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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

6.1.3 HF With Preserved or Reduced Ejection Fraction

Synopsis CAD is the most common cause of HF in the United States and has a pivotal role in the development and progression of both HF with preserved ejection fraction and HF with reduced ejection fraction.1,2 Management of patients with CCD and HF with preserved ejection fraction and HF with reduced ejection fraction should follow associated guideline recommendations for revascularization3 and HF,4,5 as well as sections in this guideline: Section 4.2, “Guideline-Directed Management and Therapy,” Section 4.3, “Medical Therapy to Prevent Cardiovascular Events and Manage Symptoms,” and Section 5, “Revascularization.”

6.2 CCD With Valvular Heart Disease

Synopsis Concurrent CCD is common in patients with valvular heart disease.1,2 The evaluation and management of CCD at the time of valve intervention is discussed in the “2021 ACC/ AHA Guideline for the Management of Patients With Valvular Heart Disease.”3 After valve intervention, patients

Table 17.  Invasive Coronary Function Testing Definition and Linked Pharmacotherapy for INOCA Endotypes Endotype Disorder of Coronary Artery Function Linked Pharmacotherapy Microvascular angina (nonobstructive CAD and proven CMD) ↑ Microvascular

resistance

↓ Coronary

vasorelaxation

↓ Microvasodilator

capacity

Microvascular

spasm IMR ≥25.

IMR is a quantitative method for specifically assessing microvascular function independent resting hemodynamics. IMR is distal coronary pressure* transmit time (average time for 3 saline bolus runs at hyperemia). CFR by thermodilution <2.0. This reflects the inability to increase coronary flow above 2 times the resting flow. Resistive reserve ratio <2.0. This reflects the vasodilator capacity of the microcirculation to change from baseline to hyperemia (resistance at rest divided by resistance at hyperemia). Angina during acetylcholine infusion or bolus with typical ischemic ST-segment changes and epicardial coronary constriction <90% reduction in epicardial coronary artery diameter. Represents inappropriate susceptibility microvascular constriction. Baseline therapy: Consider aspirin, statin, and ACEi therapy in all patients. Sublingual nitroglycerin as needed.

Smoking cessation and lifestyle changes. Antianginal Rx First line: Beta blocker (eg, carvedilol 6.25 mg BID uptitrated) Second line: CCB substituted (non DHP [eg, verapamil 40 mg BID titrated]) where beta blockers are not tolerated or ineffective. Third line: Add-in therapy CCB-DHP (eg, amlodipine)-only for those on beta blockers Nicorandil* (5 mg BID, uptitrated) Ranolazine (375 mg BID, uptitrated)

Vasospastic angina Epicardial spasm Epicardial coronary artery spasm is defined as reduction in coronary diameter >90% after intracoronary acetylcholine in comparison with baseline resting condition after intracoronary glyceryl trinitrate (nitroglycerin) administration in any epicardial coronary artery segment together with symptoms and ST-segment deviation on the ECG. Baseline therapy: If atherosclerosis or endothelial impairment, aspirin and statin should be considered. Sublingual nitroglycerin as needed.

Smoking cessation and lifestyle changes. Antianginal Rx First line: CCB (eg, verapamil 40 mg BID uptitrated) Second line: Add long-acting nitrate (eg, isosorbide monotitrate 10 mg BID) Third line: Change nitrate to nicorandil* (eg, nicorandil 5 mg BID)

Mixed MVA/VSA CMD and epicardial vasospasm Epicardial spasm plus any abnormality of: Microvascular resistance Coronary vasorelaxation Microvasodilator capacity Baseline therapy: Consider aspirin, statin and ACEi therapy in all patients. Sublingual nitroglycerin as needed. Obstructive CAD >50% lesion by diameter stenosis in epicardial artery >2.5 mm or a FFR ≤0.80 Baseline therapy: If atherosclerosis or endothelial impairment, patients should be considered for aspirin, statin, and ACEi.

Consideration of revascularization, antianginal therapy as per guidelines

Noncardiac None Exclusion of diffuse or obstructive epicardial coronary disease (FFR >0.8) without any of the after abnormalities of coronary function: CFR <2.0, IMR ≥25 or functional angina/spasm during acetylcholine. Cessation of antianginal therapy. Stop antiplatelet and statins unless other indication.

Consider noncardiac investigation or referral where appropriate (eg, psychology, gastroenterology)

*Currently unavailable in the United States. ACEi indicates angiotensin converting enzyme inhibitor; CAD, coronary artery disease; CCB, calcium channel blocker; CFR, coronary flow reserve; CMD, coronary microvascular disease; DHP, dihydropyridine; ECG, electrocardiogram; FFR, fractional flow reserve; IMR, index of microvascular resistance; MVA, microvascular angina; and VSA, vasospastic angina.

Modified with permission from Ford TJ, et al.1 Copyright 2018 American College of Cardiology Foundation.

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