AHA/ACC 2023 Guidelines Downgrade Long-term Use of Beta Blockers

Long-term use of beta-blocker therapy is no longer recommended to improve outcomes in patients with chronic coronary disease in the absence of myocardial infarction (MI) in the past year, left ventricular ejection fraction (LVEF) < 50%, or another primary indication for beta-blocker therapy. The guidelines also suggested calcium channel or beta-blockers as first-line antianginal therapy.

The beta blockers widely in clinical use include metoprolol tartrate, metoprolol succinate, nebivolol, bisoprolol, carvedilol, labetalol, propranolol, nadolol, timolol and sotalol.

The 2023 AHA/ACC Guideline for managing patients with Chronic Coronary Disease is published online in the latest issue of Circulation. It was developed in collaboration with and endorsed by the American College of Clinical Pharmacy(ACCP), the American Society for Preventive Cardiology (ASPC), the National Lipid Association(NLA), the Preventive Cardiovascular Nurses Association (PCNA), and the Society for Cardiovascular Angiography and Interventions.

The new guideline updates and consolidates new evidence since the 2012 and 2014 guidelines for the diagnosis and management of patients with Stable Ischemic Heart Disease (SIHD)

The updated guideline emphasized the importance of team-based, patient-centre care that considers social determinants of health and associated costs while incorporating shared decision-making in risk assessment, testing, and treatment.

Recommendations on Pharmacological Management

Regarding guidelines on pharmacological treatment, another key recommendation includes using sodium-glucose cotransporter 2 inhibitors (SGLT2-i) and glucagon-like peptide-1 receptor agonists (GLP1-RA) for selected patients with chronic coronary disease, including groups without diabetes.

The recommendation for statins as the first-line lipid-lower therapy in patients with chronic coronary disease remains unchanged. Several adjunctive therapies (e.g., ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors, inclisiran, bempedoic acid) may be used in select populations.

The new guideline also suggested that shorter durations of dual antiplatelet therapy (DAPT) are safe and effective in many circumstances, particularly when the risk of bleeding is high and the ischemic risk is low to moderate.

Non-Pharmacological Interventions

The 2023 guideline also recommended non-pharmacological interventions for all patients with chronic coronary disease, including healthy dietary habits and exercise. Those patients who are free from contraindications are encouraged to participate in habitual physical activity, including activities to reduce sitting time and increase aerobic and resistance exercise. The updated guideline also noted cardiac rehabilitation's significant cardiovascular benefits in eligible patients, including decreased morbidity and mortality outcomes.

Other Recommendations

Routine periodic anatomic or ischemic testing without a change in clinical or functional status is not recommended for risk stratification or to guide therapeutic decision-making in patients with chronic coronary disease.

Reference: Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2023;148:e9–e119. doi: 10.1161/CIR.0000000000001168