2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guidelines for Management of Pts wtih Chronic Coronary Disease PDF

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. -, NO. -, 2023 ª 2023 BY THE AMERICAN HEART ASSOCIATION, INC., AND THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION. PUBLISHED BY ELSEVIER. ALL R...

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. -, NO. -, 2023 ª 2023 BY THE AMERICAN HEART ASSOCIATION, INC., AND THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION. PUBLISHED BY ELSEVIER. ALL RIGHTS RESERVED CLINICAL PRACTICE GUIDELINE 2023AHA/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 Developed in Collaboration With and Endorsed by the American College of Clinical Pharmacy, American Society for Preventive Cardiology, National Lipid Association, and Preventive Cardiovascular Nurses Association Endorsed by the Society for Cardiovascular Angiography and Interventions Writing Salim S. Virani, MD, PHD, FACC, FAHA, FASPC, Chairy Fatima Rodriguez, MD, MPH, FACC, FAHA Committee L. Kristin Newby, MD, MHS, FACC, FAHA, Vice Chairy Amy W. Talbot, MPHy Members* Viviany R. Taqueti, MD, MPH, FACC, FAHA Suzanne V. Arnold, MD, MHA, FAHA Randal J. Thomas, MD, MS, FACC, FAHA Vera Bittner, MD, MSPH, FACC, FAHA, MNLAz Sean van Diepen, MD, MSC, FAHA LaPrincess C. Brewer, MD, MPH, FACC, FASPC Barbara Wiggins, PHARMD, MBA, FACC, FNLA, FCCPzz Susan Halli Demeter, DNP, FNLA, FPCNAx Marlene S. Williams, MD, FACCxx Dave L. Dixon, PHARMD, FAHA, FACC, FCCP, FNLAk William F. Fearon, MD, FAHA, FACC *Writing committee members are required to recuse themselves from Beverly Hess, MSW{ voting on sections to which their specific relationships with industry may Heather M. Johnson, MD, MS, FAHA, FACC, FASPC**# apply; see Appendix 1 for detailed information. Dhruv S. Kazi, MD, MSC, MS, FAHA, FACC yACC/AHA representative. Dhaval Kolte, MD, PHD, FACCyy zNational Lipid Association representative. xPreventive Cardiovascular Nurses Association representative. Dharam J. Kumbhani, MD, SM, FAHA, FACC kFormer Joint Committee on Clinical Practice Guideline member; current Jim LoFaso{ member during the writing effort. Dhruv Mahtta, DO, MBA {Patient representative/lay stakeholder. Daniel B. Mark, MD, MPH, FACC, FAHAk #American Society for Preventive Cardiology representative. **AHA/ACC Joint Committee on Clinical Practice Guidelines. Margo Minissian, PHD, ACNP, FAHA yyAHA/ACC Joint Committee on Clinical Data Standards. Ann Marie Navar, MD, PHD, FAHA, FACC, FASPC zzAmerican College of Clinical Pharmacy representative. Amit R. Patel, MD, FACC xxAHA/ACC Joint Committee on Performance Measures. Mariann R. Piano, RN, PHD, FAHAk Peer Review H. Vernon Anderson, MD, FAHA, FACC, Chairy Cynthia Jackevicius, BScPhm, PharmD, MSc, BCPS, BCCP, Committee Sunil V. Rao, MD, FACC, Vice Chairy FAHA, FACC, FCCPzz Members Friederike K. Keating, MD, FACC Columbus Batiste II, MD, FACC Thomas S. Metkus, MD, PhD, FACC Roger Blumenthal, MD, FAHA, FACC Leslee J. Shaw, PhD, FACC, FAHA Matthew A. Cavender, MD, MPH, FACC Chloe D. Villavaso, MN, APRN, FPCNA, AACCx Anne Carol Goldberg, MD, FNLA, FAHAz Brittany A. Zwischenberger, MD, MHS ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2023.04.003 2 Virani et al JACC VOL. -, NO. -, 2023 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline -, 2023:-–- AHA/ACC Joint Joshua A. Beckman, MD, MS, FAHA, FACC, Chair José A. Joglar, MD, FAHA, FACCk Committee on Catherine M. Otto, MD, FACC, FAHA, Chair-Elect Heather M. Johnson, MD, MS, FAHA, FACC, FASPC Clinical Practice Patrick T. O’Gara, MD, MACC, FAHA, Immediate W. Schuyler Jones, MD, FACC Guidelines Past Chairk Prateeti Khazanie, MD Michelle Kittleson, MD, PhD, FAHA Anastasia Armbruster, PharmD, FACC Daniel B. Mark, MD, MPH, FACCk Kim K. Birtcher, PharmD, MS, AACCk Debabrata Mukherjee, MD, FACC, FAHA, FSCAI Leslie L. Davis, PhD, ANP-BC, FACC, FAHA, FPCNA Latha Palaniappan, MD, MS, FAHA, FACCk Lisa de las Fuentes, MD, MS, FAHA Mariann R. Piano, RN, PhD, FAHAk Anita Deswal, MD, MPH, FACC, FAHA Tanveer Rab, MD, FACC Dave L. Dixon, PharmD, FAHA, FACC, FCCP, FNLAk Erica S. Spatz, MD, MHS, FACCk Victor A. Ferrari, MD, FACC, FAHA Jacqueline E. Tamis-Holland, MD, FACC, FAHA Bulent Gorenek, MD, FACCk Y. Joseph Woo, MD, FACC, FAHA Norrisa Haynes, MD, MPHk Boback Ziaeian, MD, PhD, FAHA Adrian F. Hernandez, MD, FAHA ABSTRACT AIM The “2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease” pro- vides