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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

7 PATIENT FOLLOW-UP: MONITORING

AND MANAGING SYMPTOMS

7.1 Follow-Up Plan and Testing in Stable

Patients Recommendations for Follow-Up Plan and Testing in Stable Patients Referenced studies that support the recommendations are summarized in the Online Data Supplement.

COR LOE Recommendations

2b B-R 1 In stable patients with CCD and with previous ACS

or coronary revascularization, referral to telehealth programs, community-based programs, or both for lifestyle interventions may be reasonable as an adjunct to usual care to improve management of cardiovascular risk factors.1–7

3: No benefit B-R 2 In patients with CCD without a change in clinical

or functional status on optimized GDMT, routine periodic testing with coronary CTA or stress testing with or without imaging is not recommended to guide therapeutic decision-making.8–10

3: No benefit B-R 3 In patients with CCD without a change in clinical

or functional status, routine periodic reassessment of LV function is not recommended to guide therapeutic decision-making.11,12

3: Harm B-NR 4 In patients with CCD without a change in clinical or

functional status, routine periodic invasive coronary angiography should not be performed to guide therapeutic decision-making.13–17

Synopsis Patients with CCD are at elevated risk for future MACE and should be observed periodically in the outpatient setting.18,19 Central components of the management of patients with CCD include long-term risk factor modification and active management of GDMT to achieve maximally tolerated doses,20 with shared decisionmaking involving effective communication between cardiologists, primary, and specialty care teams (see Section 4.1, “General Approach to Treatment Decisions,” Section 4.1.1, “Team-Based Approach,” Section 4.1.2, “Patient Education,” and Section 4.1.4, “Social Determinants of Health”).21–23 Over the past 2 decades, rates of MACE in patients with CCD have declined, and contemporary studies suggest overall low event rates in patients with CCD on GDMT, especially in the absence of anginal symptoms.19,24 After index diagnostic evaluation, treatment, and optimization of lifestyle and medical interventions, follow-up testing should be reserved for instances when there has been a significant change in symptom and/or clinical status. Periodic recording of the standard resting 12-lead ECG in patients with CCD may provide a baseline waveform against which future tracings taken during symptoms may be reasonably compared to avoid overdiagnosis of a change in clinical status.14,15 Patients with CCD who have accelerating symptoms or decreasing functional capacity despite optimized GDMT should undergo assessment as per Section 3 (“Evaluation, Diagnosis, and Risk Stratification”). Recommendations regarding CR can be found in Section 4.2.10.

Recommendation-Specific Supportive Text

1 A Dutch multicenter trial randomized 374 adults

<8 weeks after hospitalization for ACS to usual care plus telehealth coaching with the lifestyle intervention “Hartcoach” every 4 weeks versus usual care alone.1 After 6 months of follow-up, patients randomized to Hartcoach had modest improvement in BMI, waist circumference, physical activity, intake of vegetables, self-management, and anxiety. An Australian trial randomized 430 adults with previous MI to a telephonedelivered 6-month secondary prevention program (“Proactive Heart”) versus usual care.2 Patients in the intervention group had significantly improved health outcomes as assessed by health-related QOL and physical activity surveys, including anxiety outcomes.3 A subsequent randomized trial of 121 adults found that a 6-month telehealth program (MoodCare) improved depression scores in patients post-ACS compared with usual care,4 and effects persisted at 1-year follow-up in those with major depressive disorder.5 In the RESPONSE-2 (Ruxolitinib Efficacy and Safety in Patients with HU Resistant or Intolerant Polycythemia Vera versus Best Available Therapy) trial, nurse-coordinated referral of 711 patients with previous ACS, coronary revascularization, or both and their partners to 3 widely available community-based lifestyle programs in 15 hospitals in the Netherlands led to significant improvements in lifestyle-related factors.6 Text messaging interventions may7 or may not25,26 be beneficial. The cost-effectiveness of such approaches remains uncertain.27

2 The evidence base surrounding the long-term

prognosis and appropriate management of the spectrum of contemporary patients with CCD is evolving. Routine periodic anatomic or ischemic testing in asymptomatic, nonsedentary patients is not recommended. Limited data are available to guide management of asymptomatic patients with CCD on GDMT who receive functional or anatomic testing and have a positive result. In the ISCHEMIA trial, 5179 patients with stable CAD and site-determined moderate-severe ischemia on stress testing were randomized to invasive versus conservative care strategies, with no difference in the composite primary MACE endpoint at 3.3 years of follow-up.8 Only patients presenting with daily, weekly, or monthly angina experienced prompt and durable improvement in symptoms

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