Clinical Update

ADAPTED FROM:

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline

for the Management of Patients With
Chronic Coronary Disease
 CLASS (STRENGTH) OF RECOMMENDATION LEVEL (QUALITY) OF EVIDENCE‡

Table 1. CLASS 1 (STRONG) Benefit >>> Risk LEVEL A

Applying Class of Suggested phrases for writing recommendations:

• Is recommended
• Is indicated/useful/effective/beneficial
• High-quality evidence‡ from more than 1 RCT
• Meta-analyses of high-quality RCTs
• One or more RCTs corroborated by high-quality registry studies
Recommendation and • Should be performed/administered/other
• Comparative-Effectiveness Phrases†: LEVEL B-R (Randomized)

Level of Evidence to − Treatment/strategy A is recommended/indicated in preference to treatment B

− Treatment A should be chosen over treatment B
• Moderate-quality evidence‡ from 1 or more RCTs
• Meta-analyses of moderate-quality RCTs

Clinical Strategies, CLASS 2a (MODERATE) Benefit >> Risk LEVEL B-NR (Nonrandomized)
Suggested phrases for writing recommendations:
Interventions, • Is reasonable
• Can be useful/effective/beneficial
• Moderate-quality evidence‡ from 1 or more well-designed, well-executed
nonrandomized studies, observational studies, or registry studies
• Meta-analyses of such studies
Treatments, or • Comparative-Effectiveness Phrases†:
− Treatment/strategy A is probably recommended/indicated in preference to LEVEL C-LD (Limited Data)
Diagnostic Testing in treatment B
− It is reasonable to choose treatment A over treatment B • Randomized or nonrandomized observational or registry studies with
limitations of design or execution
Patient Care CLASS 2b (Weak)
Suggested phrases for writing recommendations:
Benefit ≥ Risk • Meta-analyses of such studies
• Physiological or mechanistic studies in human subjects

(Updated May 2019)* • May/might be reasonable

• May/might be considered
LEVEL C-EO (Expert Opinion)
• Usefulness/effectiveness is unknown/unclear/uncertain or not well-established • Consensus of expert opinion based on clinical experience.

CLASS 3: No Benefit (MODERATE) Benefit = Risk

•COR and LOE are determined independently (any COR may be paired with any LOE).
Suggested phrases for writing recommendations: •A recommendation with LOE C does not imply that the recommendation is weak. Many
• Is not recommended important clinical questions addressed in guidelines do not lend themselves to clinical
• Is not indicated/useful/effective/beneficial trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a
particular test or therapy is useful or effective.
• Should not be performed/administered/other
•*The outcome or result of the intervention should be specified (an improved clinical
CLASS 3: Harm (STRONG) Risk > Benefit outcome or increased diagnostic accuracy or incremental prognostic information).
• †For comparative-effectiveness recommendation (COR 1 and 2a; LOE A and B only),
Suggested phrases for writing recommendations: studies that support the use of comparator verbs should involve direct comparisons of
the treatments or strategies being evaluated.
• Potentially harmful
• Causes harm •‡The method of assessing quality is evolving, including the application of standardized,
widely-used, and preferably validated evidence grading tools; and for systematic
• Associated with excess morbidity/mortality reviews, the incorporation of an Evidence Review Committee.
• Should not be performed/administered/other
•COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE,
Level of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled
trial.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation.
Chronic Coronary Disease
Guidelines apply to the following categories of
Definition:
patients in the outpatient setting

Discharged after an LV systolic Stable angina (or Angina symptoms and Diagnosed based
ACS event or after dysfunction and ischemic equivalents evidence of coronary solely on results of a
coronary known or suspected such as dyspnea or arm vasospasm or screening study (stress
revascularization CAD or with pain with exertion) microvascular angina. test, CTA), and treating
procedure and after established medically managed clinician concludes the
stabilization of all cardiomyopathy of with/without positive patient has CAD.
acute CV issues. an ischemic origin. imaging test results.

Abbreviations: ACS indicates acute coronary syndrome; CAD, coronary artery disease; CHD, coronary heart disease; CKD, chronic kidney
disease; CTA, computed tomography angiography; CV, cardiovascular; HLD, hyperlipidemia; and LV, left ventricular.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 3
Epidemiology
United States Heart Disease Prevalence, by Age, Race, Ethnicity, and Sex, 2015–2018
Prevalence of CHD 2015-2018 ≥20 y Prevalence of AP 2015-2018 ≥20 y Prevalence of MI 2015-2018 ≥20 y

6% 8% 3%
17% 16%
10% 7% 12% 20%

10%
13% 12% 15% 14%
9%

14% 14% 12% 17%

12%
18%
14% 16% 11%

• NH White men have the highest prevalence of CHD, MI and AP

Summary: • NH Black women have a prevalence of AP which is equal to that of NH White men
• NH Asian women have the lowest prevalence of CHD, AP, and MI