an update to and consolidates new evidence since the “2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease” and the corresponding “2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease.” METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic re- views and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected da- tabases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team- based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost–value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. This document was approved by the American College of Cardiology Clinical Policy Approval Committee and the American Heart As- sociation Science Advisory and Coordinating Committee in January 2023, and the American College of Cardiology Science and Quality Committee and the American Heart Association Executive Committee in April 2023. The American College of Cardiology requests that this document be cited as follows: Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 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;xx:xx-xx. This article has been copublished in Circulation. Copies: This document is available on the websites of the American College of Cardiology (www.acc.org) and the American Heart Association (professional.heart.org). For copies of this document, please contact the Elsevier Inc. Reprint Department via fax (212-633-3820) or e-mail ([email protected]). Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (http://www.elsevier. com/about/policies/author-agreement/obtaining-permission). JACC VOL. -, NO. -, 2023 Virani et al 3 -, 2023:-–- 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline TABLE OF CONTENTS ABSTRACT...................................... - 4.3. Medical Therapy to Prevent Cardiovascular Events and Manage Symptoms...................... - TOP 10 TAKE-HOME MESSAGES................... - 4.3.1. Antiplatelet Therapy and Oral Anticoagulants........................ - PREAMBLE...................................... - 4.3.2. Beta Blockers......................... - 4.3.3. Renin-Angiotensin-Aldosterone 1. INTRODUCTION............................... - Inhibitors............................ - 4.3.4. Colchicine............................ - 1.1. Methodology and Evidence Review............ - 4.3.5. Immunizations........................ - 1.2. Organization of the Writing Committee......... - 4.3.6. Medical Therapy for Relief of Angina..... - 1.3. Document Review and Approval............... - 4.3.7. Management of Refractory Angina........ - 1.4. Scope of the Guideline....................... - 4.3.8. Chelation Therapy..................... - 1.5. Class of Recommendations and 5. REVASCULARIZATION......................... - Level of Evidence........................... - 5.1. Revascularization........................... - 1.6. Abbreviations.............................. - 5.2. Revascularization: PCI Versus CABG............ - 2. EPIDEMIOLOGY AND GENERAL PRINCIPLES...... - 6. SPECIAL POPULATIONS........................ - 3. EVALUATION, DIAGNOSIS, AND RISK 6.1. Existing Heart Diseases and Conditions......... - STRATIFICATION.............................. - 6.1.1. Chronic Management After SCAD......... - 6.1.2. Ischemia With Nonobstructive 3.1. Diagnostic Evaluation........................ - Coronary Arteries...................... - 3.2. Risk Stratification and Relationship to 6.1.3. HF With Preserved or Reduced Treatment Selection......................... - Ejection Fraction...................... - 6.2. CAD With Valvular Heart Disease.............. - 4. TREATMENT.................................. - 6.3. Young Adults.............................. - 4.1. General Approach to Treatment Decisions....... - 4.1.1. Team-Based Approach.................. - 6.4. Cancer.................................... - 4.1.2. Patient Education...................... - 6.5. Women, Including Pregnancy and 4.1.3. Shared Decision-Making................ - Postmenopausal Hormone Therapy............ - 4.1.4. Social Determinants of Health........... - 6.6. Older Adults............................... - 6.7. Chronic Kidney Disease...................... - 4.2. Guideline-Directed Management and Therapy.... - 6.8. HIV and Autoimmune Disorders............... - 4.2.1. Nutrition, Including Supplements........ - 4.2.2. Mental Health Conditions.............. - 6.9. Cardiac Allograft Vasculopathy in Heart Transplant Recipients.................. - 4.2.3. Tobacco Products..................... - 4.2.4. Alcohol and Substance Use............. - 7. PATIENT FOLLOW-UP: MONITORING AND 4.2.5. Sexual Health and Activity............. - MANAGING SYMPTOMS........................ - 4.2.6. Lipid Management.................... - 7.1. Follow-Up Plan and Testing in Stable Patients.... - 4.2.7. Blood Pressure Management............ - 4.2.8. SGLT2 Inhibitors and GLP-1 Receptor 8. OTHER IMPORTANT CONSIDERATIONS.......... - Agonists............................ - 8.1. Cost and Value Considerations................ - 4.2.9. Weight Management.................. - 4.2.10. Cardiac Rehabilitation................. - 8.2. Evidence Gaps and Areas of Future Research Needs............................. - 4.2.11. Physical Activity...................... - 4.2.12. Environmental Exposures.............. - REFERENCES................................... - 4 Virani et al JACC VOL. -, NO. -, 2023 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline -, 2023:-–- APPENDIX 1 9. Routine periodic anatomic or ischemic testing without a change in clinical or functional status is not recom- Author Relationships With Industry and Other Entities.................................. - mended for risk stratification or to guide therapeutic decision-making in patients with CCD. APPENDIX 2 10. Although e-cigarettes increase the likelihood of suc- cessful smoking cessation compared with nicotine Reviewer Relationships With Industry and replacement therapy, because of the lack of long-term Other Entities.................................. - safety data and risks of sustained use, e-cigarettes are not recommended as first-line therapy for smoking TOP 10 TAKE-HOME MESSAGES FOR CHRONIC cessation. CORONARY DISEASE PREAMBLE 1. Emphasis is on team-based, patient-centered care that considers social determinants of health along with Since 1980, the American College of Cardiology (ACC) and associated costs while incorporating shared decision- American Heart Association (AHA) have translated scien- making in risk assessment, testing, and treatment. tific evidence into clinical practice guidelines with rec- 2. Nonpharmacologic therapies, including healthy di- ommendations to improve cardiovascular health. These etary habits and exercise, are recommended for all guidelines, which are based on systematic methods to patients with chronic coronary disease (CCD). evaluate and classify evidence, provide a foundation for 3. Patients with CCD who are free from contraindications the delivery of quality cardiovascular care. The ACC and are encouraged to participate in habitual physical ac- AHA sponsor the development and publication of clinical tivity, including activities to reduce sitting time and practice guidelines without commercial support, and to increase aerobic and resistance exercise. members volunteer their time to the writing and review Cardiac rehabilitation for eligible patients provides efforts. Guidelines are official policy of the ACC and AHA. significant cardiovascular benefits, including For some guidelines, the ACC and AHA collaborate with decreased morbidity and mortality outcomes. other organizations. 4. Use of sodium glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists are recom- Intended Use mended for select groups of patients with CCD, Clinical practice guidelines provide recommendations including groups without diabetes. applicable to patients with or at risk of developing 5. New recommendations for beta-blocker use in pa- cardiovascular disease (CVD). The focus is on medical tients with CCD: (a) Long-term beta-blocker therapy is practice in the United States, but these guidelines are not recommended to improve outcomes in patients relevant to patients throughout the world. Although with CCD in the absence of myocardial infarction in guidelines may be used to inform regulatory or payer the past year, left ventricular ejection fraction #50%, decisions, the intent is to improve quality of care and or another primary indication for beta-blocker ther- align with patients’ interests. Guidelines are intended to apy; and (b) Either a calcium channel blocker or beta define practices meeting the needs of patients in most, blocker is recommended as first-line antianginal but not all, circumstances and should not replace clin- therapy. ical judgment. 