Management of Chronic Coronary Disease: Guidelines From the American College of Cardiology and American Heart Association

Approximately 20 million people in the United States live with chronic coronary disease. In 2023, the American College of Cardiology and American Heart Association released guidelines for management of chronic coronary disease, primarily for primary care physicians and cardiologists who provide care in the outpatient setting. Chronic coronary disease includes acute coronary syndrome, coronary revascularization, angina or ischemia equivalents, coronary disease diagnosed with coronary computed tomography angiography, or a positive stress test. Chronic coronary disease may be managed in the acute, postacute, or chronic setting.

Nutrition

A Mediterranean diet can reduce cardiovascular events by up to 65% in less than 4 years while improving comorbidities, including hypertension, dyslipidemia, diabetes mellitus, and obesity. Based on moderate-quality evidence, a Mediterranean-type diet emphasizing vegetables, fruits, legumes, nuts, whole grains, and lean protein is strongly recommended to reduce the risk of cardiovascular events. Trans fats, found in hydrogenated oil products, increase morbidity and mortality and should be avoided. Nonprescription supplements, including omega-3 fatty acids, are not recommended due to lack of evidence of benefit.

Exercise

Cardiac rehabilitation with aerobic exercise and resistance training is an important aspect of treatment following a recent cardiac event. Patients with chronic coronary disease and a recent cardiac event or intervention have lower all-cause and cardiovascular death when referred for cardiac rehabilitation. If there are no contraindications, patients should be encouraged to perform at least 150 minutes per week of moderate-intensity aerobic exercise or 75 minutes per week of high-intensity aerobic exercise to improve functional capacity and quality of life and reduce mortality. Sexual activity is as safe as other moderate-intensity activity. Resistance training is recommended at least 2 days per week to improve muscle strength, functional capacity, and quality of life.

Weight Management

Weight should be assessed at every appointment to help with weight loss counseling. In individuals with a body mass index of at least 27 kg per m² with weight-related comorbidities, a glucagon-like peptide-1 (GLP-1) receptor agonist may be considered if lifestyle modifications have not improved body mass index. Sympathomimetic drugs, such as phentermine, should be avoided in patients with chronic coronary disease. Individuals who are severely obese and not meeting weight loss goals with lifestyle and pharmacologic interventions may benefit from bariatric surgery.

Substance use

Due to the profound negative effect of tobacco use in patients with chronic coronary disease, discussing smoking cessation at every visit is recommended. Combining behavioral interventions with pharmacotherapy is the most effective strategy for cessation. Varenicline (Chantix) is the most effective pharmacotherapy for cessation. e-Cigarettes appear to be more effective than nicotine replacement therapy but are not recommended as first-line therapy because of the risk of long-term dependence on e-cigarettes.