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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

The writing committee acknowledges that care of patients with CCD is a continuum from postacute care in patients presenting with chest pain, acute coronary syndromes (ACS), or both to outpatient CCD-related management. The primary intended audience for this guideline is clinicians in primary care and cardiology specialty who care for patients with CCD in the outpatient setting. It aims to provide succinct recommendations in the domains of diagnostic evaluation, symptom relief, improvement in QOL, and reduction of future atherosclerotic cardiovascular disease (ASCVD)–related events and heart failure (HF) in patients with CCD. The recommendations provided in this guideline pertain to the chronic outpatient care of patients with CCD. Clinicians are referred to the relevant guidelines when evaluating patients with acute chest pain, ACS, or both.5–9 See Table 2 for other relevant guidelines.

1.4.1. CCD Definition This guideline is intended to apply to the following categories of patients in the outpatient setting: •	 Patients discharged after admission for an ACS event or after coronary revascularization procedure and after stabilization of all acute cardiovascular issues. •	 Patients with left ventricular (LV) systolic dysfunction and known or suspected coronary artery disease (CAD) or those with established cardiomyopathy deemed to be of ischemic origin. •	 Patients with stable angina symptoms (or ischemic equivalents such as dyspnea or arm pain with exertion) medically managed with or without positive results of an imaging test. •	 Patients with angina symptoms and evidence of coronary vasospasm or microvascular angina. •	 Patients diagnosed with CCD based solely on the results of a screening study (stress test, coronary computed tomography angiography [CTA]), and the treating clinician concludes that the patient has coronary disease. This guideline is structured to address epidemiology and general principles in the management and transition of care in patients with CCD (Section 2, “Epidemiology/General Principles”). This is followed by evaluation of patients with CCD presenting with angina symptoms and risk stratification for future CVD events in patients with CCD (Section 3, “Evaluation, Diagnosis, and Risk Stratification”). Section 4, “Treatment” focuses on guiding principles in the management of patients with CCD (Section 4.1, “General Approach to Treatment Decisions”), overview of lifestyle and medical therapy (Section 4.2, “Guideline-Directed Management and Therapy”), and medical therapies to reduce cardiovascular events and manage symptoms (Section 4.3, “Medical Therapy to Prevent Cardiovascular Events and Manage Symptoms”) in patients with CCD. This is followed by key considerations in decision-making related to revascularization in patients with CCD (Section 5, “Revascularization”). Special populations with key considerations are discussed next (Section 6, “Special Populations”), followed by recommendations related to follow-up and monitoring of patients with CCD (Section 7, “Patient Follow-up: Monitoring and Managing Symptoms”). Cost and value considerations while treating patients with CCD and future research needs in patients with CCD are covered in Section 8 (“Other Important Considerations”). Where applicable, key recommendations from ACC/ AHA guidelines and other scientific statements (Table 2) pertinent to outpatient management of patients with CCD are referenced and discussed. Readers should refer to these ACC/AHA guidelines and scientific statements for further details.

The writing committee acknowledges several principles while managing patients with CCD. First, the population of patients with CCD is heterogenous, and the risk of future cardiovascular events is not uniform across this patient population. Therefore, clinicians should prioritize therapies based on a patient’s future risk of CVD-related events. Second, symptom relief and improvement in QOL are extremely important considerations in patients with CCD. In several circumstances and after shared decision-making, clinicians may, as a first step, recommend therapies that improve symptom relief without necessarily improving cardiovascular outcomes. Third, several domains in the management of patients with CCD (eg, lifestyle, medical therapy, management of symptoms, and initial work-up) can be effectively performed by primary care clinicians. Therefore, this guideline acknowledges the principle of collaboration between clinicians in primary care and cardiology specialties. Lastly, the writing committee acknowledges that asymptomatic patients with significant coronary artery calcium noted on cardiac computed tomography (CT) or chest CT performed for noncardiac indications showing extensive coronary artery calcifications without history of a previous ASCVD event, have a high risk of future ASCVD events. Although this guideline does not address those patients, aggressive lifestyle management and the use of evidence-based medical therapies to prevent further progression of atherosclerosis and to reduce the risk of future cardiovascular events remain important considerations in such patients. Readers are referred to the appropriate ACC/AHA guidelines that address ASCVD risk reduction in this patient phenotype.7,10 In developing the 2023 CCD guideline, the writing committee reviewed previously published guidelines and related scientific statements. Table 2 contains a

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