p.73 抽出テキスト

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

or their care support team should identify the best source of out-of-pocket costs in their health systems; in some cases, information may be readily available in the electronic health record at the point of order entry, but in others, clinicians may have to order “test prescriptions” to ascertain coverage. Clinicians or their care support team should review each patient’s out-of-pocket costs when starting a new medication and periodically thereafter. Shared decision-making (Section 4.1.3) with patients is paramount because affordability may vary substantially based on the patient’s socioeconomic status (Section 4.1.4, “Social Determinants of Health”). Clinicians or their care support team should inform patients of cost-saving approaches such as the use of mail order pharmacies or patient assistance programs or consider lower-cost alternatives when appropriate.

8.2 Evidence Gaps and Areas of Future

Research Needs Although the past decade has seen numerous advancements in the diagnosis and treatment of patients with CCD, several gaps still exist in our understanding. These gaps should serve as areas of future research and are described below. •	 With an evolving definition of patients who have CCD, research is needed to determine how advances in noninvasive imaging technology (ie, allowing sensitive detection and quantification of calcified and noncalcified atherosclerotic plaque burden) may affect identification of patients with CCD, their prognostication, and their eligibility for preventive therapies. •	 Comprehensive risk scores need to be developed and validated for MACE in patients with CCD in the contemporary era that include patient demographics, medical information, social determinants, and data from noninvasive test results, or invasive test results, or both. •	 Although studies have shown deficiencies with clinician-estimation of patient’s symptoms, research is needed to understand whether routine use of patient-reported measures in clinical care improve patient-centered outcomes. •	 Decision aids that are tested and validated in diverse populations are needed to support shared decision-making in patients with CCD. •	 High-quality studies are needed to assess the effect of various substances, including marijuana, on cardiovascular outcomes in patients with CCD. •	 With several therapies available to treat symptoms or improve outcomes in patients with CCD, research is needed on how to sequence GDMT in patients with CCD (ie, how to judge relative importance of different components of GDMT in specific patients). •	 Randomized trials with longer-term cardiovascular outcomes are needed to determine the effectiveness of interventions that limit sedentary time. •	 Research is needed to understand whether the efficacy of therapies used in patients with CCD is uniform across men and women with CCD and across various racial and ethnic groups of patients with CCD that have traditionally been underrepresented in clinical trials. •	 Further research is needed to assess the use of personalized medicine approaches, including the assessment of the use of artificial intelligence, text messaging, wearable technology, genomics, and proteomics to improve risk assessment and treatment approaches in diverse populations of patients with CCD. •	 Additional research is needed to assess the effect of hybrid CR, as well as home-based CR, on longerterm clinical outcomes and on outcomes for various population subgroups, including women, older adults, and those from underrepresented racial and ethnic groups. •	 Future research is needed on patients with CCD on the long-term effect of treatment of mental health conditions (namely depression): (1) patients with a previous (known) diagnosis of mental health condition and concomitant CCD, or (2) patients with a new diagnosis of a mental health condition after MI. •	 Future research is needed on the long-term risk of e-cigarette use on cardiovascular health in patients with CCD. •	 Further research is needed on whether there is utility for the use of GLP-1 receptor agonists in patients with CCD but not type 2 diabetes for cardiovascular risk reduction. Research is also needed to determine whether there is utility for the combined use of SGLT2 inhibitors and GLP-1 receptor agonists in patients with CCD. •	 Further research is needed on the optimal antiplatelet regimen choices for patients with CCD who are 1 year post-MI or PCI. •	 Further research is needed on what is the optimal antithrombotic strategy in patients with CCD and atrial fibrillation. •	 In patients with CCD and refractory angina, research is needed to assess the utility of neuromodulation and thoracic spinal cord stimulation, therapeutic angiogenesis with cell/gene therapies, coronary sinus occlusion, and shockwave therapy. •	 Additional research is needed in populations with SCAD to determine optimal pharmacological management strategy after SCAD and the potential impact of vasculopathy screening on future cardiovascular outcomes. •	 As climate change–related extreme environmental events become more severe and more intense,

Downloaded from http://ahajournals.org by on October 7, 2026