Clinical Question

What are the most recent guideline recommendations for the management of chronic coronary disease in adults?

Bottom Line

Key changes in the recommendations include shortening the duration of dual antiplatelet therapy and the use of beta blockers in patients with chronic coronary disease, not recommending fish oil or omega-3 fatty acids for primary or secondary prevention, not using e-cigarettes as first-line agents for smoking cessation, and incorporating sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists for some patients with chronic coronary disease. (Level of Evidence = 1a)

Synopsis

The guideline states that recommendations are based on literature searches that focused on randomized trials and systematic reviews, but that the authors also commissioned their own systematic reviews as needed. They included 17 women, and only six authors reported consulting for relevant companies and one was on a speakers bureau. The authors helpfully summarize the 10 top take-home messages. They emphasize team-based care that considers social determinants, takes a shared decision-making approach, and emphasizes exercise and a healthy diet.

SGLT-2 inhibitors and GLP-1 receptor agonists should be considered for patients with chronic coronary disease, including those without comorbid diabetes mellitus. Long-term beta blockers are no longer routinely recommended and should be limited to patients with heart failure, myocardial infarction in the past year, or another indication. Beta blockers and calcium channel blockers are recommended as first-line agents for the treatment of chronic anginal symptoms. Dual antiplatelet therapy, similar to the use of beta blockers, should not be used for life. Dual antiplatelet therapy is recommended for one to three months after percutaneous coronary intervention in patients with a high risk of bleeding, for six months in patients with a low to moderate risk of bleeding, and for 12 months in those with prior acute coronary syndrome. Dual antiplatelet therapy is not recommended in patients without recent percutaneous coronary intervention or in those who have not had acute coronary syndrome in the past 12 months. Statins are the first-line lipid-lowering agent for patients with chronic coronary disease. Fish oil, omega-3 fatty acids, and vitamins are not recommended to reduce cardiovascular events based on a lack of benefit in randomized trials. Icosapent ethyl (Vascepa) may be considered in patients using maximally tolerated statin therapy with persistently elevated triglyceride levels. Routine surveillance using stress tests, coronary computed tomography, or angiography is not recommended in the absence of a change in symptoms or function. Finally, e-cigarettes get a qualified recommendation as second- or third-line agents for smoking cessation, but behavioral interventions combined with bupropion, varenicline (Chantix), and/or nicotine replacement remain first-line agents.

Study design: Practice guideline

Funding source: Foundation

Setting: Various (guideline)

Reference: Virani SS, Newby LK, Arnold SV, et al. 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 [published corrections appear in Circulation. 2023;148(13):e148, and Circulation. 2023;148(23):e186]. Circulation. 2023;148(9):e9-e119.

Editor's Note: Dr. Ebell is deputy editor for evidence-based medicine for AFP and cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell.