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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 Published evidence suggests favorable cost-effectiveness of CR.34–36 One multicenter, randomized trial of longer-term “maintenance” CR of up to 3 years was associated with moderate but significant improvements in cardiovascular outcomes compared with those who participated in the traditional 12-week course of CR.37 For related information, refer to these Sections: 3.2, “Risk Stratification and Relationship to Treatment Selection”; 4.1.1, “Team-Based Approach”; 4.1.2, “Patient Education,” 4.1.3, “Shared Decision-Making”; 4.2.1, “Nutrition, Including Supplements”; 4.2.2, “Mental Health”; 4.2.6, “Lipid Management”; 4.2.7, “Blood Pressure Management”; 4.2.8, “Sodium Glucose Cotransporter 2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists”; 4.2.9, “Weight Management”; 6.1, “Existing Heart Diseases and Conditions”; 6.9, “Post- Heart Transplant Cardiac Allograft Vasculopathy”; and 2022 ACC/AHA/HFSA heart failure guideline.38 Recommendation-Specific Supportive Text 1 Patients with CCD with a recent MI, PCI, or CABG procedure who participate in CR have significantly better outcomes compared with those who do not participate,39–41 including lower all-cause and cardiovascular mortality rates,27,41,42 lower rehospitalization rates (total, cardiovascular, and noncardiovascular),43–45 and superior QOL.27,41,42,44,45 Participation in CR appears to improve symptom control, functional capacity, and QOL in patients with stable angina.2,40 CR is also associated with improved outcomes in special populations with CCD. CR improves exercise capacity in heart transplant recipients,8 including those in maintenance (1–8 years after heart transplant) as well as de novo (7–16 weeks after heart transplant).9,10 In maintenance of patients with heart transplant with or without cardiac allograft vasculopathy, high-intensity interval training versus usual care resulted in significantly lower rates of cardiac allograft vasculopathy progression at 1 year,11 but these effects were no longer present on long-term (3–5 years) follow-up, suggesting that continued intermittent periods of high-intensity interval training may be necessary to maintain the initial benefits.12,46,47 One observational study showed an association between the dose of CR sessions and survival in patients with heart transplant.48 Similarly, patients with spontaneous coronary artery dissection (SCAD) who participated in CR, compared with those who did not, had lower MACE and lower rates of recurrent MI with favorable trends in physical, emotional, and mental domains.14–17 For patients with CCD and concomitant HF, CR is also recommended as a Class 2a recommendation, LOE B-NR (see 2022 ACC/ AHA/HFSA heart failure guideline).38 4.2.11 Physical Activity Recommendations for Physical Activity Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 A 1 For patients with CCD who do not have contrain- dications, an exercise regimen is recommended, including ≥150 minutes/wk of moderate-intensity aerobic activities or ≥75 minutes/wk of higherintensity aerobic activities to improve functional capacity and QOL, and to reduce hospital admission and mortality rates.1–3 1 B-R 2 For patients with CCD who do not have contraindi- cations, resistance (strength) training exercises are recommended on ≥2 days/wk to improve muscle strength, functional capacity, and cardiovascular risk factor control.4–6 2a B-NR 3 For patients with CCD who do not have contra- indications, lower-intensity lifestyle activities (eg, walking breaks at work) to reduce sedentary behavior (ie, sitting time) are reasonable to improve functional capacity and reduce cardiovascular risk, especially in individuals with low levels of habitual leisure time physical activity.7–9 Synopsis Habitual physical activities—including nonexercise lifestyle activities, aerobic (cardiovascular) exercise training, and resistance (strength) training—are associated with improved outcomes in individuals with CVD, including functional capacity, QOL, and mortality and morbidity rates.1–9 Moving individuals from sedentary lifestyle habits to at least lower-intensity physical activities can improve metabolic and cardiovascular health.9–11 Health benefits occur even with lower doses (eg, frequency, duration, and intensity) of physical activity and increase with increasing doses of physical activity.7 Mechanisms of the benefits from physical activity and exercise training include antiatherosclerotic, antiarrhythmic, antithrombotic, anti-ischemic, and antidepressant effects.12 Exercise is contraindicated in patients with severe, lifethreatening, and unstable conditions. Contraindications include unstable angina, other high risk cardiovascular conditions (eg, high-grade arrhythmias, decompensated heart failure, active thromboembolic disease), or other unstable or life-threatening noncardiovascular conditions such as active infection, uncontrolled diabetes, end-stage cancer, or unstable psychological issues. Recommendation-Specific Supportive Text 1 Moderate-to-higher intensity exercise training in individuals with CCD, which is done in CR programs, improves functional capacity, health-related QOL, cardiovascular risk factor control, and mortality rates.2,3,13,14 In addition to continuous, moderateintensity exercise training, high-intensity interval training also appears to be an effective and safe Downloaded from http://ahajournals.org by on October 7, 2026