Abbreviations: AP indicates angina pectoris; CHD, coronary heart disease; MI, myocardial infarction; NH, non-Hispanic; and y, years.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 4
Prevalence of CCD in 2020

Worldwide Nationwide
Highest Prevalence Lowest Prevalence • Highest in the southern
1. Northern Africa 1. Canada region of the US
2. Middle East 2. Northern Europe • CCD increases with age and
3. Eastern 3. Western coast of highest in males except in
Mediterranean South America 20 to 39 y range

Abbreviations: CCD indicates chronic coronary disease; US, United States; and y, years.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 5
Evaluation of CCD

In stable CCD with change in symptoms or functional capacity

that persists despite GDMT

PET/SPECT MPI, When selected for Exercise treadmill CCTA is reasonable to

CMR or Stress ICA to guide rest/stress nuclear MPI, testing can be useful evaluate bypass graft or
Echocardiogram to decision-making and PET is reasonable in for evaluation of stent patency in those
improve diagnostic improve symptoms preference to SPECT to symptoms and who have had previous
accuracy (Class 1) improve diagnostic functional capacity coronary revascularization
(Class 1) accuracy (Class 2a) (Class 2a) (Class 2a)

MBFR can be useful to improve diagnostic accuracy and enhance risk stratification with stress PET, MPI or CMR
(Class 2a)

Abbreviations: AP indicates angina pectoris; CCD, chronic coronary disease; CCTA, coronary computed tomography angiography; CMR, cardiovascular magnetic resonance; GDMT,
guideline-directed medical therapy; ICA, invasive coronary angiography; MACE, major adverse cardiovascular events; MBFR, myocardial blood flow reserve; mm, millimeter;
MPI, myocardial perfusion imaging; PET, positron emission tomography; and SPECT, single-photon emission computed tomography.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 6
Risk Stratification and Relationship to Treatment Selection in
Patents with CCD
Risk Stratification requires incorporating
the following: (Class 1) Treatment Selection

Demographic variables Optimize GDMT (Class 1)

Social variables ICA to assess coronary anatomy and revascularization

potential with newly LVEF and/or HF (Class 1)
Medical variables

Validated risk scores ICA is not routinely recommended without LV systolic

(where available) dysfunction, HF, stable CP refractory to GDMT, and/or
noninvasive testing indicating significant LM disease.
Noninvasive cardiac (Class 3: No benefit)
diagnostic testing
Invasive cardiac diagnostic
testing results (if available)

Abbreviations: CCD indicates chronic coronary disease; CP, chest pain; GDMT, guideline-directed medical therapy; HF, heart failure; ICA, invasive coronary
angiography; LM, left main; LV, left ventricular; LVEF, left ventricular ejection fraction; and MACE, major adverse cardiovascular event.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 7
Features Associated with a Higher Risk of MACE in
CCD

Demographics & Medical History

Socioeconomic status • Elevated BMI • CKD
• Age • Previous MI ± • Smoking history
• Male sex intervention • PAD
• Poor social support • HF • Depression
• Poverty • AF • Poor adherence
• Lack of health care access • DM to therapy
• Dyslipidemia

Abbreviations: AF indicates atrial fibrillation; BMI, body mass index; CCD, chronic coronary disease; CKD, chronic kidney disease; DM,
diabetes mellitus; HF, heart failure; MACE, major adverse cardiovascular event; and PAD, peripheral artery disease.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 8
Features Associated with a Higher Risk of MACE in
CCD

Biomarkers CV Diagnostic Testing

• High-sensitivity • Inability to exercise TID with stress, reduced CFR, ischemic
troponin • Angina with stress ECG changes with stress
• B-type natriuretic • ECG: LBBB, LVH, high resting HR • Higher calcium score
peptide • Echo: reduced LVEF, LVH • CCTA: total plaque burden, high-risk
• EST: high DTS, high resting HR, achieve HR plaque, reduced CT-fractional flow reserve
<85% predicted • CMR: reduced LVEF and/or RVEF, LVH,
• Stress echo (exercise or dobutamine): scar or infarct, reduced myocardial
high DTS, low exercise workload, peak perfusion reserve and blood flow at stress
rate-pressure product < 15,000, CFR < 2,
no change or increase in LVESV; reduced
LVEF, ischemic ECG changes with stress
• SPECT/PET: % fixed myocardium (SPECT),

Abbreviations: AF indicates atrial fibrillation; CCD, chronic coronary disease; CCTA, coronary computed tomography angiography; CFR, coronary flow reserve; CKD, chronic
kidney disease; CMR, cardiovascular magnetic resonance; CT, computed tomography; DTS, Duke Treadmill Score; echo, echocardiogram; ECG, electrocardiogram; EST,
exercise stress test; HR, heart rate; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; LVESV, left ventricular end systolic volume; LVH, left ventricular
hypertrophy; MACE, major adverse cardiovascular event; PET, positron emission tomography; RVEF, right ventricular ejection fraction; SPECT, single-photon emission
computed tomography; and TID, transient ischemic dilation.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 9
General Approach to CCD Treatment Decisions
Goals of Treatment Treatment Domains

