Updated chronic coronary disease guidelines factor in new drug therapies

Loren Bonner

Taking into consideration specific recommendations on several new classes of medications as well as placing an emphasis on social determinants of health, the American Heart Association, the American College of Cardiology, and other associations issued updated guidelines on managing chronic coronary disease.

“Our understanding of how to manage patients with chronic coronary disease both in terms of diagnosis and management has evolved considerably,” said Salim Virani, MD, chair of the guideline writing committee. “Several recent clinical trials have provided a better understanding of therapies recommended in the past as well as newer therapies that did not exist at the time of prior guideline publication.”

The last guideline on the topic was published in 2012, with an update in 2014.

The updated recommendations as they relate to medications apply to nonstatin lipid lowering therapies, dual antiplatelet therapy use and its duration, anticoagulants, SGLT-2 inhibitors, as well as GLP-1 receptor agonists. Recommendations on the use of beta-blockers in patients with chronic coronary disease are also part of the update.

“I would emphasize that the guideline endorses the importance of having pharmacists as part of the cardiovascular team,” said Virani, who is from Baylor College of Medicine. “We know that patients with chronic coronary disease have a high pill burden and that their adherence to guideline-directed medical therapy is low. Pharmacists can play a pivotal role in ensuring that patients are on the correct medications, they understand what those medications do, and why it is important for them to take these medications regularly.”

Virani specifically pointed out that medication adherence is a problem area for patients with chronic coronary disease, but pharmacists can engage in dialogue with patients to understand what their barriers to medication adherence may be.

“I believe pharmacists can play an important role in addressing this gap,” he said.

Besides being mindful of how social determinants of health affect care, Virani said other important takeaways from the new guideline include fully leveraging all members of the team—such as nurses, pharmacists, social workers, and others—who are caring for patients with chronic coronary disease; making sure practitioners help patients understand their disease and why therapy is being recommended; and lastly emphasizing to patients that as the understanding of the disease advances with the availability of new therapies, living with chronic coronary disease is much more manageable in terms of quality of life and overall prognosis.

For busy clinicians, Virani recommends taking a look at the “Top 10 take home messages” section of the guideline. Visit apha.us/CCDGuidelines to access the full guideline. ■

Key perspectives from the 2023 multisociety guideline for the management of patients with chronic coronary disease

1. The chronic coronary disease guideline emphasizes team-based, patient-centered care that considers social determinants of health along with associated costs while incorporating shared decision-making in risk assessment, testing, and treatment.
2. Lifestyle modification and nonpharmacologic therapies, including healthy dietary habits and exercise, are recommended for all patients with chronic coronary disease.
3. Patients with chronic coronary disease who are free from contraindications are encouraged to participate in habitual physical activity, including activities to reduce sitting time and to increase aerobic and resistance exercise.
4. Cardiac rehabilitation for eligible patients provides significant cardiovascular benefits, including decreased morbidity and mortality outcomes.
5. Use of SGLT-2 inhibitors and GLP-1 receptor agonists are recommended for select groups of patients with chronic coronary disease, including groups without diabetes to improve outcomes.
6. Long-term beta-blocker therapy is not recommended to improve outcomes in patients with chronic coronary disease in the absence of myocardial infarction in the past year, left ventricular ejection fraction ≤50%, or another primary indication for beta-blocker therapy.
7. Either a calcium channel blocker or beta-blocker is recommended as first-line antianginal therapy.
8. Statins remain first line for lipid lowering in patients with chronic coronary disease. Several adjunctive therapies (e.g., ezetimibe, proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors, inclisiran, bempedoic acid) may be used in select populations, although clinical outcomes data are not yet available for novel agents such as inclisiran and bempedoic acid.
9. Shorter durations of dual antiplatelet therapy are safe and effective in many circumstances, particularly when the risk of bleeding is high and the ischemic risk is not high.
10. The use of nonprescription or dietary supplements, including fish oil and omega-3 fatty acids or vitamins, is not recommended in patients with chronic coronary disease given the lack of benefit in reducing cardiovascular events.
11. 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.
12. Although they increase the likelihood of successful smoking cessation, because of the lack of long-term safety data and risks of sustained use, e-cigarettes are not recommended as first-line therapy.
13. In patients with chronic coronary disease and lifestyle-limiting angina despite guideline-directed management and therapy and with significant coronary artery stenoses amenable to revascularization, revascularization is recommended to improve symptoms.
14. In patients with chronic coronary disease who require revascularization for multivessel coronary artery disease with complex and diffuse coronary artery disease (e.g., SYNTAX score >33), it is reasonable to choose coronary artery bypass grafting over percutaneous coronary intervention to improve survival.
15. Finally, studies are needed to assess which interventions lead to effective guideline implementation in clinical practice. Similarly, research is needed to assess the effect of a new guideline release at the patient, clinic, hospital, health care system, and community levels. ■