6. Statins remain first line therapy for lipid lowering in patients with CCD. Several adjunctive therapies (eg, Clinical Implementation ezetimibe, PCSK9 [proprotein convertase subtilisin/ Management, in accordance with guideline recommen- kexin type 9] inhibitors, inclisiran, bempedoic acid) dations, is effective only when followed by both prac- may be used in select populations, although clinical titioners and patients. Adherence to recommendations outcomes data are unavailable for novel agents such can be enhanced by shared decision-making between as inclisiran. clinicians and patients, with patient engagement 7. Shorter durations of dual antiplatelet therapy are safe in selecting interventions on the basis of individual and effective in many circumstances, particularly values, preferences, and associated conditions and when the risk of bleeding is high and the ischemic risk comorbidities. is low to moderate. 8. The use of nonprescription or dietary supplements, Methodology and Modernization including fish oil and omega-3 fatty acids or vitamins, The AHA/ACC Joint Committee on Clinical Practice is not recommended in patients with CCD given the Guidelines (Joint Committee) continuously reviews, up- lack of benefit in reducing cardiovascular events. dates, and modifies guideline methodology on the basis of JACC VOL. -, NO. -, 2023 Virani et al 5 -, 2023:-–- 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline published standards from organizations, including the with industry and other entities (RWI) can be found at National Academy of Medicine (formerly the Institute of online. Appendix 1 of the guideline lists writing commit- Medicine),1,2 and on the basis of internal reevaluation. tee members’ comprehensive and relevant RWI; for the Similarly, presentation and delivery of guidelines are purposes of full transparency, comprehensive and reevaluated and modified in response to evolving tech- relevant disclosure information for the Joint Committee nologies and other factors to optimally facilitate dissem- is also available online. ination of information to health care professionals at the Evidence Review and Evidence Review Committees point of care. In developing recommendations, the writing committee Numerous modifications to the guidelines have been uses evidence-based methodologies that are based on all implemented to make them shorter and enhance “user available data. 4,5 Literature searches focus on randomized friendliness.” Guidelines are written and presented in a controlled trials (RCTs) but also include registries, non- modular, “knowledge chunk” format in which each randomized comparative and descriptive studies, case chunk includes a table of recommendations, a brief series, cohort studies, systematic reviews, and expert synopsis, recommendation-specific supportive text opinion. Only key references are cited. and, when appropriate, flow diagrams or additional ta- An independent evidence review committee is bles. Hyperlinked references are provided for each commissioned when there are $1 questions deemed of modular knowledge chunk to facilitate quick access and utmost clinical importance and merit formal systematic review. review to determine which patients are most likely to In recognition of the importance of cost–value consid- benefit from a drug, device, or treatment strategy, and to erations, in certain guidelines, when appropriate and what degree. Criteria for commissioning an evidence re- feasible, an assessment of value for a drug, device, or view committee and formal systematic review include intervention may be performed in accordance with the absence of a current authoritative systematic review, ACC/AHA methodology. 3 feasibility of defining the benefit and risk in a time frame To ensure that guideline recommendations remain consistent with the writing of a guideline, relevance to a current, new data will be reviewed on an ongoing basis by substantial number of patients, and likelihood that the the writing committee and staff. When applicable, rec- findings can be translated into actionable recommenda- ommendations will be updated with new evidence or new tions. Evidence review committee members may include recommendations will be created when supported by methodologists, epidemiologists, clinicians, and bio- published evidence-based data. Going forward, targeted statisticians. Recommendations developed by the writing sections/knowledge chunks will be revised dynamically committee on the basis of the systematic review are after publication and timely