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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

2 Implementation of healthy plant-based and

Mediterranean-based diets includes reducing saturated fat and optimizing caloric intake to include higher intake of monounsaturated fats, polyunsaturated fats, and complex carbohydrates.2,34,35,38 Higher dietary fiber intake is associated with improvement in CVD risk factors, including lower BP, improved insulin sensitivity, and support of weight loss goals,3,5 in addition to a lower risk of CVD events and all-cause death in patients with CCD.3 A meta-analysis of prospective cohorts and randomized clinical trials supports a dose-response relationship of higher quality carbohydrate intake and lower CVDrelated morbidity and mortality rates.5,39 For patients at higher CVD risk, the AHA recommends lowering saturated fatty acids to <6% of total caloric intake.30 Reduction in saturated fatty acids, with healthier fat and carbohydrate intake, lowers LDL-C, which is associated with lower CVD morbidity and mortality rates.3,30,38–40 A recent Cochrane review of randomized trials that reduced saturated fat intake, altered dietary fats, or both highlighted a 17% reduction of CVD events in patients with CCD.6 Among secondary prevention trials, the number needed to treat for an additional benefit was 53, by lowering saturated fat >4 years.6,29

3 Dietary sodium reduction to <2300 mg/d (optimal

target of 1500 mg/d) is important to lower BP.8,41 Sodium reduction with a healthy diet reduces the risk of future CVD events, even in patients with CCD.3,7 Recent analysis of the DASH (Dietary Approaches to Stop Hypertension)-Sodium study showed that sodium reduction may improve biomarkers of cardiac injury, inflammation, and cardiac strain.42 Dietary education should highlight potential sources of dietary sodium, including processed meat, which is a significant contributor to dietary sodium in the United States.43,44 According to the AHA, processed meats include smoked, cured, salted meats, and/or meats with chemical preservatives.23 Although the DASH diet supports higher potassium intake,8 insufficient data are available in populations with CCD to provide specific potassium recommendations. 4.	 The consumption of simple carbohydrates (eg,

high-fructose corn syrup) and refined grains (eg, containing <25% whole grain by weight, including some refined cold ready-to-eat breakfast cereal, white bread, white rice)4 has adverse effects on lipoproteins, including LDL-C, apolipoprotein B, and plasma triglycerides.6,38 Minimizing intake of simple carbohydrates and refined grains supports a healthier cardiometabolic profile.4,6,39 Sugarsweetened beverages are defined by the AHA as “manufactured carbonated and noncarbonated beverages containing caloric sweeteners or syrups and include caloric soft drinks (ie, not sugar-free), fruit drinks, sports and energy drinks, sweetened waters, and tea and coffee beverages with added sugars.”45 Sugar-sweetened beverage consumption is associated with an increased risk of CVD events, including in patients with CCD,3 and associated with chronic conditions including diabetes, CKD, and obesity.23,46 Overall, multiple healthy dietary components, including reduction in dietary sodium, sugar-sweetened beverages, and saturated fat reduces all-cause death among secondary prevention cohorts.3 Recommendations are unavailable for artificial sweeteners because of limited data in populations with CCD. 5.	 Consumption of trans fat has been associated with

an increased risk of CVD events, including CVD mortality rate, and all-cause death in primary prevention populations and among individuals with CCD.9,10,23,47 This association has been primarily attributed to industrially processed hydrogenated vegetable oils (eg, baked goods, fried foods), and less from ruminant trans fats (eg, meat and milk from ruminant animals, including cattle and sheep),40,47 resulting in a higher risk of CHD.9,10,23,47

Figure 7. Recommended Nutrition.

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