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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

6 In patients at high risk for CCD, nonprescription

dietary omega-3 fatty acid supplements (eg, capsules, oil, soft gels) do not reduce CVD events or all-cause death12,13; a Cochrane meta-analysis including 86 RCTs showed “little or no effect.”11 See Section 4.2.6 (“Lipid Management”) on the role of prescription icosapent ethyl (highly purified eicosapentaenoic acid ethyl ester).48 Despite observational studies,49,50 insufficient evidence is available that shows vitamin D supplementation reduces CVD events.14,15,51 In a meta-analysis of 21 RCTs (vitamin D [n=41 669] versus placebo [n=41 662]), vitamin D supplementation did not lower the risk of MACE.15 Additionally, antioxidant therapy is not associated with a decreased risk of CVD events.17,19,22,31 Vitamin C, beta-carotene, multivitamins, or all of them do not decrease CVD event risk19 or CVD mortality rate.52 Insufficient data are available to support calcium supplementation (elemental calcium supplement ≥500 mg/d; carbonate, citrate, or gluconate formulation) in patients with CCD for CVD event reduction.21 A metaanalysis of double-blind RCTs (n=14 692 [calcium supplement intervention] versus n=14 243 [placebo-controlled]) showed an increased risk of CVD and CHD events with calcium supplementation.21 Mixed results on dietary calcium supplementation and CVD events suggests a U-shaped dose-response pattern.20,21

4.2.2 Mental Health Conditions

Recommendations for Mental Health Conditions Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

2a B-R 1 In patients with CCD, targeted discussions and

screening for mental health is reasonable for clinicians to assess and to refer for additional mental health evaluation and management.1–4

2a B-R 2 In patients with CCD, treatment for mental health

conditions with either pharmacologic or nonpharmacologic therapies, or both, is reasonable to improve cardiovascular outcomes.2,4–6 Synopsis

Mental health has a major role in overall cardiovascular health and well-being in patients with CCD.7 Mental health is defined as “a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community.”8 Mental health can have positive or negative effects on cardiovascular risk factors and outcomes.7,9 It is estimated that 20% to 40% of patients with CCD have concomitant mental health conditions such as depression and anxiety.10,11 Meta-analyses have shown that negative psychological states (eg, general distress) are associated with MACE in men and women with CCD.12 Despite being a modifiable prognostic risk factor for CCD outcomes, screening for mental health disorders is seldom addressed in the clinical setting.4,13 Potentially underpinning the bidirectional relationship between mental health and CCD is the resulting influence on health behaviors (eg, medication and CR adherence, diet, physical activity, sleep, smoking) and risk factors (eg, BP, lipids, body mass index [BMI], inflammation, thrombosis).4,7 Pharmacologic and psychotherapeutic treatments may reduce recurrent cardiovascular events and mortality rate in patients with CCD.5,14–17 See Section 4.1.4 for discussion of the interplay between mental health and SDOH.

Recommendation-Specific Supportive Text

1 Mental health factors, including depression, anxi-

ety, anger or hostility, general distress and type D personality (where D stands for “distressed”), are common in diverse populations with CCD.12 Psychological stress from environmental sources (eg, financial hardships, social isolation, discrimination) can have deleterious effects.7,18–22 Studies consistently show that comorbid depression, anxiety, or emotional distress in patients with CCD is associated with diminished QOL,23 atherosclerotic disease progression,24 and negative effects on cardiovascular risk factors, leading to poorer cardiovascular outcomes.6,7,25–30 An assessment of the use of depression screening found that among patients with recent ACS, screening positive for depression was associated with a 2-fold increase in MACE (adjusted hazard ratio, 2.15 [95% CI, 1.63- 2.83]).2 Patients randomized to antidepressants had significantly lower all-cause death than those not receiving treatment.2 However, the CODIACS- QoL (Comparison of Depression Interventions After Acute Coronary Syndrome: Quality of Life) trial of patients after ACS showed no benefit of systematic depression screening (with or without subsequent treatment) on QOL or mortality.2,3 Short, well-validated screening tools for depression or anxiety

Table 6.  Suggested Screening Tool to Assess Psychological Distress: Patient Health Questionnaire-2 Depression Screen Over the past 2 weeks, how often have you been bothered by the following problems? Not at all Several days More than half the days Nearly every day Little interest or pleasure in doing things 0 1 2 3 Feeling down, depressed, or hopeless 0 1 2 3 Total score of ≥3 warrants further assessment for depression. Data derived from Kroenke et al.31 and Levine et al.7,46 Reprinted with permission from Levine GN et al. Copyright 2021 American Heart Association, Inc.

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