2023 Chronic Coronary Disease - ClinicalUpdate Slide Deck

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
• High-quality evidence‡ from more than 1 RCT
Applying Class of Suggested phrases for writing recommendations:
• Is recommended
• Meta-analyses of high-quality RCTs
• One or more RCTs corroborated by high-quality registry studies
Recommendation and • Is indicated/useful/effective/beneficial

• 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 • Moderate-quality evidence‡ from 1 or more RCTs
• Meta-analyses of moderate-quality RCTs
Clinical Strategies, − Treatment A should be chosen over treatment B
CLASS 2a (MODERATE) LEVEL B-NR

(Nonrandomized)
Interventions, Benefit >> Risk
Suggested phrases for writing recommendations: • Moderate-quality evidence‡ from 1 or more well-designed, well-
Treatments, or • Is reasonable
• Can be useful/effective/beneficial
executed nonrandomized studies, observational studies, or
registry studies
• Meta-analyses of such studies
Diagnostic Testing in
• Comparative-Effectiveness Phrases†:
− Treatment/strategy A is probably recommended/indicated in preference to LEVEL C-LD
treatment B
(Limited Data)
Patient Care − It is reasonable to choose treatment A over treatment B
CLASS 2b (Weak)
• Randomized or nonrandomized observational or registry studies
(Updated May 2019)*

with limitations of design or execution
Benefit ≥ Risk • Meta-analyses of such studies
Suggested phrases for writing recommendations: • Physiological or mechanistic studies in human subjects
• May/might be reasonable LEVEL C-EO
• May/might be considered
(Expert Opinion)
• Usefulness/effectiveness is unknown/unclear/uncertain or not well- •COR and LOE are determined independently (any COR may be paired with any LOE).
established • Consensus of expert opinion based on clinical experience.
•A recommendation with LOE C does not imply that the recommendation is weak. Many
CLASS 3: No Benefit (MODERATE) important clinical questions addressed in guidelines do not lend themselves to clinical
trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a
Benefit = Risk particular test or therapy is useful or effective.
Suggested phrases for writing recommendations: •*The outcome or result of the intervention should be specified (an improved clinical
outcome or increased diagnostic accuracy or incremental prognostic information).
• Is not recommended
• Is not indicated/useful/effective/beneficial • †For comparative-effectiveness recommendation (COR 1 and 2a; LOE A and B only),
studies that support the use of comparator verbs should involve direct comparisons of the
• Should not be performed/administered/other treatments or strategies being evaluated.
CLASS 3: Harm (STRONG) •‡The method of assessing quality is evolving, including the application of standardized,
widely-used, and preferably validated evidence grading tools; and for systematic reviews,
Risk > Benefit the incorporation of an Evidence Review Committee.
Suggested phrases for writing recommendations: •COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level
of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled trial.
• Potentially harmful
• Causes harm
• Associated with excess morbidity/mortality
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease.
• Should not be performed/administered/other
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 Diagnosed based
ACS event or after dysfunction and ischemic equivalents and evidence of solely on results of a
coronary known or such as dyspnea or coronary vasospasm screening study
revascularization suspected CAD or arm pain with or microvascular (stress test, CTA),
procedure and after with established exertion) medically angina. and treating clinician
stabilization of all cardiomyopathy of managed with/without concludes the patient
acute CV issues. an ischemic origin. positive imaging test has CAD.
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. 3
Circulation.
Epidemiology
United States Heart Disease Prevalence, by Age, Race, Ethnicity, and Sex, 2015–2018
Prevalence of CHD 2015-2018 Prevalence of AP 2015-2018 Prevalence of MI 2015-2018 ≥20
≥20 y ≥20 y y
6% 8% 3%
17% 16%
10% 7% 12% 20%
10%
13% 12% 15% 14%
9%
14% 13% 12% 12% 17%