peer review of potentially marked “SR”. practice-changing science. The previous designations of “full revision” and “focused update” will be phased out. Guideline-Directed Management and Therapy For additional information and policies on guideline The term guideline-directed management and therapy development, readers may consult the ACC/AHA guide- (GDMT) encompasses clinical evaluation, diagnostic line methodology manual4 and other methodology arti- testing, and both pharmacological and procedural treat- cles.5-7 ments. For these and all recommended drug treatment regimens, the reader should confirm dosage with product Selection of Writing Committee Members insert material and evaluate for contraindications and The Joint Committee strives to ensure that the guideline interactions. Recommendations are limited to drugs, de- writing committee contains requisite content expertise vices, and treatments approved for clinical use in the and is representative of the broader cardiovascular com- United States. munity by selection of experts across a spectrum of Joshua A. Beckman, MD, MS, FACC, FAHA backgrounds, representing different geographic regions, Chair, AHA/ACC Joint Committee on sexes, races, ethnicities, intellectual perspectives/biases, Clinical Practice Guidelines and clinical practice settings. Organizations and profes- sional societies with related interests and expertise are 1. INTRODUCTION invited to participate as collaborators. 1.1. Methodology and Evidence Review Relationships With Industry and Other Entities The recommendations listed in this guideline are, when- The ACC and AHA have rigorous policies and methods to ever possible, evidence based. An initial extensive evi- ensure that documents are developed without bias or dence review—which included literature derived from improper influence. The complete policy on relationships research involving human subjects, published in English, 6 Virani et al JACC VOL. -, NO. -, 2023 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline -, 2023:-–- and indexed in MEDLINE (through PubMed), EMBASE, 1.2. Organization of the Writing Committee the Cochrane Library, the Agency for Healthcare Research The writing committee consisted of general cardiologists, and Quality, and other selected databases relevant to this interventional cardiologists, cardiovascular surgeons, guideline—was conducted from September 24, 2021, to cardiac imaging experts, advance practice nurses, clinical May 2022. Key search words included but were not pharmacists, health economists, and lay/patient repre- limited to the following: AHA/ACC Clinical Practice sentatives. The writing committee included representa- Guidelines; acute coronary syndrome; angina; cardiac tives from the AHA, ACC, American College of Clinical rehabilitation; cardiovascular diseases; coronary artery Pharmacy (ACCP), American Society for Preventive Car- disease; coronary disease; diabetes; type 2 diabetes; diet; diology (ASPC), National Lipid Association (NLA), and diet therapy; dietary supplements; drug therapy; dual an- Preventive Cardiovascular Nurses Association (PCNA). tiplatelet therapy; factor Xa inhibitors; hypertension; out- Appendix 1 of the current document lists writing com- comes; quality of life; secondary prevention; therapy. mittee members’ comprehensive and relevant RWI. Additional relevant studies, which were published through November 2022 during the guideline writing 1.3. Document Review and Approval process, were also considered by the writing committee This document was reviewed by 2 official reviewers each and added to the evidence tables when appropriate. The nominated by the ACC and AHA; 1 reviewer each from the final evidence tables are included in the Online Data ACCP, ASPC, NLA, PCNA, and 6 individual content re- Supplement and summarize the evidence used by the viewers. Reviewers’ RWI information was distributed to writing committee to formulate recommendations. Ref- the writing committee and is published in this document erences selected and published in the present document (Appendix 2). are representative and not all-inclusive. This document was approved for publication by the The ACC and AHA have acknowledged the importance governing bodies of the ACC and the AHA and was of value in health care to include development of cost– endorsed by the ACCP, ASPC, NLA, PCNA, and Society for value statements for clinical practice