Today, I review, link to, and excerpt from 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. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Circulation. 2023 Aug 29;148(9):e9-e119. doi: 10.1161/CIR.0000000000001168. Epub 2023 Jul 20.
All that follows is from the above resource.
Abstract
Aim:The “2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease” provides 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 reviews 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 databases 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.
Keywords:AHA Scientific Statements; acute coronary syndrome; air pollution; angina; antiplatelet therapy; aspirin; atherosclerosis; autoimmune diseases; cardiac events; cardiac rehabilitation; cardiovascular diseases; colchicine; coronary artery disease; coronary disease; cost-benefit analysis; depression; diabetes; diet; diet therapy; dietary supplements; drug therapy; dual antiplatelet therapy; environmental exposure; exercise tolerance; factor Xa inhibitors; fibrinolytic agents; glucagon-like peptide-1 receptor agonists; guideline-directed management and therapy; health care outcome assessments; health equity; heart disease risk factors; heart failure; hormone replacement therapy; hypercholesterolemia; hypertension; immunization; ischemic heart disease; mental health; multidisciplinary; myocardial ischemia; outcomes; outpatient; patient care team; pharmacology; pregnancy; proton pump inhibitors; quality of life; safety; secondary prevention; sexual behavior; sexual health; shared decision-making; smoking cessation; social determinants of health; sodium-glucose cotransporter 2 inhibitors; spontaneous coronary artery dissection; stress; therapeutic use; therapy; type 2 diabetes; vaccination.
TOP 10 TAKE-HOME MESSAGES FOR CHRONIC CORONARY DISEASE
Emphasis is on team-based, patient-centered care that considers social determinants of health along with associated costs while incorporating shared decision-making in risk assessment, testing, and treatment.
Nonpharmacologic therapies, including healthy dietary habits and exercise, are recommended for all patients with chronic coronary disease (CCD).
Patients with CCD who are free from contraindications are encouraged to participate in habitual physical activity, including activities to reduce sitting time and to increase aerobic and resistance exercise. Cardiac rehabilitation for eligible patients provides significant cardiovascular benefits, including decreased morbidity and mortality outcomes.
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*Sodium Glucose Contransporter 2 ((SGLT2) Inhibitors from StatPearls:
Indications
Sodium-glucose co-transporter-2 (SGLT-2) inhibitors are antihyperglycemic agents acting on the SGLT-2 proteins expressed in the proximal convoluted tubules.These drugs exerttheir effect by preventing the reabsorption of filtered glucose from the tubular lumen. To date, there are four SGLT-2 inhibitors: canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin that are approved by Food Drug Administration (FDA) for their use in adults. The indications for use vary per agent, but all four agents are approved for use in adults with type 2 diabetes mellitus (DM) to improve blood sugar control adjunct to diet and exercise.[1]
FDA-approved indications for SGLT-2 Inhibitors
Improvement of glycemic control in type 2 diabetes mellitus (adjunct to diet and exercise)[2]
Reduction of major adverse cardiovascular events (nonfatal myocardial infarction and nonfatal stroke, cardiovascular death) in patients with type 2 DM and established cardiovascular disease.[3]
To decrease the risk of cardiovascular hospitalization and death for heart failure in patients with HFrEF (heart failure with reduced ejection fraction-NYHA class II-IV)[4]
Reduction of the risk of eGFR decline and hospitalization in patients with chronic kidney disease at risk of progression.[5]
Improvement of cardiovascular outcomes in patients with HFpEF (Heart failure with preserved ejection fraction)[6]
Dapagliflozin is now FDA-approved for thetreatment of heart failureacross the full spectrum of left-ventricular ejection fraction (LVEF), including HFrEF, HFpEF, and HFmrEF (Heart failure with mildly reduced ejection fraction- LVEF of 40–49%)[7]
Off-label use of SGLT2 Inhibitors
**Glucagon-Like Peptide-1 Receptor from StatPearls:
Indications