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.
Circulation.
Prevalence of CCD in 2020
Worldwide Nationwide
Highest Prevalence Lowest Prevalence • Highest in the southern region
1. Northern Africa 1. Canada of the US
2. Middle East 2. Northern Europe • CCD increases with age and
3. Eastern Mediterranean 3. Western coast of South highest in males except in 20
America to 39 y range
Abbreviations: CCD indicates chronic coronary disease; US, United States; and y, years.
Circulation.
Evaluation of CCD
In stable CCD with change in symptoms or functional

capacity that persists despite GDMT
PET/SPECT Exercise treadmill

When selected for CCTA is reasonable to
MPI, CMR or testing can be
ICA to guide rest/stress nuclear evaluate bypass graft
Stress useful for
decision-making MPI, PET is or stent patency in
Echocardiogram evaluation of
and improve reasonable in those who have had
to improve symptoms and
symptoms preference to SPECT previous coronary
diagnostic functional
(Class 1) to improve diagnostic revascularization
accuracy capacity
(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.
Circulation.
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
ICA is not routinely recommended without
Validated risk scores LV systolic dysfunction, HF, stable CP
(where available) refractory to GDMT, and/or noninvasive
Noninvasive cardiac testing indicating significant LM disease.
diagnostic testing (Class 3: No benefit)
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.
Circulation.
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 to
• Lack of health care access • DM 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.
Circulation.
Features Associated with a Higher Risk of MACE
in CCD
Biomarkers CV Diagnostic Testing

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

Patients with CCD should receive ongoing
individualized education on symptom Shared decision making when evidence is unclear
management, lifestyle changes, and SDOH risk or significant risk or benefit tradeoff. (Class 1)
factors to improve knowledge and facilitate
behavior change. (Class 1)
Patients with CCD should receive ongoing Consider validated decision aid to improve
individualized education on medication adherence understanding and knowledge. (Class 2b)
to improve knowledge and facilitate behavior
change. (Class 1)
Abbreviations: CCD indicates chronic coronary disease; and SDOH, social determinants of health.
Circulation.
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.
Circulation.
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
• • Dietary sodium hydrogenated
Whole grains (1500-<2300 mg/day) oil/shortening
• Lean protein • Processed meat
• Complex carbohydrates (eg, cured hot dogs)
In patients with CCD, the use of
• Dietary fiber • Refined carbohydrates
(eg, white rice) nonprescription or dietary
• Monounsaturated fat supplements, including omega-3
(≤20% of daily calories; • Sugar-sweetened beverages
(eg, sugar-added soft drinks, fatty acid, vitamins C, D, E, beta-
eg, olive oil)
fruit drinks) carotene, and calcium, is not
• Polyunsaturated fat beneficial to reduce the risk of acute
(≤10% of daily calories; e • Alcoholic beverages
g, salmon) CVD events.
(Class 3: No Benefit)
Abbreviations: CCD indicates chronic coronary disease; CVD, cardiovascular disease; and mg,
milligram.
Circulation.
Screen and Treat Mental Health Conditions
Screen for depression. Assess psychological health.

In patients with CCD, targeted discussions and In patients with CCD, treatment for mental health
screening for mental health is reasonable for clinicians to conditions with either pharmacologic or
assess and to refer for additional mental health nonpharmacologic therapies, or both, is reasonable to
evaluation and management. (Class 2a) improve cardiovascular outcomes. (Class 2a)
More Well-being
Over the past 2 weeks, how often have Nearly Question
Not at Severa than parameter
you been bothered by the following every
all l days half the
problems? day Health-related
days How do you think things will go with your health moving forward?
Little interest or pleasure in doing 0 1 2 3 optimism
things Positive affect How often do you experience pleasure or happiness in your life?
Feeling
Total down,
score depressed,
of ≥3 warrants or hopeless
further 0 depression.
assessment for 1 2 3
Do you ever feel grateful about your health? Do you ever feel
Gratitude
grateful about other things in your life?
Circulation.
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)
Circulation.
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.
Circulation.
Counsel about Sexual Health
Individualize resumption of Cardiac rehabilitation and Phosphodiesterase type 5

sexual activity based on: regular exercise reduces the inhibitors should not be used
• Type of sexual activity risk of cardiovascular concomitantly with nitrate
• Exercise capacity complications with sexual medications.
• Postprocedural healing activity*
(Class 2a) (Class 2a) (Class 3:Harm)
*Note: Sexual activity is 3-5 metabolic equivalents.
Circulation.
Chronic Coronary Disease: Lipid management
Patients with CCD
Healthy Lifestyle
Not at Very High
Very High Risk
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 tolerated Dashed arrow

