidence of improvement in response to cardiac symptoms or psychosocial well-being was observed.1 A review of 7 RCTs of Internet-based education and support found there was some supportive evidence for these interventions, but the overall effectiveness could not be determined.8 Education should be tailored to individual patients and their caregivers, reinforced at regular intervals, and modified as the patient’s circumstances change. Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”9 Verbal and written communications should be designed at the appropriate reading level, preferably in a patient’s native language, and culturally and contextually appropriate. The Agency for Healthcare Research and Quality has created a toolkit with detailed guidance on improving written and spoken communication, self-management and empowerment, and improving supportive systems.10 Internet-based self-management programs to improve access to ongoing support have been developed, but data on their efficacy are limited.8 2 Of the 68 trials and 20 intervention approaches in an Agency for Healthcare Research and Quality comparative effectiveness analysis, only 1 trial enrolled patients with CCD (those with recent MI).4 In that trial, patients in the treatment arm had 1.3 extra days of medication coverage per month over 9 months of follow-up and were 17% more likely to have >80% adherence compared with patients in the control arm. No significant difference in persistence of medication use was observed.11 Another systematic review found no convincing evidence of improved medication adherence with educational interventions.1 A 2020 systematic review of pharmacist-based patient education for patients on cardiovascular medications (only some with CCD) concluded that the interventions improved medication adherence but not necessarily clinical outcomes.2 Another systematic review with the goal of comparing outcomes of different types of educational interventions targeting medication adherence found interventions delivered by pharmacists and nurses had the most favorable outcomes, although results were very heterogeneous.12 A recent RCT of a pharmacist-administered intervention that used motivational interviewing to improve medication adherence among CCD patients improved medication adherence but had no effect on low-density lipoprotein cholesterol (LDL-C) levels, systolic BP, unplanned health care contact, or physical or emotional scores of the Heart Quality of Life Instrument.3 4.1.3 Shared Decision-Making Recommendations for Shared Decision-Making Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 C-LD 1 Patients with CCD and their clinicians should engage in shared decision-making particularly when evidence is unclear on the optimal diagnostic or treatment strategy, or when a significant risk or benefit tradeoff exists.1–3 2b B-R 2 For patients with CCD and angina on GDMT who are engaged in shared decision-making regarding revascularization, a validated decision aid may be considered to improve patient understanding and knowledge about treatment options.4 Synopsis Shared decision-making is a collaborative decisionmaking process that includes patient education about risks, benefits, alternatives to treatment and testing options, and clinician ascertainment of patient values and goals. Shared decision-making helps to maximize patient engagement in medical decision-making, increase patient knowledge about their care, and align treatment decisions with patient preferences. Even when evidence suggests one treatment or testing modality compared with another may lead to improved cardiovascular outcomes at a population level, the optimal treatment or testing choice for an individual patient may vary based on patient values and preferences, as well as the financial implications of the choice to the patient. Decision aids can improve knowledge and reduce decisional conflict in shared decision-making, but few validated decision aids are available for patients with CCD. Clinician-patient conversations, as well as corresponding educational materials, should be tailored to the patient’s preferred language, reading level, health literacy, and visual acuity. Downloaded from http://ahajournals.org by on October 7, 2026