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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

6.3. Young Adults ���������������������������������������������������e69 6.4. Cancer ���������������������������������������������������������������e70 6.5. Women, Including Pregnancy and Postmenopausal Hormone Therapy ���������e71 6.6. Older Adults �����������������������������������������������������e74 6.7. Chronic Kidney Disease �������������������������������e75 6.8. HIV and Autoimmune Disorders �����������������e75 6.9. Cardiac Allograft Vasculopathy in Heart Transplant Recipients �����������������������e77 7. Patient Follow-Up: Monitoring and Managing Symptoms ���������������������������������������������������������������������e79 7.1. Follow-Up Plan and Testing in Stable Patients �����������������������������������������������e79 8.	 Other Important Considerations ����������������������������e80 8.1. Cost and Value Considerations �������������������e80 8.2. Evidence Gaps and Areas of Future Research Needs ���������������������������������������������e81 References ��������������������������������������������������������������������������e83 Appendix 1 Author Relationships With Industry and Other Entities ������������������������������������������������������������e114 Appendix 2

Reviewer Relationships With Industry and Other Entities ������������������������������������������������������������e118

TOP 10 TAKE-HOME MESSAGES FOR CHRONIC CORONARY DISEASE

1 Emphasis is on team-based, patient-centered care

that considers social determinants of health along with associated costs while incorporating shared decision-making in risk assessment, testing, and treatment. 2.	 Nonpharmacologic therapies, including healthy dietary habits and exercise, are recommended for all patients with chronic coronary disease (CCD). 3.	 Patients with CCD who are free from contraindications are encouraged to participate in habitual physical activity, including activities to reduce sitting time and to increase aerobic and resistance exercise. Cardiac rehabilitation for eligible patients provides significant cardiovascular benefits, including decreased morbidity and mortality outcomes. 4.	 Use of sodium glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists are recommended for select groups of patients with CCD, including groups without diabetes. 5.	 New recommendations for beta-blocker use in

patients with CCD: (a) Long-term beta-blocker therapy is not recommended to improve outcomes in patients with CCD in the absence of myocardial infarction in the past year, left ventricular ejection fraction ≤50%, or another primary indication for beta-blocker therapy; and (b) Either a calcium channel blocker or beta blocker is recommended as first-line antianginal therapy. 6.	 Statins remain first line therapy for lipid lowering

in patients with CCD. Several adjunctive therapies (eg, ezetimibe, PCSK9 [proprotein convertase subtilisin/kexin type 9] inhibitors, inclisiran, bempedoic acid) may be used in select populations, although clinical outcomes data are unavailable for novel agents such as inclisiran. 7.	 Shorter durations of dual antiplatelet therapy are safe and effective in many circumstances, particularly when the risk of bleeding is high and the ischemic risk is low to moderate. 8.	 The use of nonprescription or dietary supplements, including fish oil and omega-3 fatty acids or vitamins, is not recommended in patients with CCD given the lack of benefit in reducing cardiovascular events. 9.	 Routine periodic anatomic or ischemic testing without a change in clinical or functional status is not recommended for risk stratification or to guide therapeutic decision-making in patients with CCD. 10.	 Although e-cigarettes increase the likelihood of

successful smoking cessation compared with nicotine replacement therapy, because of the lack of long-term safety data and risks of sustained use, e-cigarettes are not recommended as first-line therapy for smoking cessation.

PREAMBLE

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a foundation for the delivery of quality cardiovascular care. The ACC and AHA sponsor the development and publication of clinical practice guidelines without commercial support, and members volunteer their time to the writing and review efforts. Guidelines are official policy of the ACC and AHA. For some guidelines, the ACC and AHA collaborate with other organizations.

Intended Use Clinical practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease (CVD). The focus is on medical practice in the United States, but these guidelines are relevant to patients throughout the world. Although guidelines may be used to inform regulatory or payer decisions, the intent is to improve quality of care and align with patients’ interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment.

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