Cardiac Death

Nonfatal
Ischemic Events

Disease Progression

Symptoms and Functional

Limitations

Abbreviations: CCD indicates chronic coronary disease; CV, cardiovascular; SDOH, social determinants of health;
and QOL, quality of life.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 10
Patient Education and Shared Decision Making

Patient Education Shared Decision Making

Patients with CCD should receive ongoing individualized
education on symptom management, lifestyle changes, Shared decision making when evidence is unclear or
and SDOH risk factors to improve knowledge and facilitate significant risk or benefit tradeoff. (Class 1)
behavior change. (Class 1)
Consider validated decision aid to improve understanding
Patients with CCD should receive ongoing individualized and knowledge. (Class 2b)
education on medication adherence to improve knowledge
and facilitate behavior change. (Class 1)

Abbreviations: CCD indicates chronic coronary disease; and SDOH, social determinants of health.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 11
Social Determinants of Health*
Healthcare System Education/ Health Literacy

Economic
Systemic Racism Stability

Gender Considerations
&/or Sexual Orientation
Physical Environment

Social Support Culture & Language

*Adapted from Figure 6 in guideline document.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 12
Nutrition for a Healthy Heart

Choose These Instead of These AVOID TRANS FAT

• Vegetables, fruit • Saturated fat • Baked goods
(≤6% of daily calories) • Fried foods with
• Legumes, nuts
• Whole grains • Dietary sodium hydrogenated
(1500-<2300 mg/day) oil/shortening
• Lean protein • Processed meat
• Complex carbohydrates (eg, cured hot dogs)
• Dietary fiber • Refined carbohydrates In patients with CCD, the use of
(eg, white rice) nonprescription or dietary supplements,
• Monounsaturated fat
(≤20% of daily calories; • Sugar-sweetened beverages including omega-3 fatty acid, vitamins C,
eg, olive oil) (eg, sugar-added soft drinks, fruit D, E, beta-carotene, and calcium, is not
drinks) beneficial to reduce the risk of acute CVD
• Polyunsaturated fat (≤10%
of daily calories; e • Alcoholic beverages events.
g, salmon) (Class 3: No Benefit)

Abbreviations: CCD indicates chronic coronary disease; CVD, cardiovascular disease; and mg, milligram.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 13
Screen and Treat Mental Health Conditions

Screen for depression. Assess psychological health.

In patients with CCD, targeted discussions and screening for In patients with CCD, treatment for mental health conditions with
mental health is reasonable for clinicians to assess and to refer for either pharmacologic or nonpharmacologic therapies, or both, is
additional mental health evaluation and management. (Class 2a) reasonable to improve cardiovascular outcomes. (Class 2a)

More than Well-being

Over the past 2 weeks, how often have you Not at Several Nearly Question
half the parameter
been bothered by the following problems? all days every day
days Health-related
Little interest or pleasure in doing things 0 1 2 3 How do you think things will go with your health moving forward?
optimism
Feeling down, depressed, or hopeless 0 1 2 3
Positive affect How often do you experience pleasure or happiness in your life?
Total score of ≥3 warrants further assessment for depression.
Do you ever feel grateful about your health? Do you ever feel grateful about
Gratitude
other things in your life?

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 14
Tobacco Cessation

Treat with:
• Behavioral interventions
Assess for tobacco smoking at every health visit and if
• Pharmacotherapy (bupropion, varenicline)
smoking, advise to quit. (Class 1)
• Nicotine replacement therapy
(Class 1)

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 15
Alcohol and Substance Use in Patients with CCD

Routinely ask and counsel about substance use Limit alcohol intake
(Class 1) (Class 2a)

Cocaine,
methamphetamine
≤1 drink/day

Opioids

≤2 drink/day

Marijuana

Abbreviation: CCD, chronic coronary disease.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 16
Counsel about Sexual Health

Individualize resumption of sexual

Cardiac rehabilitation and regular Phosphodiesterase type 5
activity based on:
exercise reduces the risk of inhibitors should not be used
• Type of sexual activity
cardiovascular complications with concomitantly with nitrate
• Exercise capacity
sexual activity* medications.
• Postprocedural healing
(Class 2a) (Class 2a) (Class 3:Harm)

*Note: Sexual activity is 3-5 metabolic equivalents.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 17
 Chronic Coronary Disease: Lipid management
Patients with CCD

Healthy Lifestyle
Not at Very High Risk Very High Risk

High-intensity statin (Goal: ↓ LDL-C ≥50%) (Class 1) High-intensity or maximal statin (Class 1)

