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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

approach to aerobic exercise training in individuals with CCD.15,16 US guidelines recommend that adults who do not have contraindications to exercise should do at least 150 to 300 minutes per week of moderate-intensity aerobic physical activity, or at least 75 to 150 minutes per week of vigorous (higher)-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. 2.	 Muscle-strengthening (resistance training) activi-

ties are recommended on ≥2 days a week.17 Resistance training to safely improve muscular strength improves functional capacity and QOL.5,6,18 Resistance training may also reduce mortality rates in individuals with CCD.19

3 Compared with a sedentary lifestyle, lower-inten-

sity lifestyle activities (eg, gardening), office-based physical activities, and climbing stairs improve energy expenditure, functional capacity, and cardiometabolic risk, especially in previously sedentary individuals who are not exercising on a regular basis.20–25 Interventions, such as the use of step counters and walking prompts, may be helpful in decreasing sedentary time and increasing lifestyle activities in individuals with CCD.9-11,20-23,26

4.2.12 Environmental Exposures

Recommendations for Environmental Exposures Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

2a B-NR 1 In patients with CCD, minimization of exposure to

ambient air pollution is reasonable to reduce the risk of cardiovascular events.1–7

2b B-NR 2 In patients with CCD, minimization of

climate-related exposures (eg, extreme temperatures, wildfire smoke) may be reasonable to reduce the risk of cardiovascular events.8–10

Synopsis Adverse environmental exposures such as air pollution, extremes of ambient temperature, and excess noise should be systematically assessed in patients with CCD. Numerous ecological studies have examined the adverse effect on cardiovascular health of ambient air pollution such as that produced by transportation exhaust or wildfire smoke.1-7,11,12 Exposure to extreme heat or extreme cold ambient temperatures has been associated with increased cardiovascular events among patients with CCD.8-10,13,14 As extreme temperatures have become increasingly frequent, clinicians should identify at-risk individuals, provide guidance regarding medication titration (eg, loop diuretics) during extreme temperature events, and encourage the use of publicly available controlled-temperature environments during extreme weather events. Numerous observational studies document a connection between excess environmental noise and the progression of CCD,15,16 but data are limited regarding the benefit of noise reduction devices. Adverse environmental exposures disproportionately affect racial and ethnic minority populations and individuals of low socioeconomic status; therefore, they contribute to inequitable health outcomes.17,18 Policy interventions that reduce the burden of these exposures or provide resources to mitigate their adverse effects may reduce health disparities.18

Recommendation-Specific Supportive Text 1.	 Ambient air pollution, especially small particulate

matter with an aerodynamic diameter ≤2.5 microns (also referred to as “PM2.5”), is associated with worse cardiovascular outcomes.1–7 Most outdoor and indoor PM2.5 pollutants are produced by combustion (eg, car engines, coal- or natural gas-fired power plants, woodstoves, or wildfires). Proximity to automobile traffic or fossil fuel-dependent industries and use of poorly ventilated stoves are key predictors of exposure to increased PM2.5 levels. Longterm exposure to PM2.5 levels >10 micrograms per cubic meter (μg/m3) is associated with a >10% increase in the odds of having CCD, progression of CCD, and suffering an acute MI or cardiovascular mortality.1–5 Even short-term exposure (<7 days) to elevated levels is associated with increased hospitalization and cardiovascular death.6,7 There are insufficient data to support regular use of in-home high-efficiency air purifiers or N95 filters to improve cardiovascular outcomes.19 Other pollutants, such as ground-level ozone, are associated with a small increase in risk of cardiovascular death, but additional studies are needed to quantify the magnitude of risk.20 Information regarding air pollutants and their relation to air quality in a specific geography can be found via the US Environmental Protection Agency at AirNow.gov.21

2 Exposure to extreme ambient heat or several con-

secutive days of extreme heat (“heat wave”) is associated with increased death from ischemic heart disease.8 Older adults, individuals with outdoor jobs, and patients receiving certain medications such as loop diuretics are at increased risk.8,9 The effects of extreme heat are exacerbated in urban areas because of the “urban heat island effect,” wherein dense concentrations of pavement and buildings absorb and retain heat.13 Individualized assessment should include risk of exposure (ie, regional temperature and occupational exposure), clinical susceptibility (ie, age, comorbidities, and medications used), and capacity for adaptation (ie, cognitive skills, housing quality, and community resources).14 Similarly, exposure to wildfire smoke has been associated with increased hospitalizations for acute

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