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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

Verapamil SR/Trandolapril Study) trial, CCB and ACE inhibitors and beta-blocker/thiazide diuretic therapy had similar cardiovascular morbidity and death outcomes.31 In the EUROPA (Exclusive Endocrine Therapy or Partial Breast Irradiation for Women ≥70 Years Early Stage Breast Cancer) study involving patients with CCD, ACE inhibitor therapy produced a 20% reduction in risk of CVD death, MI, or cardiac arrest compared with placebo.15 Beta blockers are particularly effective in patients with CCD, especially those with recent MI and those with ongoing angina, given their ability to reduce angina, improve anginafree exercise tolerance, reduce exertion-related myocardial ischemia, and reduce risk of CVD events.17,23,27,32,33 Because of the significant benefits from beta blockers and ACE inhibitors and ARB agents in patients with CCD, these medications are recommended as a first-line therapy in the treatment of hypertension in such individuals. GDMT beta blockers for CCD and for lowering BP include carvedilol, metoprolol tartrate, metoprolol succinate, nadolol, bisoprolol, propranolol, and timolol.19 Outcomes with atenolol appear to be inferior compared with other antihypertensive drugs in the treatment of hypertension.34 When beta blockers, ACE inhibitors, and ARB therapies do not sufficiently control BP, additional GDMT BP-lowering therapies can be added, including thiazide diuretics, CCB, and mineralocorticoid receptor antagonists.19

4.2.8 SGLT2 Inhibitors and GLP-1 Receptor Agonists

Recommendations for Use of SGLT2 Inhibitors and GLP-1 Receptor Agonists Referenced studies that support the recommendations are summarized in the Online Data Supplement.

COR LOE Recommendations

1 A 1.	 In patients with CCD who have type 2 diabetes,

the use of either an SGLT2 inhibitor1–8 or a GLP-1 receptor agonist9–17 with proven cardiovascular benefit is recommended to reduce the risk of MACE.

Cost Value Statement: High Value B-NR 2 In patients with CCD and type 2 diabetes, addi-

tion of a GLP-1 receptor agonist at US prices is projected to be of high value compared with standard of care.18

Table 12.  Nonpharmacologic Strategies for Blood Pressure Management* Approximate Impact on SBP Nonpharmacologic Intervention Dose Hypertension Normotension Reference Weight loss Weight/body fat Best goal is ideal body weight but aim for at least a 1-kg reduction in body weight for most adults who are overweight. Expect about 1 mm Hg for every 1-kg reduction in body weight. −5 mm Hg −2/3 mm Hg 5 Healthy diet DASH dietary pattern Consume a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat. −11 mm Hg −3 mm Hg 2,3 Reduced intake of dietary sodium Dietary sodium Optimal goal is <1500 mg/d but aim for at least a 1000-mg/d reduction in most adults. −5/6 mm Hg −2/3 mm Hg 29,30 Enhanced intake of dietary potassium Dietary potassium Aim for 3500–5000 mg/d, preferably by consumption of a diet rich in potassium. −4/5 mm Hg −2 mm Hg 35 Physical activity Aerobic 90–150 min/wk

65%–75% heart rate reserve −5/8 mm Hg −2/4 mm Hg 4,8

Dynamic resistance 90–150 min/wk

50%–80% of 1 repetition maximum 6 exercises, 3 sets/exercise, 10 repetitions/set −4 mm Hg −2 mm Hg 4

Isometric resistance 4×2 min (hand grip), 1 min rest between exercises, 30%–40% maximum voluntary contraction, 3 sessions/wk

8–10 wk −5 mm Hg −4 mm Hg 36,37

Moderation in alcohol intake Alcohol consumption In individuals who drink alcohol, limit alcohol† to: Men: ≤2 drinks daily

Women: ≤1 drink daily −4 mm Hg −3 mm Hg 6

Resources: Your Guide to Lowering Your Blood Pressure With DASH—How Do I Make the DASH?38 Available at: https://www.nhlbi.nih.gov/files/docs/public/heart/ new_dash.pdf. *Type, dose, and expected impact on BP in adults with a normal BP and with hypertension. †In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure. Modified with permission from Whelton PK, et al.19 Copyright 2018 American Heart Association, Inc., and American College of Cardiology Foundation.

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