FDA-Approved Indications
GLP-1 agonists (also known as GLP-1 receptor agonists, incretin mimetics, or GLP-1 analogs) represent a class of medications used to treatT2DM and, in some cases, obesity. Examples of drugs in this class include Exenatide, Liraglutide, Dulaglutide, and Semaglutide. According to the American Diabetes Association (ADA), metformin remains the preferred first-line therapy for treating T2DM. However, the addition of a GLP-1 analog should be considered in patients with a contraindication or intolerance to metformin, in patients with a hemoglobin A1c greater than 1.5% over target, or in patients who do not reach their target A1c in3 months, particularly in patients with atherosclerosis, heart failure, or chronic kidney disease.[1][2][3][4]Furthermore, Semaglutide and high-dose Liraglutide are FDA-approved as pharmacologic treatments for obesity or can be prescribed to overweight patients with comorbidities. The utilization of GLP-1 analogs is anarea of research with favorable hemoglobin A1c results and weight loss results in patients with type-1 diabetes mellitus (T1DM). Of note, higher costs, as well as tolerability, remain significant barriers to prescribing these medications.[5][6][7][8]
As per the 2023 ADA guidelines, GLP-1 receptor agonists are recommended for mitigating cardiovascular risk. These agents not only lower the chances of cardiovascular events and hypoglycemia but also demonstrate potential in potentiallydecreasingthe progression of chronic kidney disease (CKD). GLP-1 agonists are recommended for individuals with a history of clinical ASCVD (eg, prior myocardial infarction, stroke.[9][10]GLP-1 agonists, with proven cardiovascular benefits, include Liraglutide, subcutaneous Semaglutide, and Dulaglutide.[11]
Structurally, these agents fall into2 broad categories: human GLP-1 backbone agents and exendin-4 backbone agents. Below are FDA-approved GLP-1 agonists.
Human GLP-1 backbone:
Dulaglutide
Albiglutide – discontinued
Liraglutide
Semaglutide
Exendin-4 backbone:
Exenatide (2 formulations)
Lixisenatide – discontinued
Tirzepatide isa GIP analog that activates both the GLP-1 and GIP receptors.
Liraglutide/insulin-degludechas obtained FDA approval, affirming their effectiveness and safety in diabetes management.[12][13]Because of safety concerns, research on another agent, taspoglutide, has been halted in phase III trials.[14]Recently, Orforglipron, a nonpeptide oral GLP-1 receptor agonist, has demonstrated promising results in phase 2 clinical trials.[15]
Resuming excerpts from 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. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Circulation. 2023 Aug 29;148(9):e9-e119. doi: 10.1161/CIR.0000000000001168. Epub 2023 Jul 20.:
5. New recommendations for beta-blocker use in patients with CCD: (a) Long-term beta-blocker therapy is not recommended to improve outcomes in patients with CCD in the absence of myocardial infarction in the past year, left ventricular ejection fraction ≤50%, or another primary indication for beta-blocker therapy; and (b) Either a calcium channel blocker or beta blocker is recommended as first-line antianginal therapy.
6. Statins remain first line therapy for lipid lowering in patients with CCD. Several adjunctive therapies (eg, ezetimibe, PCSK9 [proprotein convertase subtilisin/kexin type 9] inhibitors, inclisiran, bempedoic acid) may be used in select populations, although clinical outcomes data are unavailable for novel agents such as inclisiran.
7. Shorter durations of dual antiplatelet therapy are safe and effective in many circ*mstances, particularly when the risk of bleeding is high and the ischemic risk is low to moderate.
8. The use of nonprescription or dietary supplements, including fish oil and omega-3 fatty acids or vitamins, is not recommended in patients with CCD given the lack of benefit in reducing cardiovascular events.
9.Routine periodic anatomic or ischemic testing without a change in clinical or functional status is not recommended for risk stratification or to guide therapeutic decision-making in patients with CCD.
10. Although e-cigarettes increase the likelihood of successful smoking cessation compared with nicotine replacement therapy, because of the lack of long-term safety data and risks of sustained use, e-cigarettes are not recommended as first-line therapy for smoking cessation.
