p.49 抽出テキスト

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

Synopsis Patients at high risk for CCD who have structural abnormalities (LVEF ≤40%), comorbid conditions (eg, diabetes, CKD, hypertension), or both are at significantly elevated risk of developing symptomatic HF and recurrent cardiovascular events. In addition to lowering BP (see Section 4.2.6, “Lipid Management”), renin-angiotensin-aldosterone system inhibitors (RAASi) decrease MACE in highrisk patients with CCD.1,3,5,8 In contrast, the efficacy of RAASi is less certain among populations with CCD with LVEF >40% and without comorbid hypertension, diabetes, or CKD.6,8,9,11,12 RAASi trials (PEACE [Prevention of Events with Angiotensin Converting Enzyme Inhibition], QUIET [Quinapril Ischemic Event Trial], CAMELOT [Comparison of Amlodipine versus Enalapril to Limit Occurrences of Thrombosis], and IMAGINE [Clazakizumab for the Treatment of Chronic Active Antibody Mediated Rejection in Kidney Transplant Recipients]) in lowerrisk populations with CCD showed no consistent CVD event reduction.8,11,13 Patients on RAASi therapy require close follow-up after medication initiation and titration, including assessment of adherence, BP control, laboratory testing, evaluation for potential adverse effects (eg, orthostatic hypotension), intolerance (eg, cough, angioedema), or both. ARBs should be used as an alternative for patients who are ACE intolerant.14,15 Recommendation-Specific Supportive Text

1 In RCTs,1–5 RAASi improved symptoms, reduced

hospitalizations, prolonged survival, or all 3 among high-risk patients with CCD. In patients with hypertension and diabetes, RAASi reduce the incidence of moderate albuminuria and end-stage renal disease.16–18 For patients with CCD and LVEF ≤40% who are clinically symptomatic beyond stage B, refer to the 2022 AHA/ACC/HFSA heart failure guideline.19

2 In the HOPE trial,10 high-risk patients with CCD

and preserved LVEF assigned to ramipril 10 mg daily had significant reductions in the composite of death, cardiovascular events, and stroke, although the concurrent use of other risk reduction medications was low compared with other trials.10 The EUROPA trial compared perindopril 8 mg daily to placebo in a lower risk population.9 In the PEACE trial,20 which compared trandolapril versus placebo in populations with CCD and normal LVEF, RAASi were not associated with reduced total mortality rate; however, there was a benefit in a subset of patients with reduced renal function (eGFR, <60 mL/min/m2).11 In QUIET,13 quinapril had no effect on progression of atherosclerosis in patients with CCD and preserved LVEF, except in those with CKD. The CAMELOT study8 found no reduction in MACE among patients with CCD and normal BP. The lack of overall benefit of RAASi in lower risk populations likely reflects both baseline comorbidities and levels of concurrent pharmacotherapies with other evidence-based therapies for CCD.20,21

4.3.4 Colchicine

Recommendation for Colchicine Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation

2b B-R 1 In patients with CCD, the addition of colchicine for

secondary prevention may be considered to reduce recurrent ASCVD events.1,2

Synopsis Inflammation is a key component in the development of atherosclerosis.3 As a result, using select anti-inflammatory agents may have a role in improving cardiovascular outcomes. However, studies evaluating agents thus far have showed mixed results.4,5 Colchicine exhibits antiinflammatory properties by altering inflammatory cellmedicated chemotaxis and phagocytosis by inhibiting microtubule polymerization.6 Colchicine also reduces the expression of adhesion molecules and has an effect on cytokine production.7 Given its broad cellular effects and its established role in the management of pericarditis, there has been renewed interest in its potential benefits in patients with CCD. Colchicine is considered a drug with narrow therapeutic index, meaning there is a small difference in the dose that is effective and what can lead to serious or toxic adverse effects. Additionally, colchicine is metabolized by cytochrome P450 3A4 and p-glycoprotein, making it prone to drugdrug interactions. Therefore, monitoring for adverse effects is of paramount importance. Given this, there is a need for a highly individualized approach, limiting the use of colchicine to those patients who remain at very high risk despite maximum tolerated GDMT until further data become available. A cost-effectiveness analysis of COLCOT (Colchicine Cardiovascular Outcomes Trial) showed a 47% reduction in the mean overall per patient costs and increased the QALYs from 1.30 to 1.34 for the trial period of 24 months with the addition of colchicine to standard of care for post MI treatment.8 There was also a 69% reduction in lifetime per patient cost and an increase in QALYs from 8.82 to 11.68 with colchicine compared to placebo, respectively. Based on the dose tested in clinical trials, the recommended dose of colchicine for use in secondary prevention in patients with CCD is 0.5 mg daily.

Recommendation-Specific Supportive Text

1 The LoDoCo2 (Colchicine Reduces Risk of Major

Cardiovascular Events in CCD) trial aimed to validate the LoDoCo (Low Dose Colchicine for Secondary

Downloaded from http://ahajournals.org by on October 7, 2026