Chronic Coronary Disease: The Latest Recommendations

Neil Skolnik, MD


September 12, 2023

This transcript has been edited for clarity.

I'm Dr Neil Skolnik. Today I'm going to talk about the 2023 American College of Cardiology/American Heart Association Guideline for the Management of Patients With Chronic Coronary Disease. Now, let me emphasize, this is about patients with stable diagnosed coronary artery disease (CAD). This is not about managing acute coronary syndromes, myocardial infarction (MI), or post-acute management; those are managed by our cardiology colleagues. Patients with chronic coronary disease represent a large group — over 20 million people in the United States.

There's a lot in this guideline, so I'm going to select the parts that are most important for us in primary care. First and new in this guideline is that routine testing for ischemia (such as stress testing) is not recommended except when there is a change in symptoms or functional status. Three trials (COURAGE, ISCHEMIA, and BARI 2D) showed that in patients with stable coronary disease, there's no benefit of revascularization compared with optimal medical therapy. So, when we see patients with coronary disease, we want to make sure that their symptoms are stable and that their medical therapy is optimized.

Let's talk about what that means. Nutrition and physical activity — we often skip over these topics, but they are critically important. Mediterranean-style dietary plans can lead to a 65% reduction in composite cardiovascular outcomes like cardiac death and recurrent MI. Higher-quality carbohydrate intake, which means cutting down on highly processed carbohydrates, leads to lower cardiovascular morbidity and mortality, as does lower saturated fat intake. Now, what doesn't work when it comes to diet is fish oils, particularly omega-3 fatty acids, as well as antioxidants like vitamins C and E. Don't forget physical activity — the goal being 150-300 minutes a week of moderate to vigorous aerobic activity.

But remember, smaller amounts of activity are also helpful. All of this leads to improved functional capacity and quality of life, and a decrease in hospital admissions and mortality. Resistance training (strength training exercises) should be done 2 or more days a week, and patients should try to reduce the amount of time spent in sedentary activities.

Mental health is also important. Depression and anxiety diminish quality of life and lead to worse cardiovascular outcomes. Obviously, if someone is smoking, do your best to get them to quit.

Let's talk about lipid management. High-intensity statin therapy is recommended with the goal of 50% or more reduction in low-density lipoprotein (LDL) cholesterol. Among patients at very high risk, the goal is an LDL cholesterol level < 70 mg/dL. If a patient is not to goal on a statin, then ezetimibe can be added. If adding ezetimibe doesn't do the trick to get LDL cholesterol below 70 mg/dL, then we can consider adding a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor if further lowering is needed. After that, then the newer agents bempedoic acid or inclisiran can be considered if the patient is on maximally tolerated statin therapy.

If the fasting triglyceride level is repeatedly between 150 and 499 mg/dL, then, based on the REDUCE-IT trial, icosapent ethyl may be considered. Remember, icosapent ethyl is different from over-the-counter fish oil.

Hypertension management is important here. The blood pressure goal is < 130/80 mm Hg. Regarding some specific medications: Beta-blockers (the old staple for coronary disease) do not have a benefit in patients who have not had a previous ST segment elevation MI (STEMI) or who have a left ventricular ejection fraction < 50%. If it has been more than a year since their MI without other indications for a beta-blocker, then a beta-blocker might not be particularly helpful.

Angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) have a class 1 recommendation for patients with chronic coronary disease and hypertension or diabetes, a left ventricular ejection fraction ≤ 40%, or chronic kidney disease and a class 2b recommendation in the absence of those indications. So ACEs and ARBs are good initial choices for treatment of hypertension in people with coronary disease.

For people with diabetes and chronic coronary disease, remember that glucagon-like peptide 1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk for major adverse cardiovascular events (MACEs). Weight management is important. Excess weight accelerates atherosclerotic formation. Lots of options exist, of course. Discuss lifestyle management, diet, and exercise. A GLP-1 receptor agonist can also be considered, and the guidelines say it's reasonable to choose semaglutide over liraglutide because of its greater efficacy. Recognize that the guidelines were released before the topline results of the SELECT trial were announced, which showed that semaglutide decreased MACEs in people with chronic coronary disease and obesity. Remember, bariatric surgery can also be considered where appropriate.

The guidelines cover a lot of details about antiplatelet therapy. Sticking to those with coronary disease, but without atrial fibrillation or another reason for anticoagulation, people with coronary disease should be on low-dose aspirin (81 mg/d). If someone is post-MI or post-stent, there are lots of nuances with regard to antiplatelet therapy. Regarding length of dual-acting, dual-antiplatelet therapy, even the place of low-dose direct oral anticoagulants. These decisions will be made by our cardiology colleagues. Colchicine, the old staple for gout, which acts as an anti-inflammatory agent, is now in the guidelines with a class 2b recommendation and may be considered to reduce recurrent atherosclerotic cardiovascular disease (ASCVD) events.

Don't forget immunizations: influenza, COVID, and pneumococcal vaccines. These aren't trivial. An association has been found between respiratory infections and MIs. And in fact, there's now good evidence that influenza vaccine leads to a lower risk for MI, cardiovascular death, MACEs, and all- cause death in patients with chronic coronary disease or heart failure.

Beta-blockers, calcium-channel blockers, and long-acting nitrates are recommended for symptom relief, and ranolazine is recommended for patients who remain symptomatic on those medications. Those patients should be seeing a cardiologist to decide whether they need further evaluation for their high-risk disease.

Clinical judgment determines when to do further testing or refer patients with significant changes in either function or symptoms.

This is a lot of information. In summary:

  • Routine stress testing in patients with stable coronary disease is no longer recommended.

  • Diet and exercise are critical, are underappreciated, and make a big difference.

  • The LDL cholesterol goal is < 70 mg/dL. Don't be afraid to add a medicine to the statin.

  • Consider icosapent ethyl for triglycerides over 150 mg/dL.

  • The blood pressure target is < 130/80 mm Hg, with a preference for an ACE inhibitor or ARB as a part of the regimen.

  • Don't forget the importance of weight management.

  • For patients with diabetes, use a GLP-1 receptor agonist or an SGLT2 inhibitor to reduce CV events.

  • Don't forget about immunizations and a daily aspirin.

This is important information for a common condition. I'm interested in your thoughts; please leave them in the comments section below. I'm Neil Skolnik, and this is Medscape.

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