If high-intensity If on maximal and LDL-C < 100 mg/dL with a statin and LDL-C ≥70 indicates RCT-
statin not tolerated statin persistent fasting TG level of mg/dL, adding *ezetimibe supported efficacy,
tolerated, use and LDL-C ≥70 150-499 mg/dL, after can be beneficial but is less cost
moderate-intensity mg/dL, *ezetimibe addressing secondary causes, (Class 2a) effective
statin may be reasonable icosapent ethyl may be
(Class 1) (Class 2b) considered
(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
*secondary causes include medications, diabetes and lifestyle
further reduce risk of MACE (Class 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.
Circulation.
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
• Reduce dietary sodium <1500 mg/d indication present†
• Physical activity • Add CCB, long-acting thiazide
• Reduction or elimination of alcohol or 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.
Circulation.
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.
Circulation.
Weight management in Patients with CCD
MEASURE COUNSEL TREAT AVOID
• Dietary modification If pharmacologic therapy is

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

circumference In severe obesity in which weight
>102 cm (men) or >88 cm loss goals have not been met,
(women) referral for consideration of a
bariatric procedure is reasonable
(Class 1) 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.
Circulation.
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.
Circulation.
Environmental Exposure
Minimize exposure to ambient air pollution Minimize exposure to extreme temperatures

(Class 2a) and wildfire smoke (Class 2b)
Circulation.
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 If no indication for OAC, low dose aspirin 81mg
1 1
PCI followed by SAPT (75mg-100mg) recommended
If patient also has drug eluting stent, and completed + previous MI and at low bleeding risk, extended
2a 1-3 months of DAPT, use of P2Y12 inhibitor 2b DAPT (12 months- 3 yrs) may be reasonable to reduce
monotherapy ( for least 12 months) MACE
+ 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 Use of DAPT after CABG may be useful to reduce
2b
the incidence of saphenous vein graft occlusion.
COR RECOMMENDATIONS
w/o recent ACS or a PCI-related indication for DAPT,
3: Prasugrel should not be used due to risk of 3: No
the addition of clopidogrel to aspirin therapy is not
Harm significant/fatal bleed Benefit
useful to reduce MACE.
3: Vorapaxar should not be added to DAPT Chronic NSAID’s should not be used because of
Harm (increased risk of major bleed/ICH) 3: Harm
increased 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.
Circulation.
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 Antiplatelet therapy and
months should be administered in
addition to DOAC. † Low dose DOAC
(Class 1)
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
If no acute indication for twice daily to aspirin 81 mg daily  Reasonable for long
concomitant antiplatelet Patients with If High thrombotic risk +
Low bleeding risk  term reduction of risk for MACE (Class 2a)
 Consider DOAC CCD and oral
monotherapy anticoagulation Continuing aspirin and
clopidogrel for up to 1 month
(Class 2b)
is reasonable*
(Class 2a)
DAPT and PPI
With Low Atherothrombotic Risk *

Patients with CCD on DAPT  PPI can be effective in
Discontinuation of Aspirin
reducing 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.
Circulation.
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.
Circulation.
Recommendations for Beta-Blockers
Patients with CCD
If on Beta Blocker therapy without history If No Previous MI

If LVEF ≤40%
If LVEF <50% of Mi with or without a history of EF ≤50%, or LVEF ≤50%
+/- Previous MI
(Class 1) Angina, Arrhythmias, Uncontrolled (Class 3: No
(Class 1)
Hypertension (Class 2b) Benefit)
Treatment with beta- The use of sustained

blocker is release metoprolol Beta-blocker therapy is
recommended to succinate, carvedilol, or Reassess long-term not beneficial in reducing
reduce the risk of bisoprolol + titration to (>1 year) MACE, without another
future MACE, target doses is use of beta-blocker therapy for reducing MACE primary indication for
including recommended over other beta-blocker therapy
cardiovascular death 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.
Circulation.
Recommendations for
Recommendations
Renin-Angiotensin-Aldosterone
for Colchicine
Inhibitors
Patient’s with CCD Inflammation Development

of Atherosclerosis
With hypertension,
Without hypertension,
diabetes, LVEF ≤40%,
diabetes, or CKD and
or CKD, the use of ACE
LVEF >40%, the use of The addition of colchicine for Secondary
inhibitors, or ARBs if
ACE inhibitors or Prevention may be considered to reduce
ACE inhibitor–
ARBs may be recurrent ASCVD events
intolerant, is
considered to reduce (Class 2b)
recommended to reduce
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.
Circulation.
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.
Circulation.
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.
Circulation.
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
LVEF<35% or LM
disease & complex
disease Intermediate disease
clinic/social situation
on LHC Improve long-term
survival
CABG unless poor Multidisciplinary
FFR/iFR prior to PCI
surgical candidate Heart 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.
Circulation.
Revascularization: PCI Versus CABG
Patients with CCD requiring

revascularization
CABG if… PCI if…
Left Main involvement Poor surgical

with high-complexity candidate
CAD (Class 1) (Class 2a)
DM with multivessel DM with LM stenosis

disease & LAD and low- to
involvement (Class 1) intermediate-
Multivessel disease complexity CAD
with SYNTAX score (Class 2b)
>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.
Circulation.
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