If on maximal tolerated statin

If on maximal If on maximal tolerated statin and Dashed arrow indicates
If high-intensity statin and LDL-C ≥70 mg/dL, adding
tolerated statin and LDL-C < 100 mg/dL with a persistent RCT-supported efficacy,
not tolerated, use *ezetimibe can be beneficial
LDL-C ≥70 mg/dL, fasting TG level of 150-499 mg/dL, but is less cost effective
moderate-intensity (Class 2a)
*ezetimibe may be after addressing secondary causes,
statin
reasonable icosapent ethyl may be considered
(Class 1)
(Class 2b) (Class 2b)
If judged to be on maximal LDL-C lowering therapy and LDL-C ≥70
mg/dL, or non-HDL-C ≥100 mg/dL, a *PCSK9 monoclonal
antibody can be beneficial to further reduce risk of MACE (Class
*secondary causes include medications, diabetes and lifestyle
2a)

Abbreviations: ACS indicates acute coronary syndrome; ASCVD, atherosclerotic cardiovascular disease; CABG, coronary artery bypass grafting; CCD, chronic
coronary disease; eGFR, estimated glomerular filtration rate in ml/min/1.73 m2; LDL-C, low density lipoprotein-C; MACE, major adverse cardiovascular
event; mg/dL, milligrams per deciliter; MI, myocardial infarction; PAD, peripheral artery disease; PCI, percutaneous coronary intervention; PCSK9,
proprotein convertase subtilisin/kexin type 9; RCT, randomized clinical trials; and TG, triglycerides.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 18
Chronic Coronary Disease: BP Management

Elevated blood pressure Hypertension

SBP 120-129 mm Hg and SBP > 130 mm Hg or
DBP <80 mmHg DBP > 80 mm Hg

Nonpharmacologic (Class 1) Pharmacologic (Class 1)

• Weight loss • ACE inhibitor/ARB or beta-
• Heart-healthy (DASH) diet blocker* if compelling indication
• Reduce dietary sodium <1500 mg/d present†
• Physical activity • Add CCB, long-acting thiazide or
• Reduction or elimination of alcohol MRA if not at goal

*Beta-blockers include carvedilol, metoprolol tartrate, metoprolol succinate, nadolol, bisoprolol, propranolol, timolol
†CCD with recent MI or ongoing angina

Abbreviations: ACE indicates angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; BP, blood pressure; CCB, calcium
channel blocker; DASH, Dietary Approaches to Stop Hypertension; DBP, diastolic blood pressure; MI, myocardial infarction;
MRA, mineralocorticoid receptor antagonist; and SBP, systolic blood pressure.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 19
Chronic Coronary Disease: SGLT2 and GLP-1

Type 2 diabetes Heart failure (± diabetes)

GLP-1 LVEF ≤ 40% LVEF > 40%

SGLT2 Inhibitors
Receptor Agonists
(Class 1)
(Class 1)
SGLT2 Inhibitors SGLT2 Inhibitors
(Class 1) (Class 2a)

Abbreviations: GLP-1 indicates glucagon-like peptide-1; LVEF, left ventricular ejection fraction; and SGLT2, sodium glucose transporter 2.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 20
Weight management in Patients with CCD
MEASURE COUNSEL TREAT AVOID

• Dietary modification If pharmacologic therapy is warranted Use of sympathomimetic

• Physical activity for further weight reduction, a GLP-1 weight loss drugs is potentially
Assess during routine clinical follow-up • Behavioral counseling (Class 1) receptor agonist can be beneficial in harmful.
Overweight BMI 25 – 29.9 kg/m2 addition to counseling for diet and (Class 3:Harm)
Obese BMI ≥ 30 kg/m2 physical activity, and it is reasonable to
Severe obesity BMI ≥40 kg/m2 or BMI choose semaglutide over liraglutide
35-39.9 kg/m2 with a weight-related (Class 2a)
comorbidity

Central obesity waist circumference

>102 cm (men) or >88 cm (women) In severe obesity in which weight loss
goals have not been met, referral for
(Class 1) consideration of a bariatric procedure
is reasonable for weight loss and CV
risk factor reduction. (Class 2a)

Abbreviations: BMI indicates body mass index; CCD, chronic coronary disease; cm, centimeter; CV, cardiovascular;
GLP-1, indicates glucagon-like peptide-1; and kg/m2, kilogram per meters squared.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 21
Cardiac Rehabilitation programs

Refer CCD patients with:

• Recent MI, PCI, CABG
• Recent SCAD
• Stable angina
• Heart transplant

(Class 1)

Taylor et al. Nature Reviews Cardiology. 2022

Abbreviations: CABG indicates coronary artery bypass graft; CCD, chronic coronary disease; MI, myocardial infarction;
PCI, percutaneous coronary intervention; and SCAD, spontaneous coronary artery dissection.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 22
Environmental Exposure

Minimize exposure to ambient air pollution Minimize exposure to extreme temperatures and
(Class 2a) wildfire smoke (Class 2b)

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 23
 Recommendations for Antiplatelet therapy without OAC

Patients with CCD + PCI Patients with CCD

COR RECOMMENDATIONS COR RECOMMENDATIONS
DAPT (Aspirin and clopidogrel) for 6 months post PCI If no indication for OAC, low dose aspirin 81mg
1 1
followed by SAPT (75mg-100mg) recommended
If patient also has drug eluting stent, and completed 1-3 + previous MI and at low bleeding risk, extended DAPT (12
2b
2a months of DAPT, use of P2Y12 inhibitor monotherapy ( for months- 3 yrs) may be reasonable to reduce MACE
least 12 months)
+ history of MI (w/out stroke, TIA, ICH) vorapaxar
2b
may be added to aspirin therapy to reduce MACE.
Patients with CCD + Stroke/TIA/ICH history 2b
Use of DAPT after CABG may be useful to reduce
the incidence of saphenous vein graft occlusion.
COR RECOMMENDATIONS
w/o recent ACS or a PCI-related indication for DAPT, the
Prasugrel should not be used due to risk of 3: No
3: Harm addition of clopidogrel to aspirin therapy is not useful to
significant/fatal bleed Benefit
reduce MACE.
Vorapaxar should not be added to DAPT Chronic NSAID’s should not be used because of increased
3: Harm 3: Harm
(increased risk of major bleed/ICH) cardiovascular & bleeding complications

Abbreviations: CABG indicates coronary artery bypass graft; CCD, chronic coronary disease; DAPT, dual antiplatelet therapy; ICH, intracranial hemorrhage;
NSAID, non-steroidal anti-inflammatory drug; MACE, major adverse cardiac event; MI, myocardial infarction; OAC, oral anticoagulant; PCI,
percutaneous coronary intervention; SAPT, singe antiplatelet therapy; TIA, transient ischemic attack; and yrs, years.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 24
 Recommendations for Antiplatelet therapy with OAC
With elective PCI
Those who require oral anticoagulant
therapy, DAPT for 1 to 4 weeks followed by
clopidogrel alone for 6 months should be Antiplatelet therapy and
administered in addition to DOAC. †
(Class 1)
Low dose DOAC

Patients with CCD without an indication

for therapeutic DOAC or DAPT
High risk of recurrent ischemic events + low-to-moderate
With PCI bleeding risk  Adding low dose Rivaroxaban 2.5 mg twice
If no acute indication for daily to aspirin 81 mg daily  Reasonable for long term
concomitant antiplatelet  Patients with CCD If High thrombotic risk + Low
bleeding risk  reduction of risk for MACE (Class 2a)
Consider DOAC monotherapy and oral
anticoagulation Continuing aspirin and
(Class 2b) clopidogrel for up to 1 month is
reasonable*
(Class 2a)
DAPT and PPI

With Low Atherothrombotic Risk *

Patients with CCD on DAPT  PPI can be effective in reducing
Discontinuation of Aspirin
GI bleeding risk.* (Class 2a)
and continuation of DOAC Monotherapy
may be considered 1 year after PCI to reduce bleeding
risk *Modified from the 2016 ACC/AHA Guideline Focused Update on DAPT
(Class 2b) †Modified from the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.

Abbreviations: CCD indicates chronic coronary disease; DAPT, dual anti-platelet therapy; DOAC, direct oral anticoagulant; MACE, major adverse coronary event; OAC, oral
anticoagulants; PCI, percutaneous coronary intervention; and PPI, proton pump inhibitors.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 25
Recommended Duration of Antiplatelet Therapy*†

*Colors correspond to Class of

Recommendation in Table 1.

†This figure does not encompass all

recommendations within
this section.

Abbreviations: ACS indicates acute coronary syndrome; ASA, aspirin; CCD, chronic coronary disease; DAPT, dual antiplatelet therapy;
DES, drug-eluting stent; DOAC, direct oral anticoagulants; MI, myocardial infarction; OAC, oral anticoagulants; PCI, percutaneous
coronary intervention; and SAPT, single antiplatelet therapy.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 26
Recommendations for Beta-Blockers

Patients with CCD

If LVEF ≤40% +/- If on Beta Blocker therapy without history of Mi with If No Previous MI or
If LVEF <50%
Previous MI or without a history of EF ≤50%, Angina, LVEF ≤50%
(Class 1)
(Class 1) Arrhythmias, Uncontrolled Hypertension (Class 2b) (Class 3: No Benefit)

The use of sustained release

Treatment with beta- Beta-blocker therapy is not
metoprolol succinate,
blocker is recommended to Reassess long-term beneficial in reducing MACE,
carvedilol, or bisoprolol +
reduce the risk of future (>1 year) without another primary
titration to target doses is
MACE, including use of beta-blocker therapy for reducing MACE indication for beta-blocker
recommended over other
cardiovascular death therapy
beta-blockers

Abbreviations: CCD indicated chronic coronary disease; EF, ejection fraction; LVEF, left ventricular ejection fraction; MACE, major
adverse cardiovascular event; and MI, myocardial infarction.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 27
 Recommendations for
Recommendations
Renin-Angiotensin-Aldosterone
for Colchicine
Inhibitors

Patient’s with CCD Inflammation Development

of Atherosclerosis

With hypertension,
Without hypertension,
diabetes, LVEF ≤40%, or
diabetes, or CKD and LVEF
CKD, the use of ACE The addition of colchicine for Secondary
>40%, the use of ACE
inhibitors, or ARBs if ACE Prevention may be considered to reduce recurrent
inhibitors or ARBs may be
inhibitor–intolerant, is ASCVD events
considered to reduce
recommended to reduce (Class 2b)
cardiovascular events
cardiovascular events
(Class 2b)
(Class 1)

Abbreviations: ACE indicates angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; ASCVD, atherosclerotic
cardiovascular disease; CCD indicated chronic coronary disease; CKD, chronic kidney disease; LVEF, left ventricular
ejection fraction; MACE, major adverse cardiovascular event; and MI, myocardial infarction.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 28
Immunizations in Patients with CCD

COR RECOMMENDATIONS

1 Annual influenza vaccination is recommended

1 COVID-19 vaccination is recommended

2a Pneumococcal vaccine is reasonable

Abbreviation: CCD indicates chronic coronary disease.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 29
Medical Therapy For Angina in patients with CCD

Beta blocker, CCB or long-acting nitrate is

recommended for angina relief.
(Class 1)
Sublingual nitroglycerin or nitroglycerin spray
is recommended for immediate
short-term relief. (Class 1)

If symptoms continue, add a second

antianginal agent from a different class (beta
blockers, CCB, long-acting nitrates). (Class 1)
Adding ivabradine to standard
anti-anginal therapy is potentially harmful in
those with normal LV function.
(Class 3: Harm)
Ranolazine is recommended in patients who
remain symptomatic. (Class 1)

Abbreviations: CCB indicates calcium channel blocker; CCD, chronic coronary disease; and LV, left ventricular.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 30
Revascularization in CCD
CCD + Anginal Symptoms Principles of CCD
Management in patients
Maximize GDMT (Class 1)
with Stable Angina
Continued lifestyle limiting symptoms
Relief of symptoms
Consider Revascularization (Class 1)

Prevention of
Special considerations non-fatal events
Complex coronary disease
LVEF<35% or LM disease & complex clinic/social
situation Intermediate disease
on LHC Improve long-term
survival
CABG unless poor surgical Multidisciplinary Heart
FFR/iFR prior to PCI
candidate Team evaluation
(Class 1)
(Class 1) (Class 1)

Abbreviations: CABG indicates coronary artery bypass graft; CCD, chronic coronary disease; FFR, fractional flow reserve; GDMT,
guideline direction medical therapy; iFR, instantaneous wave-free ratio; LHC, left heart catheterization; LM, left main; LVEF,
left ventricular ejection fraction; and PCI, percutaneous coronary intervention.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 31
Revascularization: PCI Versus CABG

Patients with CCD requiring

revascularization

CABG if… PCI if…

Left Main involvement with

Poor surgical candidate
high-complexity CAD (Class
(Class 2a)
1)

DM with multivessel
DM with LM stenosis and
disease & LAD involvement
low- to intermediate-
(Class 1)
complexity CAD
Multivessel disease with (Class 2b)
SYNTAX score >33
(Class 2a)

Abbreviations: CABG indicates coronary artery bypass graft; CAD, coronary artery disease; CCD, chronic coronary disease; DM, diabetes mellitus; LAD, left anterior
descending artery; LM, left main; PCI, percutaneous coronary intervention; and SYNTAX, Synergy Between PCI with TAXUS and Cardiac Surgery.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 32
Special Populations: Spontaneous Coronary Artery
Dissection

Spontaneous Coronary Artery Dissection

COR RECOMMENDATIONS

Counseling should be provided regarding potential

1 triggers and risk of SCAD recurrence.

Evaluation for underlying vasculopathies is reasonable to

2a identify abnormalities in other vascular beds.

Beta-blocker therapy may be reasonable to reduce

2b incidence of recurrent SCAD.

Abbreviation: SCAD indicates spontaneous coronary artery dissection.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 33
Special Populations: Nonobstructive Coronary Arteries and
Microvascular Angina
Microvascular angina Ischemia with Nonobstructive Coronary Arteries

A strategy of stratified medical therapy guided by invasive coronary physiologic

Definitive Suspected
testing can be useful for improving angina severity and quality of life. (Class 2a)
All 4 criteria from Criteria 1 + 2 met,
table below met but only 3 OR 4

Clinical Criteria for Suspecting Microvascular Angina

CRITERIA EVIDENCE DIAGNOSTIC PARAMETERS
1 Symptoms of myocardial ischemia Effort or rest angina; exertional dyspnea

Absence of obstructive CAD (<50%

2 diameter reduction or FFR >0.80)
Coronary CTA; invasive coronary angiography

Objective evidence of myocardial Ischemic ECG changes during an episode of chest pain; stress-induced chest pain and/or ischemic ECG changes in the
3 ischemia presence of absence of transient/reversible abnormal myocardial perfusion and/or wall motion abnormality

Impaired coronary flow reserve (cut-off value depending on methodology between ≤0.20 and ≤0.25); coronary microvascular
Evidence of impaired coronary spasm, defined as reproduction of symptoms, ischemic ECG shifts but no epicardial spasm during acetylcholine testing;
4 microvascular function abnormal coronary microvascular resistance indices (eg, IMR >25); coronary slow flow phenomenon, defined as TIMI frame
count >25

Abbreviations: CAD indicates coronary artery disease; CFR, coronary flow reserve; CTA, computed tomographic angiography; ECG,
electrocardiogram; FFR, fractional flow reserve; and IMR, index of microcirculatory resistance.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 34
Special Populations with CCD:
Young Adults and Cancer

Young Adults Cancer

A strategy of stratified medical therapy guided by Multi-disciplinary team including cardiology and
invasive coronary physiologic testing can be useful oncology expertise is recommended to improve
for improving angina severity and quality of life long-term cardiovascular disease outcomes (Class
(Class 2a) 1)

Abbreviation: CCD, chronic coronary disease.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 35
Special Populations with CCD: Women, Including Pregnancy
and Postmenopausal Hormone Therapy
Pregnancy
Postmenopausal
COR RECOMMENDATIONS Hormone Therapy
Risk-stratify and counsel regarding risks of adverse COR RECOMMENDATIONS
1 maternal, obstetric, and fetal outcomes. Women should not receive systemic
postmenopausal hormone therapy because
Multi-disciplinary cardio-obstetric care team involvement 3: Harm of lack of benefit on MACE and mortality, and
1 from before conception through pregnancy, delivery, and increased risk of venous thromboembolism.
postpartum to improve outcomes.

Continuation of statin use during pregnancy may be

2b considered.

Should not use ACE inhibitors, ARBs, direct renin

3: Harm inhibitors, ARNIs, or aldosterone antagonists during
pregnancy to prevent harm to fetus.

Abbreviations: ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor neprilysin inhibitor;
CCD, chronic coronary disease; COR, class of recommendation; and MACE, major adverse cardiovascular events.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 36
Special Populations: Older Adults with Chronic Coronary
Disease
The 5 Ms™ of Geriatric Care
To be used for educational purposes

MIND MOBILITY MEDICATIONS MULTICOMPLEXITY MATTERS MOST

• Mentation, • Impaired gait • Polypharmacy, • Multimorbidity • Each individual’s own
dementia, and balance, deprescribing, optimal • Complex meaningful health
delirium, fall injury prescribing biopsychosocial outcome goals and care
depression prevention • Adverse medication situations preferences
effects and medication
burden

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 37
Special Populations: Chronic Kidney Disease and CCD

In patients with CCD and CKD, measures should be taken to minimize the risk of
treatment-related acute kidney injury. (Class 1)

Revascularization for patients with moderate to

severe ischemia burden can be reserved for Radial access may minimize the role of
patients who remain symptomatic despite medical aeroembolism on the development of AKI
therapy

Minimize risk of contrast nephropathy in clinically

Delay of CABG (when feasible) in stable patients
indicated PCI: avoid nephrotoxic agents, ensure
after angiography beyond 24 hours may reduce risk
adequate pre-hydration, minimize volume of
of AKI
contrast media

High dose statins may reduce the occurrence of No benefit of bicarbonate or N-acetyl-L-cysteine over
contrast-induced AKI normal saline for prevention of AKI

Abbreviations: AKI indicates acute kidney injury; CABG, coronary artery bypass graft; and PCI, percutaneous coronary intervention.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 38
 Recommendations for HIV and Autoimmune Disorders in CCD

HIV Autoimmune Disorders

Rheumatoid Arthritis Others

Antiretroviral Choose antiretroviral Tx Lovastatin or
therapy is with favorable lipid and simvastatin should
beneficial to CV risk profiles to
not be used with
decrease the risk decrease drug-drug High-dose Consider biologics and
of CV events interactions protease inhibitors DMARDs are glucocorticoids
(Class 3: Harm) other immune
(Class 1) (Class 2a) beneficial to should not be used
modulators to
decrease the risk long term if
of CV events alternatives decrease risk of CV
(Class 2a) available events
(Class 3: Harm) (Class 2b)

Abbreviations: CCD indicates chronic coronary disease; CV, cardiovascular; DMARD, disease-modifying
antirheumatic drug; and HIV, human immunodeficiency virus.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 39
Cardiac Allograft Vasculopathy in Heart Transplant
Recipients

Heart Transplant recipients with cardiac allograft vasculopathy

Secondary prevention to reduce MACE Severe cardiac allograft vasculopathy

Statin Aspirin Consider

(Class 1) (Class 2a) revascularization for
suitable anatomy
(Class 2a)

Abbreviation: MACE indicates major adverse cardiovascular event.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 40
Follow-Up Plan and Testing in Stable Patients With CCD

Patients with CCD

With previous ACS or With no change in clinical or

revascularization functional status

Reasonable to refer:
Routine periodic
Telehealth programs On optimized GDMT, Routine periodic invasive
reassessment of LV
Community-based routine periodic testing coronary angiography
function is not
programs for lifestyle with coronary CTA or should not be performed
recommended to guide
interventions for stress testing is not to guide therapeutic
therapeutic decision
management of cardiac recommended decision making
making
risk factors (Class 3: No benefit) (Class 3: Harm)
(Class 3: No benefit)
(Class 2b)

Abbreviations: ACS indicates acute coronary syndrome; CCD, chronic coronary disease; CTA, computed tomography angiography; GDMT,
guideline directed medical therapy; and LV, left ventricular.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 41
Cost and Value Considerations

Treatment and prevention

discussions with CCD patients

To preempt cost-related non-adherence

• Discuss out-of-pocket costs at the time of

initiating a new medication
• At least annual follow-up on out-of-pocket medication
costs
(Class 1)

Abbreviation: CCD indicates chronic coronary disease.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 42
Top 10*
1. Emphasis is on team-based, patient-centered care that effective in many circumstances, particularly when the risk
1 considers social determinants of health, costs, and shared 7 of bleeding is high, and the ischemic risk is low to
decision making. moderate.

2. Nonpharmacologic therapies, including healthy dietary habits 8. The use of nonprescription or dietary supplements,
2 and exercise, are recommended for all patients with CCD. including fish oil and omega-3 fatty acids or vitamins, is
8 not recommended in patients with CCD given the lack of
3. Patients with CCD who are free from contraindications are benefit in reducing cardiovascular events.
encouraged to participate in physical activity. Cardiac
3 rehabilitation for eligible patients provides significant 9. Routine periodic anatomic or ischemic testing without a
cardiovascular benefits. change in clinical or functional status is not recommended
9 for risk stratification or to guide therapeutic decision-
4. Use of SGLT2 inhibitors and GLP-1 RAs are recommended for making in patients with CCD.
select groups of patients with CCD, including groups without
4 diabetes. 10. Although e-cigarettes increase the likelihood of successful

5. New recommendations for beta-blocker use in patients with 10 smoking cessation compared with nicotine replacement
therapy, because of the lack of long-term safety data and
CCD. risks of sustained use, e-cigarettes are not recommended
5 as first-line therapy for smoking cessation.
6. Statins remain first line therapy for lipid lowering in patients
with CCD. Several adjunctive therapies may be used in select
6 populations.

7. Shorter durations of dual antiplatelet therapy are safe and

*Complete text available in 2023 AHA/ACC Guideline for Chronic Coronary Disease

Abbreviations: CCD indicates chronic coronary disease; GLP-1 RAs, glucagon-like peptide-1 receptor agonists; and SGLT2,
sodium glucose cotransporter 2.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 43
Evidence Gaps and Areas of Future Research Needs

• Impact of more sensitive noninvasive imaging and diagnosis

• Develop and validate MACE risk scores in CCD patients
• Leverage SDOH to improve care coordination

• Impact of marijuana and e-cigarettes on CCD

• Effects of hybrid / home-based cardiac rehabilitation programs
• Sequence of GDMT in CCD patients

• Antiplatelet regimen in CCD patients ≥ 1-year post-MI or PCI

• Antithrombotic regimen in CCD patients with atrial fibrillation
• Utility of SGLT-2 inhibitors and GLP-1 agonists in CCD patients

Abbreviations: CCD indicates chronic coronary disease; GDMT, guideline-directed medical therapy; GLP-1, glucagon-like peptide-1;
MACE, major adverse cardiovascular event; MI, myocardial infarction; PCI, percutaneous coronary intervention; SDOH, social
determinants of health; and SGLT-2, sodium-glucose cotransporter 2.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 44
Acknowledgments
Many thanks to our Guideline Ambassadors who were guided by Dr. Elliott Antman in
developing this translational learning product in support of the 2023
AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With
Chronic Coronary Disease.
Qasim Jehangir, MD Christine Shen, MD
Chanel Jonas, MD Jenna Skowronski, MD
Worawan Limpitikul, MD Monica Tung, MD
Ashely Patel, MD Raymond Yeow, MD
Lakshmi Rao, MD

The American Heart Association requests this electronic slide deck be cited as follows:
Jehangir, Q., Jonas, C., Limpitikul, W., Patel, A., Rao, L., Shen, C., Skowronski, J., Tung, M., Yeow, R., Bezanson, J. L., Reyna,
G. & Antman, E. M. (2023). AHA Clinical Update; Adapted from: [PowerPoint slides]. Retrieved from the 2023
AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease.
https://professional.heart.org/en/science-news.

Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Circulation. 45