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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

with valvular heart disease and concomitant CCD should be managed according to current recommendations for secondary prevention as outlined in this guideline. Patients with severe aortic stenosis and concomitant CCD who undergo PCI and transcatheter aortic valve implantation should be treated with DAPT according to the 2021 ACC/AHA/SCAI revascularization guidelines.4

6.3 Young Adults

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

2a C-LD 1 In young adults with CCD, after optimization of

traditional cardiovascular risk factors, a comprehensive evaluation and treatment of nontraditional cardiovascular risk factors can be beneficial in reducing the risk of cardiovascular events.1–3

Synopsis Young adults with CAD represent a unique subset of patients who remain at risk for prolonged cardiovascular morbidity, recurrent MACE, and loss of QALYs.1,4 Most have ≥1 traditional cardiovascular risk factors (Table 18).5,6 Suboptimal control of traditional risk factors has been associated with a higher incidence of recurrent MACE among young adults, thereby warranting optimization similar to older adults, including similar secondary prevention strategies.1,4,7,8 Given a substantial prevalence of FH,3 screening for FH can be beneficial (with genotypic screening performing less well than phenotypic screening in non-White population). Safety and efficacy of statin therapy in reduction of cardiovascular events was shown in a 20-year follow-up analysis of young patients with FH.9 Among those diagnosed with FH or with increased lipoprotein(a) levels, appropriate lipid screening of family members can be considered. Evaluation and treatment of nontraditional risk factors should be considered to decrease risk of future cardiovascular events. Furthermore, implementing strategies such as optimizing health care access, educating patients, motivational interviewing, using health information technology tools, and reducing barriers in obtaining medications may be beneficial in optimizing medication adherence10,11 (see Section 4.1.2, “Patient Education” and Section 4.1.4, “Social Determinants of Health”). Evaluation and management of nonatherosclerotic causes such as coronary anomalies, Kawasaki disease, or myocardial bridging may be beneficial (Table 19).12–14 Longitudinal follow-up of these patients with CVD specialists should be encouraged (see Section 7.1, “Follow-Up Plan and Testing”).

Recommendation-Specific Supportive Text

1 AFIJI (Appraisal of Risk Factors in Young Ischemic

Patients Justifying Aggressive Intervention) was a prospective multicenter cohort study evaluating young patients diagnosed with CAD at age ≤45 years.1 During their long-term follow-up, the investigators observed diabetes and current smoking to be associated with higher risk of recurrent MACE. Additionally, chronic inflammatory disease state (eg, HIV, viral hepatitis, systemic autoimmune disease) was associated with overall poor outcomes. More recently, similar observations were made by investigators from the YOUNG-MI (The Conundrum of Sex Differences in Outcomes of Young Patients with Acute MI)15 and VITAL2 registries that have highlighted the importance of traditional cardiometabolic risk factors along with nontraditional risk enhancers among young adults with CAD. Although the attributable risk of traditional risk factors such as tobacco use, vaping, hypertension, and diabetes may supersede that of nontraditional risk factors among young adults with CCD, the role of

Table 18.  Traditional and Nontraditional Risk Factors Associated With CCD in Young Adults Traditional Risk Factors Nontraditional Risk Factors Hypertension (Section 4.2.7, “Blood Pressure Management”) HIV and ART (Section 6.8, “HIV/Autoimmune Disorders”) Obesity and metabolic syndrome (Section 4.2.9, “Weight Management”) Recreational substance use (cocaine and marijuana) (Section 4.2.4, “Alcohol and Substance Use”) Diabetes (Section 4.2.8, “Sodium Glucose Cotransporter 2 Inhibitors and Glucagon Peptide-1 Receptor Agonists”) Systemic inflammatory disorders (IBD, SLE, RA, gout, PsA, AS) and vasculitides Unhealthy diet and physical inactivity (Section 4.2.1, “Nutrition, including Supplements,” and Section 4.2.11, physical activity) Pregnancy-related complications (IUGR, HDP, gestational diabetes) (Section 6.5, “Women, Including Pregnancy and Hormone Therapy”) Hyperlipidemia (LDL-C, Lp(a)) (Section 4.2.6, “Lipid Management”) Familial hypercholesterolemia Tobacco use (Section 4.2.3, “Tobacco Products”) Miscellaneous (psychological well-being, sleep quality, social determinants of health (Section 4.1.4, “Social Determinants of Health,” and Section 4.2.2, “Mental Health”) Family history of premature CAD History of chest radiation ART indicates antiretroviral therapy; AS, ankylosing spondylitis; CCD, chronic coronary disease; Ch9p21, chromosome 9p21 locus; HDP, hypertensive disorders of pregnancy; HIV, human immunodeficiency virus; IBD, inflammatory bowel disease; IUGR, intrauterine growth retardation; LDL-C, low-density lipoprotein cholesterol; Lp(a), lipoprotein (a); PsA, psoriatic arthritis; RA, rheumatoid arthritis; and SLE, systemic lupus erythematosus.

Adapted from Mahtta D, et al.18 by permission from Springer Nature, Copyright 2020.

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