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

CRITE
EVIDENCE DIAGNOSTIC PARAMETERS
RIA
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
3 ischemia the 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
Evidence of impaired coronary microvascular spasm, defined as reproduction of symptoms, ischemic ECG shifts but no epicardial spasm during
4 microvascular function acetylcholine testing; 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.
Circulation.
Special Populations with CCD:
Young Adults and Cancer
Young Adults Cancer

A strategy of stratified medical therapy Multi-disciplinary team including
guided by invasive coronary physiologic cardiology and oncology expertise is
testing can be useful for improving angina recommended to improve long-term
severity and quality of life (Class 2a) cardiovascular disease outcomes (Class 1)
Abbreviation: CCD, chronic coronary disease.
Circulation.
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
Multi-disciplinary cardio-obstetric care team 3:
because of lack of benefit on MACE and
involvement from before conception through Harm mortality, and increased risk of venous
1 pregnancy, delivery, and postpartum to improve thromboembolism.
outcomes.
Continuation of statin use during pregnancy may be

2b considered.
Should not use ACE inhibitors, ARBs, direct renin

3:
inhibitors, ARNIs, or aldosterone antagonists during
Harm 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.for the Management of Patients With Chronic Coronary Disease.
Virani, S. S., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline 36
Circulation.
Special Populations: Older Adults with Chronic Coronary
Disease
The 5 Ms™ of Geriatric Care
To be used for educational purposes
MIND MOBILIT MEDICATIONS MULTICOMPLEXIT MATTERS MOST

Y Y
• Mentation, • Impaired gait • Polypharmacy, • Multimorbidity • Each individual’s own
dementia, and balance, deprescribing, • Complex meaningful health
delirium, fall injury optimal prescribing biopsychosocial outcome goals and
depression prevention • Adverse medication situations care preferences
effects and
medication burden
Circulation.
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 aeroembolism on the development of AKI
medical therapy
Minimize risk of contrast nephropathy in

Delay of CABG (when feasible) in stable
clinically indicated PCI: avoid nephrotoxic
patients after angiography beyond 24 hours may
agents, ensure adequate pre-hydration,
reduce risk of AKI
minimize volume of contrast media
High dose statins may reduce the occurrence No benefit of bicarbonate or N-acetyl-L-
of contrast-induced AKI cysteine over normal saline for prevention of
AKI
Abbreviations: AKI indicates acute kidney injury; CABG, coronary artery bypass graft; and PCI, percutaneous coronary intervention.
Circulation.
Recommendations for HIV and Autoimmune Disorders in CCD
HIV Autoimmune Disorders
Antiretroviral Choose antiretroviral Lovastatin or Rheumatoid Arthritis Others

therapy is Tx with favorable simvastatin
beneficial to lipid and CV risk should not be
decrease the profiles to decrease used with
risk of CV drug-drug High-dose Consider biologics
protease DMARDs are
events interactions glucocorticoids and other immune
inhibitors beneficial to
(Class 1) (Class 2a) should not be
(Class 3: Harm) decrease the modulators to
used long term if
risk of CV decrease risk of CV
alternatives
events events
available
(Class 2a) (Class 2b)
(Class 3: Harm)
Abbreviations: CCD indicates chronic coronary disease; CV, cardiovascular; DMARD, disease-
modifying antirheumatic drug; and HIV, human immunodeficiency virus.
Circulation.
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.
Circulation.
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 Routine periodic
Telehealth programs On optimized GDMT,
reassessment of LV invasive coronary
Community-based routine periodic
function is not angiography should
programs for lifestyle testing with coronary
recommended to not be performed to
interventions for CTA or stress testing
guide therapeutic guide therapeutic
management of cardiac is not recommended
decision making decision making
risk factors (Class 3: No benefit)
(Class 3: No benefit) (Class 3: Harm)
(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.
Circulation.
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.
Circulation.
Top 10*
11. Emphasis is on team-based, patient-centered care that considers

social determinants of health, costs, and shared decision
7 populations.
making. 7. Shorter durations of dual antiplatelet therapy are safe and

