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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168 August 29, 2023 Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline Recommendation-Specific Supportive Text 1 Most patients prefer to have an active role in their treatment decisions.1-3,5 The right to information includes patients without decision-making capacity or who have chosen to defer treatment decisions to a designated caregiver. In shared decision-making, clinicians inform patients of the availability, risks, benefits, and alternatives of all medically appropriate testing or treatment options (which may include no testing or treatment), confirm patient understanding, assess patient values and treatment goals, and collaborate with patients to decide about their care. Patients may choose to include others in the shared decision-making process. Patient choices can include a treatment or therapeutic decision, an active choice to defer the decision, or a delegation of that decision to their care team or other designated individual. Patients and clinicians should engage in shared decisionmaking particularly when multiple medically appropriate options are available, when treatments or testing options confer increased risks, or when evidence is unclear on the optimal treatment strategy or when a risk:benefit tradeoff exists between different options. In patients with CCD, example areas for shared decision-making include duration, dose, and choice of antithrombotic therapy for secondary prevention and revascularization or medical therapy for stable angina. 2. Decision aids can increase patient knowledge, accuracy of risk perception, and agreement between patient values and care choices made, and may reduce decisional conflict for patients, but aids have not been developed and validated for many decisions made by patients with CCD.6 Before implementation of any decision aid, the decision aid should be developed according to best practice and validated in the target population.7–9 Decision aids should augment, not replace, conversations between clinicians and patients. The decision aid PCI Choice was shown to increase knowledge about therapy options among patients with CCD choosing between optimal medical therapy alone or with PCI.4 4.1.4 Social Determinants of Health Recommendation for SDOH Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation 1 B-R 1 In patients with CCD, routine assessment by clinicians and the care team for SDOH is recommended to inform patient-centered treatment decisions and lifestyle change recommendations.*1–8 *Modified from the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease.9 Synopsis SDOH, such as health care access, economic stability, and social context are key drivers of persistent health disparities and health inequities.1,10–13 SDOH have profound influences on the health and well-being of patients with CCD and have become increasingly recognized in cardiovascular medicine.2,9,10,14–18 There is an intersection of SDOH with sex, socioeconomic class, race, ethnicity, sexual orientation, and social vulnerabilities.12,19–21 SDOH impact all stages of CCD management, including secondary prevention, treatment, access to care, and patient follow-up (Section 7.1, “Follow-Up Plan and Testing”) and self-management.14 Clinicians should ensure health equity in cardiovascular care by viewing each patient through an SDOH lens with cultural humility to formulate comprehensive care plans (Figure 6). Brief, evidence-based screening tools are available to support clinicians in identifying SDOH that may negatively affect health outcomes and health care utilization.4,13,22–24 Routine SDOH screening in patients with CCD by clinicians or front-line staff should encompass assessment of mental health (Section 4.2.2), psychosocial stressors, health literacy, sociocultural influences (language, religious affiliation, body image), financial strain, transportation, insurance status, barriers to adherence to a heart healthy diet (food security) (Section 4.2.1, “Nutrition, Including Supplements”), neighborhood or environmental exposures (Section 4.2.11), and viable options for regular physical activity (Section 4.2.10, “Cardiac Rehabilitation”) and social support.1,2,25 Based on identified barriers or needs, collaborative cardiovascular care teams can provide tangible and practical community-based resources and services to patients.2,26–28 Operationalization of guidelines on addressing SDOH requires embedding health equity into clinical practice, team-based care, patient education, and shared decision-making tools (Sections 4.1.1, 4.1.2, and 4.1.3).13,14,17,19,29–33 Recommendation-Specific Supportive Text 1 Integration of SDOH is based on evidence show- ing the effect of SDOH on long-term cardiovascular outcomes.9,10 Patients experiencing an MI at a young age had higher neighborhood disadvantage that was associated with 57% higher cardiovascular mortality after an 11-year period.34 Women in the lower-income bracket were more likely to be underor uninsured and had higher medication costs and higher 5-year rehospitalization rates compared with higher-income women.35 Lower education and income levels were associated with lower prescribing of GDMT, as well as outcomes post-MI.2,36–39 Further, there are disparities in CR (Section 4.2.10) referral and completion among racial and ethnic minorities, women, according to socioeconomic status, and across those living in rural and dense urban Downloaded from http://ahajournals.org by on October 7, 2026