recommendations. Cardiovascular Angiography and Interventions. Available cost-effectiveness data were determined to be sufficient to support 9 specific recommendations in this 1.4. Scope of the Guideline guideline (Section 4.2.6, “Lipid Management”; Section The scope of the “2023 AHA/ACC/ACCP/ASPC/NLA/PCNA 4.2.8, “SGLT2 Inhibitors and GLP-1 Receptor Agonists”; Guideline for the Management of Patients With Chronic Section 5.1, “Revascularization”; and Section 8.1, “Cost Coronary Disease” (referred to hereafter as the “2023 CCD and Value Considerations”). As a result, a Level of Value guideline”) is to provide an update to and consolidate was assigned to those recommendations on the basis of new evidence since the publication of the “2012 ACCF/ the “ACC/AHA Statement on Cost/Value Methodology in AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diag- Clinical Practice Guidelines and Performance Measures,” 1 nosis and Management of Patients With Stable Ischemic as shown in Table 1. Available quality-of-life (QOL) data Heart Disease” 3 and the “2014 ACC/AHA/AATS/PCNA/ were deemed to be insufficient to support specific rec- SCAI/STS Focused Update of the Guideline for the Diag- ommendations in this guideline. nosis and Management of Patients With Stable Ischemic Heart Disease” and will replace these prior guidelines. 4 Level of Value for Clinical Guideline This current document provides a patient-centered TABLE 1 Recommendations* approach to management of chronic coronary disease Level of Value for Clinical Guideline Recommendations* (CCD) incorporating the principles of shared decision- Level of Value making, social determinants of health (SDOH), and High value: Better outcomes at lower cost or ICER 40 y of age). Percentages for racial and ethnic groups are age adjusted for U.S. adults $20 y of age. Estimates from NHANES 2015 to 2018 were applied to 2018 population estimates ($20 y of age). *AP is chest pain or discomfort that results from insufficient blood flow to the heart muscle. Stable AP is predictable chest pain on exertion or under mental or emotional stress. The incidence estimate is for AP without MI. AP indicates angina pectoris; CHD, coronary heart disease; CI, confidence interval; MI, myocardial infarction; and NH, non-Hispanic. Adapted with permission from Tsao CW, et al.1 Copyright 2022 American Heart Association, Inc. F I G U R E 1 U.S. Prevalence of CHD per 100,000, by Age and Sex (NHANES 2015 to 2018) CHD indicates coronary heart disease. Source: Centers for Disease Control and Prevention, National Center for Health Statistics. National Health and Nutrition Examination Survey (NHANES) public use data files. Accessed April 15, 2021. https://www.cdc.gov/nchs/nhanes/. Reprinted with permission from Tsao CW et al.1 Copyright 2022 American Heart Association, Inc. 12 Virani et al JACC VOL. -, NO. -, 2023 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline -, 2023:-–- F I G U R E 2 “Ever Told You Had Angina or CHD?” Age-Adjusted U.S. Prevalence, by State (BRFSS Prevalence and Trends Data, 2019) BRFSS indicates Behavioral Risk Factor Surveillance System; and CHD, coronary heart disease. Source: BRFSS prevalence and trends data. Reprinted with permission from Tsao CW et al.1 Copyright 2022 American Heart Association, Inc. Original figure has been modified to remove white space between map and legend. F I G U R E 3 Global Age-Adjusted Prevalence of CCD per 100,000, by Sex, 2020 CCD indicates chronic coronary disease. Modified with permission from Tsao CW et al.1 Copyright 2022 American Heart Association, Inc. Source: Data courtesy of the Global Burden of Disease Study 2020, Institute for Health Metrics and Evaluation. Used with permission. All rights reserved. Copyright ª 2021 University of Wash- ington. More information is available on the Global Burden of Disease Study website.5 JACC VOL. -, NO. -, 2023 Virani et al 13 -, 2023:-–- 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline Further, the fields of diabetes and lipid management have contemporary context, new therapies, and the intersec- evolved rapidly with multiple new therapies (eg, sodium tion between CCD and other comorbid diseases in a glucose cotransporter 2 [SGLT2] inhibitors, glucagon-like framework that recognizes the importance of shared peptide-1 [GLP-1] receptor agonists, proprotein con- decision-making, team-based care, and cost and value. vertase subtilisin/kexin type 9 [PCSK9] inhibitors, bem- pedoic acid, and inclisiran) emerging in these areas, and the range of diagnostic and interventional procedures 3. EVALUATION, DIAGNOSIS, AND available for use in patients with CCD has expanded. RISK STRATIFICATION Thus, this guideline will address established diagnostic, risk stratification, and treatment approaches in a 3.1. Diagnostic Evaluation Recommendations for Diagnostic Evaluation Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE RECOMMENDATIONS 1. In patients with CCD and a change in symptoms or functional capacity that persists despite GDMT, stress 1 B-NR positron emission tomography/single photon emission CT myocardial perfusion imaging (PET/SPECT MPI), cardiovascular magnetic resonance (CMR) imaging, or stress echocardiography is recommended to detect the presence and extent of myocardial ischemia, estimate risk of major adverse cardiovascular events (MACE), and guide therapeutic decision-making.* 1-23 2. In patients with CCD and a change in symptoms or functional capacity that persists despite GDMT, 1 B-R invasive coronary angiography (ICA) is recommended for guiding therapeutic decision-making with the goal of improving anginal symptoms.*24-28 3. In patients with CCD and a change in symptoms or functional capacity that persists despite GDMT, when 2a B-R selected for rest/stress nuclear MPI, PET is reasonable in preference to SPECT, if available, to improve diagnostic accuracy and decrease the rate of nondiagnostic test results.*29 4. In patients with CCD and a change in symptoms or functional capacity that persists despite GDMT, ex- 2a B-NR ercise treadmill testing can be useful to determine whether the symptoms are consistent with angina pectoris, assess the severity of symptoms, evaluate functional capacity, and guide management.* 26,30-32 5. In patients with CCD undergoing stress PET MPI or stress CMR imaging, the addition of myocardial blood 2a B-NR flow reserve (MBFR) can be useful to improve diagnostic accuracy and enhance risk stratification.*18-23 6. In patients with CCD and a change in symptoms or functional capacity that persists despite GDMT, and 2a B-NR who have had previous coronary revascularization, coronary CT angiography (CCTA) is reasonable to evaluate bypass graft or stent patency (for stents ‡3 mm).*33-37 *Modified from the 2021 AHA/ACC/Multisociety Guideline for the Evaluation and Diagnosis of Chest Pain.38 Synopsis AHA/ACC chest pain guideline,38 the 2021 ACC/AHA/SCAI In patients with CCD, if there is an opportunity to do so, revascularization guideline, 39 as well as Section 6.1.2 clinicians should first intensify GDMT and defer testing. In (“Ischemia With Nonobstructive Coronary Arteries”) of patients with CCD, assessing the severity of ischemia may this guideline. Additionally, cost–value considerations for be useful to guide clinical decision-making regarding the diagnostic testing contained within the 2021 AHA/ACC use of ICA and for intensification of preventive and anti- chest pain guideline, Section 5.3, should be considered.38 ischemic therapy. Imaging should be considered in those Recommendation-Specific Supportive Text with new-onset or persistent stable chest pain. In patients with CCD and frequent angina or severe stress-induced 1. Observational studies reveal that patients with mod- ischemia, referral to ICA or CCTA is an option. 26 For erate to severe ischemia on PET and SPECT MPI have an additional recommendations about known obstructive improved outcome with early coronary revasculariza- and nonobstructive CAD, suspected ischemia, ischemia tion.7,21,40-43 Clinical trials of CMR imaging that with nonobstructive coronary arteries (INOCA), role of included subgroups of patients with obstructive CAD, invasive testing, and revascularization, refer to the 2021 showed comparable diagnostic accuracy to stress 14 Virani et al JACC VOL. -, NO. -, 2023 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline -, 2023:-–- SPECT MPI.10,11 Several large, multicenter registries Therefore, in patients with CCD with known anat- revealed that stress CMR imaging effectively risk omy and ongoing angina despite GDMT, early inva- stratifies patients with known CAD.14-17 In a multi- sive angiography and revascularization should be center registry of 2,496 patients with a history of CAD, considered to improve symptoms. Notably, second- an abnormal stress CMR image was associated with a ary analyses of RCTs