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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

there is statin-associated increased risk of miscarriage. Statins remain contraindicated during lactation (Table 21). Lipoprotein apheresis can be considered for women with heterozygous or homozygous familial hypercholesterolemia and CCD.27

4 ACE inhibitors, ARBs, direct renin inhibitors, and

angiotensin receptor-neprilysin inhibitors can cause renal dysgenesis, oligohydramnios because of fetal oliguria, neonatal anuric renal failure, intrauterine growth retardation, pulmonary hypoplasia, and fetal death, especially when used in the second and third trimester of pregnancy.8 Benazepril, captopril, and enalapril are safe during lactation.7 Aldosterone antagonists are contraindicated in pregnancy because of their antiandrogen effects and potential teratogenesis. Aldosterone antagonists are also contraindicated during lactation.7

5 Data from secondary prevention trials of hormone

therapy11 concluded that there was no effect on cardiovascular death, nonfatal MI, stroke, angina, or coronary revascularization. A statistically significant increased risk of venous thromboembolism was observed (relative risk, 2.02 [95% CI, 1.13-3.62]). In the angiographic trials,17–20 no benefit of hormone therapy was seen on progression of disease in native CAD with estrogen only or with estrogen-progestin therapy. The EAGAR (Effects of Aspirin in Gestation and Reproduction) study20 showed enhanced progression in native coronary arteries yet slowing of disease progression in saphenous vein grafts; the reason for this differential response is unknown. Increased risk of thromboembolism also was documented in a trial of hormone therapy among women with previous venous thromboembolism.28 Less is known about the risk of oral contraceptives among women with CCD. A recent review on estrogen and thrombosis29 concluded that combined hormonal contraceptives and injectable depot medroxyprogesterone acetate should be avoided among women with CCD or previous stroke as both forms of contraceptive therapy increase thrombosis risk.30,31 Increased cardiovascular risk has been docu-

mented among transwomen with increased rates of venous thromboembolism, acute MI, and stroke compared with ciswomen but not always when compared with cismen.29,32 This increase in cardiovascular risk is at least in part related to hormone therapy. Whether prevalent CCD further increases risk in hormone-treated transgender women is unknown with future research needed.

6.6 Older Adults Synopsis

Older patients, defined as ≥75 years of age in accordance with a recent statement published by the AHA, ACC, and American Geriatrics Society,1 have a high prevalence of CCD and, when present, is more likely to be associated with high-risk anatomical features.2 Although several retrospective studies, observational studies, and subgroup analyses have suggested that medical therapy3–6 and revascularization,7–17 when needed, may be effective in older patients, they are less likely to be treated.18 A paucity of RCTs with a focus on older patients leaves clinicians with inadequate data to guide their decision-making. The available data are limited by a variable definition of the term older; in fact, some studies have included individuals as young as 60 years of age. Furthermore, many studies comprise patients with both acute and CCD, making it difficult to determine in which clinical scenario a treatment is efficacious. The treatment of CCD in older patients is further complicated by the presence of multiple comorbidities and polypharmacy, both of which can heighten the risk of treatment-related complications. Based on a patient’s comorbidities and extent of polypharmacy, scenarios may exist where alternate treatment or procedural approaches (beta blockers,19 antithrombotic and antiplatelet agents,9,20–23 coronary angiography,24 CABG,25–29 CR30,31) may be preferable. For example, a meta-analysis of 6 RCTs comparing short-term versus long-term DAPT in elderly patients.21 The use of shortterm DAPT was not associated with an increase in cardiovascular events but was associated with a significant reduction in major bleeding. Additionally, traditional risk scoring systems in patients with CCD may need to be modified to most accurately assess an older patient’s risk.32,33 Older patients also have an increased prevalence of frailty,34–37 malnourishment,38–41 and cognitive decline, all of which may be associated with poor outcomes and treatment response. Equally important, older patients are more likely to prioritize the ability to remain independent, with a focus on maintaining their mobility and functional status rather than reducing their mortality rate.3 When considering treatment options, teambased care (Section 4.1.1) and shared decision-making

Table 22.  The Geriatric 5 Ms MIND Mentation, dementia, delirium, depression MOBILITY Impaired gait and balance, fall injury prevention MEDICATIONS Polypharmacy, deprescribing, optimal prescribing

Adverse medication effects and medication burden

MULTICOMPLEXITY Multimorbidity

Complex biopsychosocial situations

MATTERS MOST Each individual’s own meaningful health outcome goals and care preferences Adapted with permission from Molnar F, et al.42 Copyright 2017 Canadian Geriatrics Society and from Molnar F, et al. Copyright 2019 The College of Family Physicians of Canada. The GERIATRIC 5Ms, Copyright © 2017 Frank Molnar, Allen Huang, Mary Tinetti. 2017. The Geriatric 5Ms may be used for educational purposes with full attribution and no alterations. This work is bound by the Creative Commons license CC-BY-NC-ND 4.0 (https://creativecommons.org/ licenses/by-nc-nd/4.0/).

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