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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 areas.2,40–42 Neighborhood environment influences healthy lifestyle promotion and maintenance, management of traditional and nontraditional cardiovascular risk factors, and outcomes.43–48 Telehealth and digital interventions are promising strategies to improve access to health care, management and health behaviors; however, consideration of SDOH influences is warranted.3,29,49–51 Empirical evidence supports the use of screening tools in patients with multiple chronic diseases to efficiently assess SDOH in the clinical setting, facilitate tailoring of individualized care plans, and improve quality of care and outcomes.4,22,30,31,52–54 Collaborative partnerships between health care systems and community-based organizations can assist clinicians, patients, and their families in meeting unmet social needs as an extension of standard cardiovascular care for health equity.3,55 4.2 Guideline-Directed Management and Therapy 4.2.1 Nutrition, Including Supplements Recommendations for Nutrition, Including Supplements Referenced studies that support the recommendations are summarized in Online Data Supplement. Recommendations COR LOE Nutrition 1 B-R 1 In patients with CCD, a diet emphasizing vegetables, fruits, legumes, nuts, whole grains, and lean protein is recommended to reduce the risk of CVD events.*1–4 2a B-NR 2 In patients with CCD, reducing the percentage of calories from saturated fat (<6% of total calories) and replacing with dietary monounsaturated and polyunsaturated fat, complex carbohydrates, and dietary fiber can be beneficial to reduce the risk of CVD events.*1–6 2a B-NR 3 In patients with CCD, minimization of sodium (<2300 mg/d; optimally 1500 mg/d) and minimization of processed meats (eg, cured bacon, hot dogs) can be beneficial to reduce the risk of CVD events.*2,3,6,7 2a B-NR 4 In patients with CCD, limiting refined carbohy- drates (eg, containing <25% whole grain by weight, including refined cold ready-to-eat breakfast cereal, white bread, white rice), and sugarsweetened beverages (eg, soft drinks, energy drinks, fruit drinks with added sugars) can be beneficial to reduce the risk of CVD events.*2–4,6,8 3: Harm B-NR 5 In patients with CCD, the intake of trans fat should be avoided because trans fat is associated with increased morbidity and mortality rates.*9,10 Nutrition Supplements 3: No Benefit B-NR 6 In patients with CCD, the use of nonprescription or dietary supplements, including omega-3 fatty acid, vitamins C, D, E, beta-carotene, and calcium, is not beneficial to reduce the risk of acute CVD events.11–22 *Modified from the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease.23 Synopsis Among patients with CCD, dietary behavior changes along with GDMT are important to reduce the risk of acute CVD events including ASCVD, and outcomes related to HF, stroke, and CVD-related deaths.1,2,24 Among patients with CCD, it is well established that healthy dietary choices improve management of CVD risk factors and target pathophysiologic mechanisms contributing to acute CVD events.25,26 Studies across diverse populations support the health benefits of a higher intake of whole grains and fiber, with lower intake of saturated fat, sodium, refined carbohydrates, and sweetened beverages23,27,28 (Figure 7). Healthy dietary choices combined with caloric reduction will support weight loss goals and improve cardiometabolic health for overweight and obese patients.29,30 In contrast, nonprescription nutrition or dietary supplements28 have insufficient evidence to support their use to reduce the risk of acute CVD events in patients with CCD.18,31 For this guideline, nutrition supplements is defined by the National Institutes of Health – Office of Dietary Supplements as nonprescription, dietary supplements that contain minerals (eg, calcium), herbs, amino acids, and vitamins across all dosage forms (eg, tablets, gummies).32 Recommendation-Specific Supportive Text 1 Mediterranean-type dietary plans with higher intake of healthy plant-based foods and lean protein (eg, fish), with lower quantities of saturated fat (eg, red meat) help reduce cardiovascular risk factors, including insulin resistance, diabetes, dyslipidemia, hypertension, and obesity.1,2,30,33–35 Multiple secondary CVD prevention studies showed lower risk of subsequent CVD events and total mortality rate with higher intake of healthy plant-based diets, including Mediterranean diets.1-3,33 The Lyon Diet Heart Study randomized participants hospitalized with their first MI to a Mediterranean diet intervention or usual care.2 After a mean intervention follow-up of 44.9 months, the Mediterranean diet showed up to a 65% reduction in composite CVD outcomes (cardiac death and nonfatal MI).2 Additionally, multiple prospective cohorts showed an inverse relationship between lower all-cause death, greater adherence across multiple components of the Mediterranean diet (including fish),36 and higher intake of healthier plantbased options.37 Specific dietary components and serving sizes have varied across studies1; the AHA has previously published recommendations according to energy needs and weight loss goals.30 However, additional research is needed on mechanisms associated with Mediterraneandiet patterns, CVD death, and all-cause death.1 Downloaded from http://ahajournals.org by on October 7, 2026