effective in many circumstances, particularly when the risk
22. Nonpharmacologic therapies, including healthy dietary habits of bleeding is high, and the ischemic risk is low to moderate.
and exercise, are recommended for all patients with CCD. 8
8. The use of nonprescription or dietary supplements, including
33. Patients with CCD who are free from contraindications are
encouraged to participate in physical activity. Cardiac
fish oil and omega-3 fatty acids or vitamins, is not
recommended in patients with CCD given the lack of benefit
rehabilitation for eligible patients provides significant 9 in reducing cardiovascular events.
cardiovascular benefits.
9. Routine periodic anatomic or ischemic testing without a
44. Use of SGLT2 inhibitors and GLP-1 RAs are recommended for change in clinical or functional status is not recommended
select groups of patients with CCD, including groups without 10 for risk stratification or to guide therapeutic decision-making
diabetes. in patients with CCD.
5
5. New recommendations for beta-blocker use in patients with 10. Although e-cigarettes increase the likelihood of successful
CCD. smoking cessation compared with nicotine replacement
6 therapy, because of the lack of long-term safety data and
6. Statins remain first line therapy for lipid lowering in patients risks of sustained use, e-cigarettes are not recommended as
with CCD. Several adjunctive therapies may be used in select first-line therapy for smoking cessation.
*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.
Circulation.
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.
Circulation.
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
Chanel Jonas, MD
Worawan Limpitikul, MD Christine Shen, MD
Ashely Patel, MD Jenna Skowronski, MD
Monica Tung, MD
Lakshmi Rao, MD Raymond Yeow, 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.
Circulation.

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Clinical Update

Table 1. CLASS 1 (STRONG)

Recommendation and • Is indicated/useful/effective/beneficial

CLASS 2a (MODERATE) LEVEL B-NR

(Updated May 2019)*

14% 13% 12% 12% 17%

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

In stable CCD with change in symptoms or functional

PET/SPECT Exercise treadmill

Demographic variables Optimize GDMT (Class 1)

Social variables ICA to assess coronary anatomy and

Demographics & Medical History

Biomarkers CV Diagnostic Testing

Symptoms and Functional

Patient Education Shared Decision Making

Social Support Culture & Language

*Adapted from Figure 6 in guideline document.

Choose These Instead of These AVOID TRANS FAT

Screen for depression. Assess psychological health.

Abbreviation: CCD, chronic coronary disease.

Individualize resumption of Cardiac rehabilitation and Phosphodiesterase type 5

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

If on maximal tolerated statin If on maximal tolerated Dashed arrow

Elevated blood pressure Hypertension

Nonpharmacologic (Class 1) Pharmacologic (Class 1)

Type 2 diabetes Heart failure (± diabetes)

GLP-1 LVEF ≤ 40% LVEF > 40%

• Dietary modification If pharmacologic therapy is

Central obesity waist

Refer CCD patients with:

Taylor et al. Nature Reviews Cardiology.

Minimize exposure to ambient air pollution Minimize exposure to extreme temperatures

With Low Atherothrombotic Risk *

*Colors correspond to Class of

†This figure does not encompass all

Patients with CCD

If on Beta Blocker therapy without history If No Previous MI

Treatment with beta- The use of sustained

Patient’s with CCD Inflammation Development

Abbreviations: ACE indicates angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; ASCVD,

1 Annual influenza vaccination is recommended

1 COVID-19 vaccination is recommended

2a Pneumococcal vaccine is reasonable

Abbreviation: CCD indicates chronic coronary disease.

Patients with CCD requiring

CABG if… PCI if…

Left Main involvement Poor surgical

DM with multivessel DM with LM stenosis

Spontaneous Coronary Artery Dissection

Counseling should be provided regarding potential

Evaluation for underlying vasculopathies is

Beta-blocker therapy may be reasonable to reduce

Abbreviation: SCAD indicates spontaneous coronary artery dissection.

Clinical Criteria for Suspecting Microvascular Angina

Absence of obstructive CAD (<50%

Young Adults Cancer

Abbreviation: CCD, chronic coronary disease.

Continuation of statin use during pregnancy may be

Should not use ACE inhibitors, ARBs, direct renin

MIND MOBILIT MEDICATIONS MULTICOMPLEXIT MATTERS MOST

Revascularization for patients with moderate

Minimize risk of contrast nephropathy in

HIV Autoimmune Disorders