have reported no differences in nearly 2-fold increased mortality hazard.14 Registry major adverse cardiovascular outcomes in medical data also reported that patients with chest pain syn- versus invasive medical treatment strategies in pa- drome with ischemia by MPI and scarring by late tient with CCD 49 when stratified by ischemia severity gadolinium enhancement had a relative hazard of 1.5 on noninvasive testing. to 2.1 for cardiovascular death or nonfatal MI. 17 3. The improved diagnostic accuracy of PET MPI is help- Prognosis worsens for patients by the extent and ful in patients with known CAD. In a randomized trial severity of inducible wall motion abnormalities on of 322 symptomatic patients with known CAD, the stress echocardiography. 44,45 Recent randomized trial presence of low- and high-risk stress PET findings was evidence supports the role of stress echocardiography associated with lower and higher rates of ICA when to guide clinical decision-making. From the ORBITA compared with SPECT MPI (P¼0.001).29 (Objective Randomized Blinded Investigation With 4. Observational studies of patients with CAD and stable Optimal Medical Therapy of Angioplasty in Stable chest pain have shown that exercise treadmill testing Angina) trial, a secondary outcome was a greater can be useful by evaluating the relation of symptoms to reduction in the stress echocardiographic wall motion graded stress testing, thereby helping to confirm the score among patients with single-vessel CAD treated diagnosis of angina pectoris; assessing symptom with percutaneous coronary intervention (PCI) severity; and selecting appropriate management (eg, compared with placebo (P50%) left main disease.5-7,10,11 *Modified from the 2021 AHA/ACC/Multisociety Guideline for the Evaluation and Diagnosis of Chest Pain.12 Synopsis Potential Features Associated With a Higher Risk TABLE 5 In patients with CCD, the results of noninvasive or of MACE Among Patients With Established CCD invasive testing alone are insufficient to accurately risk Demographics and Socioeconomic Status (also see Section 4.1.4, stratify an individual’s annual future risk of future car- “Social Determinants of Health”) diovascular death or nonfatal MI.13 Clinicians should Age integrate cardiovascular test results with demographic, Male sex social, and medical variables (Table 5) and use validated Poor social support risk prediction models (where available) to estimate the Poverty or lack of health care access annual cardiovascular risk. Although multiple randomized Past or Concurrent Medical, Mental Health Conditions trials have shown that routine revascularization does not Elevated body mass index lead to a reduction in MACE, a symptom and integrated risk Previous MI, PCI, or CABG assessment may help identify subsets of patients, such as HF those with persistent angina, reduced LV function or HF, 5-8,14 Atrial fibrillation or flutter who may benefit from routine revascularization. Diabetes Recommendation-Specific Supportive Test Dyslipidemia Chronic kidney disease 1. Noninvasive test results alone are insufficient to Current or former smoker adequately risk stratify patients with CCD, and the 4 Peripheral artery disease additional information improves risk prediction. In an externally validated study of patients who underwent Depression an exercise stress testing, the Duke Treadmill Score Poor adherence with goal-directed pharmacotherapy alone had a c-index of 0.62 for all-cause death, but the Ancillary Cardiac Testing or Imaging addition of clinical variables into an integrated risk Inability to exercise score improved discrimination (c-index¼0.83) and Angina with stress reclassified 64% of low-risk Duke Treadmill Score ECG: left bundle branch block, left ventricular hypertrophy, higher resting heart scores to intermediate or high risk. 1 Externally vali- rate dated risk scores lack some functional and anatomic Echocardiography: reduced left ventricular ejection fraction, left ventricular hypertrophy testing modalities, but observational studies and sec- ondary analyses from randomized trials consistently Continued on the next page 16 Virani et al JACC VOL. -, NO. -, 2023 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline -, 2023:-–- TABLE 5 Continued nonfatal MI between revascularization with PCI and optimal medical therapy. The BARI-2D trial random- EST: higher DTS, higher resting heart rate, achieved heart rate