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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

2a B-NR 4 In patients with CCD and severe obesity who

have not met weight loss goals with lifestyle and pharmacologic intervention, and who have acceptable surgical risk, referral for consideration of a bariatric procedure is reasonable for weight loss and cardiovascular risk factor reduction.15–18

3: Harm B-R 5.	 In patients with CCD, use of sympathomimetic

weight loss drugs is potentially harmful.19

Synopsis Compared with individuals with normal weight, patients with obesity experience CCD events at an earlier age, live with CCD for a greater proportion of their lifetime, and have a shorter average life span.6,20 Excess adiposity accelerates atherosclerosis and promotes adverse changes in cardiac function through deleterious effects on the myocardium as well as the vasculature and through obesity-related comorbidities, including hypertension, dyslipidemia and type 2 diabetes.21–23 Although BMI can be a heterogeneous marker of individual risk, increasing BMI is associated with increasing risk of morbidity and death across populations, and BMI thresholds continue to guide clinical diagnosis and management of overweight and obesity (“2013 AHA/ACC Guideline for the Management of Overweight and Obesity in Adults”).24 The general goals of weight loss and management are to: (1) prevent further weight gain, (2) reduce body weight, and (3) maintain a lower body weight over the long term. Weight loss in association with lifestyle modification (see Section 4.2.1, “Nutrition,” Section 4.2.11, “Physical Activity,” and Section 4.1.4 “Social Determinants of Health”) and select pharmacologic interventions (see Section 4.2.8, “SGLT2 Inhibitors and GLP-1 Receptor Agonists”) and surgical interventions for eligible patients with CCD improves metabolic and hemodynamic risk profiles, with potential for improved cardiovascular outcomes. Recommendation-Specific Supportive Text

1 Patients with CCD should undergo routine mea-

surement of BMI with or without waist circumference for initial evaluation and as a guide to efficacy of weight loss intervention.1–6 Although not a measure of body composition, BMI remains the most practical way to evaluate for overweight and obesity, defined as a BMI 25 to 29.9 kg/m2 and ≥30 kg/m2, respectively.24 Waist circumference, a surrogate estimate of visceral adiposity, may be a better indicator of risk than BMI in some patients and populations,25,26 with central obesity defined as a waist circumference >102 cm (40 in) in men and >88 cm (35 in) in women.24 As with BMI, racial and ethnic differences in waist circumference thresholds associated with cardiometabolic risk have been reported.27 Recognizing that weight assessment in some individuals may represent a deterrent to seeking care, genderand culturally sensitive approaches to assessing weight are recommended in all patients, with an option for patients to self-report values where appropriate. 2.	 Lifestyle modification (see Section 4.2.1, “Nutrition”

and Section 4.2.11, “Physical Activity”) with associated weight loss improves obesity-related CCD comorbidities. With lifestyle measures alone, a weight loss of 5% to 7% of body weight is typical but often difficult to sustain. Multicomponent interventions including dietary modification, exercise, and behavioral counseling are more effective than interventions targeting single components.7,8 A meta-analysis of 122 RCTs and 2 observational studies compared an intensive, multicomponent behavior-based weight loss intervention with a comparison group receiving usual care. At 12 to 18 months, patients receiving multicomponent behavior-based interventions were more likely to achieve a ≥5% weight loss (relative risk, 1.94 [95% CI, 1.70-2.22]).7 In patients with CCD, regular physical activity with increased lean mass may be more important for improving survival than achieving a normal BMI.10 Patients with CCD and overweight or obesity should be counseled to lose weight, especially if accomplished with increases in physical activity and improvements in cardiorespiratory fitness.9

3 Candidates for weight-loss drug therapy include

individuals with a BMI ≥30 kg/m2 or a BMI of 27 to 29.9 kg/m2 with weight-related comorbidities who have not met weight-loss goals (eg, loss of ≥5% of total body weight at 3–6 months) with a comprehensive lifestyle intervention alone. The decision to initiate drug therapy in patients with CCD should be individualized, considering associated

Recommendations for Weight Management (Continued )

COR LOE Recommendations

Table 13.  Core Components of CR18 Patient assessment Nutritional counseling Weight management Blood pressure management Lipid management Diabetes management Tobacco cessation Psychosocial management Physical activity counseling Exercise training CR indicates cardiac rehabilitation. Modified with permission from Balady GJ, et al. Copyright 2007 American Heart Association, Inc.

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