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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

when randomized to invasive compared with conservative management.28 In the CLARIFY (Prospective Observational Longitudinal Registry of Patients with Stable Coronary Artery Disease) registry of 32 105 outpatients with CCD across 45 countries, anginal symptoms during noninvasive testing, but not silent ischemia, were associated with increased risk of MACE, including cardiovascular death or nonfatal MI.9 Recently, the multicenter, POST-PCI (Pragmatic Trial Comparing Symptom-Oriented versus Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention) RCT compared a strategy of routine functional stress testing (using exercise ECG with or without nuclear myocardial perfusion imaging or stress echocardiography) versus standard care alone 12 months after successful PCI in 1706 high-risk patients. At 2 years of follow-up, no differences were observed between groups in the primary endpoint of composite death, MI or hospitalization for unstable angina.10

3 Routine, periodic reassessment of LV function in

asymptomatic patients without a change in functional status or clinical intervention is not recommended.11 In a post-hoc analysis of the RCT MASS II in which patients with multivessel CCD treated by CABG, PCI, or medial therapy underwent evaluation of LVEF before randomization and after 10 years of follow-up (n=350), LVEF was stable over long-term follow-up in the absence of MACE.12

4 Asymptomatic patients in the ISCHEMIA trial did

not derive a benefit when randomized to invasive compared with conservative management.8,28 Routine follow-up invasive coronary angiography has been associated with increased revascularization of nonischemic intermediate lesions without an improvement in rates of subsequent cardiac death or MI.16,17 The ReACT (Randomized Evaluation of Routine Follow-up Coronary Angiography after PCI) trial was a prospective multicenter openlabel trial in Japan in which 700 patients were randomized to receive routine follow-up coronary angiography 8 to 12 months after PCI versus clinical follow-up alone.14 During median follow-up of 4.6 years, no clinical benefit was seen for routine follow-up coronary angiography despite increased early coronary revascularization rates. Routine angiographic follow-up after PCI in patients with diabetes was associated with an increased incidence of revascularization and MACE without a change in death or reinfarction rates.29 In a contemporary Danish registry of patients with CCD, revascularization in those without ischemia conferred a higher risk of death and MI versus medical therapy alone.15 8 OTHER IMPORTANT CONSIDERATIONS

8.1 Cost and Value Considerations

Recommendation for Cost and Value Considerations Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation

1 B-NR 1 When discussing treatment and prevention with

patients who have CCD, it is recommended that the health care team discuss out-of-pocket costs for medications at the time of initiating a new medication and at least annually thereafter to preempt cost-related nonadherence.1–6

Synopsis Some new CCD therapies are only available as branded formulations, and their high out-of-pocket costs can impede adoption or increase the risk of cost-related nonadherence.1,2 High out-of-pocket costs is a frequently cited reason for patients foregoing medications, delaying a prescription refill, or skipping or reducing medication doses.3 The use of high-cost therapies in a large number of eligible patients increases pharmaceutical spending, which, in the long term, gets passed to the patient in the form of higher insurance premiums (in the case of private insurance) and to the taxpayer in the form of higher taxes (in the case of public insurance). Therefore, clinicians have a key role in ensuring access and adherence to effective therapies by regularly discussing out-of-pocket costs with their patients with CCD as a part of shared decision-making, using lower-cost alternatives when available, and guiding health systems to adopt cost-effective therapies when >1 alternative is appropriate (ie, choosing therapies that require lower incremental spending to generate 1 additional unit of health and meet conventional cost-effectiveness thresholds). For Level of Value Considerations, refer to Table 1. Refer also to the lipid management, SGLT2, and revascularization sections (4.2.6, 4.2.8, and 5.1) for applicable cost-value considerations. Recommendation-Specific Supportive Text

1 One in 8 persons with CVD in the United States

reports cost-related medication nonadherence.3 Patients may be responsible for hundreds of dollars in out-of-pocket costs for their prescriptions, which can be a barrier to initiating or continuing an effective therapy.1,2 Most patients report a desire to discuss out-of-pockets with their clinicians, particularly when considering a new therapy.4–6 Clinicians and their support team should familiarize themselves with out-of-pocket costs for commonly prescribed drugs but recognize that these may vary among patients by benefit design, time of year (eg, whether the annual deductible has been met), and concurrent medications. Clinicians

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