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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 these unique risk factors such as chronic inflammation, genetics (Ch9p21 locus, lipoprotein(a)), and recreational drug use remains at the center of clinical optimization. Assessing for and aggressive treatment of nontraditional cardiovascular risk factors (Table 18) such as inflammatory conditions or recreational drug use are important to reduce cardiovascular risk among young adults with CCD.1- 3,16,17 Evaluation for nonatherosclerotic causes of CCD among young adults (coronary anomalies, vasospasm, or spontaneous dissection) should also be prioritized (see Section 6.1, “Existing Heart Diseases and Conditions” and Section 6.5, “Women, Including Pregnancy and Hormone Therapy”). 6.4 Cancer Recommendation for Cancer Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation 1 C-LD 1 In patients with CCD and cancer, a multidisciplinary team including cardiology and oncology expertise is recommended to improve long-term CVD outcomes.1,2 Synopsis Cancer and CCD share mechanistic pathophysiology3–5 and are the 2 leading causes of death worldwide,6 sharing multiple risk factors such as sedentary lifestyle, obesity, smoking, diabetes, and age.4,7 Cancer and CVD increasingly coexist, yet patients with CCD and cancer are often undertreated4 and are high risk for cardiovascular adverse events. Commonly used chemotherapy and radiation therapy may have cardiac toxicity,8,9 and some classes of cytotoxic chemotherapy increase CVD risk factors.10 In 2022, AHA published a scientific statement on cardio-oncology drug interactions, noting communication between oncology and cardiology specialists is warranted.11 If CCD medications are stopped because of cancer treatment, they should be resumed as soon as possible. In 2019, the AHA provided a scientific statement in favor of the development of cardio-oncology rehabilitation for patients at high risk of developing cardiovascular dysfunction.2 Recommendation-Specific Supportive Text 1 A multidisciplinary cardio-oncology team should evaluate the patient before cancer treatment and monitor the patient throughout the course of treatment.10 Longitudinal registries suggest that cardiovascular outcomes have improved with the introduction of multidisciplinary care teams in cancer treatment. In settings where multidisciplinary teams are unavailable, clinicians should consider referral to relevant subspecialties as appropriate.1,12 Cardio-oncology is a growing subspecialty that promotes the need for effective cancer treatment while minimizing negative cardiovascular adverse events.13 The cardio-oncology team is involved in all aspects of the care of cancer patients, from informing pretreatment risk and regimen selection, addressing the complex cardiovascular adverse effects of cancer therapy, and mitigating the heightened long-term risks of CVD in survivorship. This team manages common conditions between subspecialties, such as antiplatelet therapy for venous thromboembolism prophylaxis. Patients with CCD and locally advanced or metastatic cancer can be at increased risk for arterial thrombosis and cardiovascular adverse events. If the patient is not already on an antithrombotic regimen, clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or low-molecular-weight heparin to selected high-risk outpatients with cancer.14 Refer to Section 4.1.1 (“Team-Based Approach”), Section 4.1.2 (“Patient Education”), and Section 4.1.4 (“Social Determinants of Health”) for management of the patient with CCD and comorbidities. Table 19. Nonatherosclerotic Causes of CCD in Young Adults: Evaluation and Management Cause Presentation Management Kawasaki disease Late sequelae: coronary artery aneurysm, stenosis, thrombosis, or fistula Lifelong follow-up with quantitative assessment of luminal dimensions. Low-dose aspirin therapy for small- or medium-sized coronary artery aneurysms. Low-dose aspirin plus anticoagulant therapy for large coronary artery aneurysms. Coronary artery anomalies Anomalous left coronary artery from the pulmonary artery Anomalous origin of the coronary artery from the opposite sinus of Valsalva with an interarterial course Surgical repair – translocation of left coronary artery to aortic root for anomalous left coronary artery from the pulmonary artery. Surgical correction among young adults with interarterial course of coronary artery originating from opposite sinus of Valsalva and symptoms during exercise suggestive of myocardial ischemia. Myocardial bridging Exercise-induced ischemia Coronary artery vasospasm Sudden cardiac death Beta-adrenergic blocking agents in symptomatic patients. Restriction to low-intensity sports. Surgical correction if symptoms refractory to medical therapy. CCD indicates chronic coronary disease. Downloaded from http://ahajournals.org by on October 7, 2026