p.57 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

surgical ineligibility. PCI was associated with significant improvements in patients’ symptom burden, physical function, and QOL. 9

4 The FREEDOM (Revascularization in Diabetics

with Multivessel Disease) trial (n=1900) compared CABG with PCI in patients with diabetes and multivessel CAD.10,11 The trial excluded patients with significant left main stenosis. Of the enrolled patients, 82% in the PCI group and 85% in the CABG group had triple-vessel disease, and 91% of patients had left anterior descending artery involvement. At 5-year follow-up, all-cause death rate was higher in the PCI group than in the CABG group. In the FREEDOM follow-up study, all-cause death rate up to 8 years continued to be significantly higher with PCI (hazard ratio, 1.36 [95% CI, 1.07-1.74]).11 The Head et al meta-analysis showed consistent results, with a nearly 50% increase in 5-year mortality risk among patients with diabetes who were treated with PCI than among those treated with CABG.5 A patient-level pooled analysis of 3 trials associated CABG with a reduction in the composite primary endpoint of death, MI, or stroke and the individual components of the endpoint except for stroke.17

5 To date, no RCTs have compared revasculariza-

tion strategies that focus exclusively on patients with diabetes with stable left main CAD. In a prespecified subgroup analysis of the EXCEL (Evaluation of XIENCE versus CABG Surgery for Effectiveness of Left Main Revascularization) trial, which included patients with left main CAD, predominantly normal ejection fraction, and lowor intermediate-complexity CAD,27 no difference was observed in the primary endpoint composite of death, stroke, or MI for PCI and CABG among patients with or without diabetes.18 However, allcause death at 3 years occurred in 13.6% of patients with diabetes treated with PCI and 8.0% of patients treated with CABG (P=0.046). No difference in the mortality rate was seen among patients without diabetes (5.5% versus 5.0% among patients treated with PCI and CABG, respectively; P=0.71).

6 SPECIAL POPULATIONS

In these sections, recommendations are highlighted for populations that are unique, either based on comorbidities, life stage, or mechanism of coronary pathology or pathophysiology. Unless modified or otherwise specified, the preceding recommendations for patients with CCD generally apply to these “special” populations. In some sections, additional recommendations that are unique to the populations being discussed are provided. 6.1 Existing Heart Diseases and Conditions

6.1.1 Chronic Management After SCAD

Recommendations for Chronic Management After SCAD Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 C-LD 1 In patients with CCD who have experienced

SCAD, counseling should be provided regarding potential triggers and risk of SCAD recurrence.1–12

2a C-LD 2.	 In patients with CCD who have experienced SCAD,

evaluation for underlying vasculopathies is reasonable to identify abnormalities in other vascular beds.1–4,7,10,13–15

2b C-LD 3.	 In patients with CCD who have experienced SCAD,

beta-blocker therapy may be reasonable to reduce the incidence of recurrent SCAD.1

Synopsis SCAD is an underrecognized cause of MI.16,17 SCAD is more common among women than men and occurs predominantly in younger women with low burden of classic risk factors for ASCVD. Triggers include pregnancy, vigorous physical exertion, and severe emotional distress.16,17 SCAD may be a manifestation of an underlying arteriopathy.1,13,16,17 Pregnancyassociated SCAD has a worse prognosis than SCAD in the absence of pregnancy.1,12,16,17 Conservative medical management of the acute event is favored, but selected unstable patients may require percutaneous or surgical revascularization.16,17 Medical care after SCAD is focused on managing sequelae of the acute event, evaluation and treatment of recurrent symptoms, and prevention of recurrent SCAD. In the absence of specific data among patients with SCAD, DAPT among those who have undergone stenting should follow current guidelines for DAPT (Section 4.3.1, “Antiplatelet Therapy and Oral Anticoagulants”), while being aware that excess uterine bleeding in premenopausal women may require treatment.1,2 Management of LV dysfunction after the ischemic insult is addressed in Section 4.3.2, “Beta Blockers,” Section 4.3.3, “Renin-Angiotensin-Aldosterone Inhibitors,” and Section 6.1.2 “INOCA.” Observational data suggest benefits of CR18–21 and beta blockade.1 CR is addressed in Section 4.2.10.

Recommendation-Specific Supportive Text

1 SCAD recurrence can be attributable to extension

of the initial dissection or attributable to a new dissection. Recurrence rates are highest early after the initial dissection but can occur years later.2,22 Reported recurrence rates of SCAD vary widely depending on participant characteristics, definition of recurrent SCAD, and length of follow-up,

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