Comprehensive Management of Chronic Coronary Disease: Multisociety Guidelines
USA: A new 2023 multi-society guideline for the management of patients with chronic coronary disease (CCD) published in the Journal of the American College of Cardiology by Debabrata Mukherjee highlights the importance of team-based, patient-centred care that considers social determinants of health, associated costs, and shared decision-making in risk assessment, testing, and treatment. The guideline encompasses various recommendations, emphasizing lifestyle modifications, pharmacologic therapies, and revascularization options for eligible patients.
- Focus on Lifestyle Modification:
The CCD guideline strongly advocates lifestyle modifications and nonpharmacologic therapies as the cornerstone of management for all patients with CCD. Healthy dietary habits and regular exercise are highly recommended to improve overall health and well-being in CCD patients.
- Importance of Physical Activity:
Patients with CCD are encouraged to engage in habitual physical activity, including activities to reduce sedentary time and promote aerobic and resistance exercise. Regular exercise has been shown to provide significant cardiovascular benefits, reducing morbidity and mortality outcomes.
- Advantages of Cardiac Rehabilitation:
Eligible patients are encouraged to participate in cardiac rehabilitation, which has been proven to offer substantial cardiovascular benefits. This comprehensive program aids in enhancing patient outcomes and contributes to decreased morbidity and mortality.
- Novel Therapies for CCD Management:
The guideline recommends using sodium glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists for select patient groups, even those without diabetes, to improve CCD outcomes. However, it stresses the need for further clinical outcomes data for newer agents like inclisiran and bempedoic acid.
- Optimal Medication Use:
For lipid lowering, statins remain the first-line therapy in CCD patients. Adjunctive therapies like ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors may be considered in specific populations, though data on novel agents such as inclisiran and bempedoic acid are limited.
- Duration of Dual Antiplatelet Therapy:
Shorter durations of dual antiplatelet therapy are deemed safe and effective, particularly in patients at high risk of bleeding but with low ischemic risk.
- Cautious Approach to Supplements:
The use of nonprescription or dietary supplements, including fish oil and omega-3 fatty acids or vitamins, is not recommended due to the lack of proven cardiovascular benefits in CCD patients.
- Rational Testing and Therapies:
The guideline advises against routine periodic anatomic or ischemic testing in patients with CCD unless there is a change in clinical or functional status to guide therapeutic decision-making.
- E-cigarettes and Smoking Cessation:
While e-cigarettes may aid smoking cessation, their use as first-line therapy is not recommended due to the lack of long-term safety data and potential risks associated with sustained use.
10. Revascularization for Symptomatic Patients:
Revascularization is recommended for patients with CCD experiencing lifestyle-limiting angina, despite guideline-directed management and therapy, and with significant coronary artery stenoses amenable to revascularization.
11. Choosing Revascularization Methods:
Patients diagnosed with chronic coronary disease (CCD) who need revascularization for multivessel coronary artery disease (CAD) characterized by complex and diffuse CAD (e.g., SYNTAX score >33) are advised to consider coronary artery bypass grafting as a preferable option over percutaneous coronary intervention. This choice is associated with improved survival rates and better outcomes for individuals with CCD in such cases.
12. The Future of CCD Management:
The guideline emphasizes the importance of research to assess effective guideline implementation in clinical practice and the impact of new guidelines on various healthcare levels and communities.
The 2023 multisociety guideline provides a comprehensive approach to managing chronic coronary disease, emphasizing patient-centered care, lifestyle modifications, evidence-based pharmacologic therapies, and appropriate revascularization options. By incorporating these recommendations into clinical practice, healthcare providers can enhance the quality of life and outcomes for patients living with CCD.
Reference:
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. J Am Coll Cardiol 2023;Jul 20:[Epub ahead of print].
