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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

to tolerate statin therapy because of severe statinassociated side effects is of intermediate value ($50 000–$150 000 per QALY gained), as is the use of inclisiran in patients with CCD and heterozygous FH.55 However, the cost-effectiveness of these novel therapies is sensitive to assumptions regarding the effect of each drug on cardiovascular and all-cause death and should be updated when long-term outcomes data become available. 12.	 Dietary supplements containing omega-3 fatty

acids (ie, fish oil) are widely used for presumed cardioprotective benefits. However, low-dose omega-3 fatty acid supplementation does not reduce MACE in patients with CCD.39–41 The only omega-3 fatty acid formulation that can be recommended in patients with CCD is icosapent ethyl (EPA only) as described in Recommendation 9. The AIM- HIGH (Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health) trial found no benefit with the addition of extended-release niacin to background statin therapy.36 Another niacin trial in secondary prevention, HPS2-THRIVE (Treatment of HDL to Reduce the Incidence of Vascular Events), also found no benefit with a combination product of niacin and laropiprant, a prostaglandin receptor antagonist; however, this product is no longer available.37 ACCORD-LIPID (Action to Control Cardiovascular Risk in Diabetes-Lipid Trial)56 found no benefit with the addition of fenofibrate to background statin therapy. Although this trial was conducted in patients with type 2 diabetes, more than half of the trial participants had established CVD at baseline, and no benefit was observed in this subgroup of patients. A selective PPARα modulator, pemafibrate, was investigated in the PROMINENT (Pemafibrate to Reduce Cardiovascular Outcomes by Reducing Triglycerides in Diabetic Patients) trial in high-risk patients with diabetes, but this trial was stopped early for futility.57 Fenofibrate should only be considered for severe hypertriglyceridemia (triglycerides, ≥500 mg/dL) to reduce the risk of acute pancreatitis.

4.2.7 Blood Pressure Management

Recommendations for Blood Pressure Management Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 A 1 In adults with CCD, nonpharmacologic strategies

are recommended as first-line therapy to lower BP in those with elevated BP (120-129/<80 mm Hg) (see Table 12).*1–9

1 B-R 2 In adults with CCD who have hypertension, a BP

target of <130/<80 mm Hg is recommended to reduce CVD events and all-cause death.*10–14 1 B-R 3 In adults with CCD and hypertension (systolic BP

≥130 and/or diastolic BP ≥80 mm Hg), in addition to nonpharmacological strategies, GDMT angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARB), or beta blockers15–17 are recommended as first-line therapy for compelling indications (eg, recent MI or angina), with additional antihypertensive medications (eg, dihydropyridine calcium channel blockers [CCB], long-acting thiazide diuretics, and/or mineralocorticoid receptor antagonists) added as needed to optimize BP control.*13,18

*Modified from the 2017 ACC/AHA Multisociety Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.19

Synopsis Hypertension is a well-established risk factor for CVD20 and is a highly prevalent comorbid condition among individuals with CCD, affecting >60% of such individuals.21 Individuals with CCD who also have hypertension are at increased risk of death and morbidity compared with individuals with CCD who are normotensive.22 Treatment of hypertension with lifestyle1-6,22 and medication therapies13,16,17,23–28 helps control hypertension and reduce subsequent risk of MACE. The recommendations apply to individuals with CCD who have hypertension. See Section 4.2.1 for additional recommendations regarding nutritional therapies and Sections 4.2.10 to 4.2.11 for additional recommendations about physical activity and CR. For additional information, see the 2017 ACC/ AHA/multisociety guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.19

Recommendation-Specific Supportive Text

1 Lifestyle-related factors influence BP levels, and

lifestyle modifications are effective strategies to help lower elevated BP. These factors include weight loss,1,5 a heart-healthy diet that is rich in fruits and vegetables,2,3 reduced dietary sodium,29,30 physical activity,4,8 and reduction or elimination of alcohol intake.6 2.	 Among patients with increased cardiovascular risk,

reduction of systolic BP to <130 mm Hg has been shown to reduce CVD complications by 25% and all-cause death by 27%.13 Optimal diastolic BP for clinical outcomes appears to be in the range of 70 to 80 mm Hg.10,14

3 In the HOPE (Heart Outcomes Prevention

Evaluation) trial, ramipril therapy in patients with CVD or at high risk for CVD reduced the risk of MI, stroke, or CVD by 22% compared with placebo.16 In patients with CAD and hypertension who were randomized into the INVEST (International

Recommendations for Blood Pressure Management (Continued ) COR LOE Recommendations

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