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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 risks and benefits. The cardiovascular safety of certain weight-loss drugs, such as naltrexone/ bupropion, has not been established and remains controversial.28 Use of a GLP-1 receptor agonist (Section 4.2.8) is beneficial when pharmacologic therapy is warranted for further weight reduction.11,12,14 Among eligible adults without diabetes, the STEP 8 (Semaglutide Treatment Effect in Patients with Obesity) randomized controlled trial (N=338, 3.3% with known CCD) found that onceweekly subcutaneous semaglutide 2.4 mg added to counseling for diet and physical activity resulted in significantly greater weight loss at week 68 compared with once-daily subcutaneous liraglutide 3.0 mg or placebo (mean weight change, –15.8% [95% CI, –17.6 to –13.9] versus –6.4% [95% CI, –8.2 to –4.6] versus –1.9% [95% CI, –4.0 to 0.2] for semaglutide versus liraglutide versus placebo, respectively).13 Both semaglutide (0.5–1.0 mg weekly) and liraglutide (1.2–1.8 mg daily) were associated with reduced MACE in patients with type 2 diabetes and CCD.29,30 Recently, the doubleblind randomized controlled trial SURMOUNT-1 (A Study of Tirzepatide [LY3298176] in Participants with Obesity or Overweight) also showed a dosedependent weight loss benefit (mean weight change up to –20.9% [95% CI, –21.8 to –19.9]) with once-weekly subcutaneous tirzepatide (at 5 mg, 10 mg, or 15 mg) relative to placebo in eligible obese adults without diabetes (N=2539, 3.1% with ASCVD) over 72 weeks.31 4. Patients with CCD and severe obesity (BMI ≥40 kg/m2 or BMI 35-39.9 kg/m2 with a weightrelated comorbidity) who have not met weight loss goals with lifestyle and pharmacologic intervention may benefit from a bariatric procedure such as gastric bypass surgery. Bariatric procedures appear to be relatively safe and effective among patients with CCD, at least in those <65 years of age.15,17,18 In the nonrandomized prospective SOS (Swedish Obese Subjects) study, bariatric surgery was associated with prevention of type 2 diabetes and fewer cardiovascular deaths and lower incidence of MI or stroke compared with matched obese controls (hazard ratio, 0.47 [95% CI, 0.29-0.76] for death, and hazard ratio, 0.67 [95% CI, 0.54-0.83] for MI or stroke).16,32 These benefits do not appear to occur with liposuction, suggesting that the negative energy balance associated with bariatric intervention may be necessary for achieving the metabolic benefits of weight loss.33 Specifically among patients with obesity and type 2 diabetes, bariatric surgery is an effective strategy for achieving weight loss, glycemic control, and reducing cardiovascular risk factors.34 More recently, 2 retrospective observational studies of patients with CCD showed significant reductions in MACE among those undergoing bariatric surgery compared with matched controls.17,18 5 Sympathomimetic drugs (eg, phentermine, dieth- ylproprion, benzphetamine, phendimetrazine) can increase heart rate and BP and are not recommended in patients with CCD. In a trial of sibutramine versus placebo in >10 000 patients with or at high risk for CCD, sibutramine was associated with a higher risk of nonfatal MI (4.1% versus 3.2%; hazard ratio, 1.28 [95% CI, 1.04-1.57]) and nonfatal stroke (2.6% versus 1.9%; hazard ratio, 1.36 [95% CI, 1.04-1.77]).19 As a result, the FDA removed sibutramine from the US market in 2010, but it can still be found illicitly in dietary supplements marketed for weight loss and in other parts of the world.35 Clinicians are encouraged to ask patients about potential use of dietary supplements for weight management. 4.2.10 Cardiac Rehabilitation Recommendation for Cardiac Rehabilitation Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation 1 A* 1. All patients with CCD and appropriate indications*†‡ should be referred to a cardiac rehabilitation program to improve outcomes.1–3 B-R† C-LD‡ *After recent MI, PCI, or CABG.1–5 †With stable angina2,3,6,7 or after heart transplant.8–13 ‡After recent spontaneous coronary artery dissection event.14–17 Synopsis CR is a comprehensive, team-based, and evidencebased approach to delivering lifestyle, behavioral, and medical therapies of known benefit to individuals with CVD.18–23 Because of underutilization of CR,24 novel delivery models have been and continue to be developed, tested, and implemented, including home-based, remote CR services.25 Home-based CR have similar shorter-term safety and clinical outcomes as facilitybased CR and can be considered as an alternative option for patients who cannot attend facility-based CR.26–29 This is of particular importance for patients with limited option for center-based CR, such as those living in rural settings and other areas with limited number of CR centers. In whatever delivery model CR is provided, the multidisciplinary CR team develops and applies patient-centered care based on specific core components (Table 13), including recovery and recuperation strategies, quality improvement, and adherence to lifestyle and medication therapies.18,30,31 Key benefits from CR have been noted to be dose-related.32,33 Downloaded from http://ahajournals.org by on October 7, 2026