Am Fam Physician. 2024;110(3):315-317
Author disclosure: No relevant financial relationships.
KEY POINTS FOR PRACTICE
• High-intensity statin therapy is recommended for patients with chronic coronary disease, with the addition of ezetimibe or PCSK9 inhibitors for those with very high risk.
• SGLT-2 inhibitors and GLP-1 receptor agonists reduce cardiac events in patients with chronic coronary disease and type 2 diabetes or systolic heart failure, and they improve quality of life in those with heart failure and preserved ejection fraction.
• Daily colchicine reduces cardiac events and stroke in patients with chronic coronary disease and previous cardiac events.
From the AFP Editors
Approximately 20 million people in the United States live with chronic coronary disease. In 2023, the American College of Cardiology and American Heart Association released guidelines for management of chronic coronary disease, primarily for primary care physicians and cardiologists who provide care in the outpatient setting. Chronic coronary disease includes acute coronary syndrome, coronary revascularization, angina or ischemia equivalents, coronary disease diagnosed with coronary computed tomography angiography, or a positive stress test. Chronic coronary disease may be managed in the acute, postacute, or chronic setting.
CONSERVATIVE TREATMENT
Nutrition
A Mediterranean diet can reduce cardiovascular events by up to 65% in less than 4 years while improving comorbidities, including hypertension, dyslipidemia, diabetes mellitus, and obesity. Based on moderate-quality evidence, a Mediterranean-type diet emphasizing vegetables, fruits, legumes, nuts, whole grains, and lean protein is strongly recommended to reduce the risk of cardiovascular events. Trans fats, found in hydrogenated oil products, increase morbidity and mortality and should be avoided. Nonprescription supplements, including omega-3 fatty acids, are not recommended due to lack of evidence of benefit.
Exercise
Cardiac rehabilitation with aerobic exercise and resistance training is an important aspect of treatment following a recent cardiac event. Patients with chronic coronary disease and a recent cardiac event or intervention have lower all-cause and cardiovascular death when referred for cardiac rehabilitation. If there are no contraindications, patients should be encouraged to perform at least 150 minutes per week of moderate-intensity aerobic exercise or 75 minutes per week of high-intensity aerobic exercise to improve functional capacity and quality of life and reduce mortality. Sexual activity is as safe as other moderate-intensity activity. Resistance training is recommended at least 2 days per week to improve muscle strength, functional capacity, and quality of life.
Weight Management
Weight should be assessed at every appointment to help with weight loss counseling. In individuals with a body mass index of at least 27 kg per m2 with weight-related comorbidities, a glucagon-like peptide-1 (GLP-1) receptor agonist may be considered if lifestyle modifications have not improved body mass index. Sympathomimetic drugs, such as phentermine, should be avoided in patients with chronic coronary disease. Individuals who are severely obese and not meeting weight loss goals with lifestyle and pharmacologic interventions may benefit from bariatric surgery.
Substance use
Due to the profound negative effect of tobacco use in patients with chronic coronary disease, discussing smoking cessation at every visit is recommended. Combining behavioral interventions with pharmacotherapy is the most effective strategy for cessation. Varenicline (Chantix) is the most effective pharmacotherapy for cessation. e-Cigarettes appear to be more effective than nicotine replacement therapy but are not recommended as first-line therapy because of the risk of long-term dependence on e-cigarettes.
Because recreational drug use is observed in 10% of younger patients with myocardial infarction (MI), screening for substance use is beneficial. Although the evidence on how alcohol consumption affects the risk of future cardiac events is inconsistent, it is reasonable to recommend less than one drink per day for women and less than two drinks per day for men.
Depression
Because the rates of major cardiovascular events are doubled in patients with recent acute coronary syndrome and depression, screening for depression is recommended.
Immunizations
Studies show a strong correlation between acute MI and recent upper respiratory tract infections; therefore, vaccinations against influenza, pneumonia, and COVID-19 are recommended based on expert opinion.
GOAL-DIRECTED MEDICAL THERAPY
Lipid Management
The guidelines recommend attempting a percentage response reduction in low-density lipoprotein (LDL) cholesterol levels relative to baseline, rather than trying to achieve a specific laboratory value. High-intensity statin therapy is recommended, with a goal of more than 50% reduction in LDL cholesterol levels. A moderate-intensity statin may be offered if high-intensity therapy is not tolerated, with the goal of a 30% to 49% reduction in LDL cholesterol levels. In patients at very high risk, adding ezetimibe to maximally tolerated statin therapy may reduce cardiac events. Proprotein convertase subtilisinkexin 9 (PCSK9) inhibitors also reduce cardiac events when added to statins and are recommended only for very high-risk patients because of their high cost. Icosapent ethyl (Vascepa), bempedoic acid (Nexletol), and inclisiran (Leqvio) may be considered as second-line therapy in patients taking a statin. Adding niacin, fenofibrate (Tricor), or dietary supplements is not recommended.
Blood Pressure Management
Individuals with systolic blood pressure below 130 mm Hg or diastolic blood pressure below 80 mm Hg have lower rates of cardiovascular events and death. First-line pharmacologic therapy should include angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, or beta blockers. If additional antihypertensive therapies are required, adding thiazide diuretics, calcium channel blockers, and mineralocorticoid receptor antagonists may be considered.
Sodium-Glucose Cotransporter-2 Inhibitors and GLP-1 Receptor Agonists
Patients with chronic coronary disease and type 2 diabetes should be treated with a sodium-glucose cotransporter-2 (SGLT-2) inhibitor or GLP-1 receptor agonist to reduce cardiac events. In patients with chronic coronary disease and systolic heart failure, SGLT-2 inhibitors reduce death and hospitalizations for heart failure. In patients with chronic coronary disease and preserved ejection fraction, SGLT-2 inhibitors reduce hospitalizations for heart failure and improve quality of life.
Antiplatelet and Anticoagulant Therapy
Aspirin, 81 mg per day, is recommended for patients with chronic coronary disease without an indication for oral anticoagulation. For patients with chronic coronary disease who take oral anticoagulation and have received percutaneous interventions, adding dual antiplatelet therapy is recommended for up to 1 month if bleeding risk is low. After completion of triple therapy, the continued use of clopidogrel is recommended for at least 6 months before shifting back to anticoagulant monotherapy.
After percutaneous intervention with a drug-eluting stent, 6 months of dual antiplatelet therapy is recommended before shifting to a single agent. In patients with low bleeding risk, extending dual antiplatelet therapy for up to 3 years may be reasonable. If there is a high risk of bleeding, 1 to 3 months of dual antiplatelet therapy followed by P2Y12 inhibitor monotherapy for 12 months should be considered before shifting to a single antiplatelet agent.
Beta Blockers
Beta blockers have limited use in the prevention of cardiac events in patients without other indications. For patients with chronic coronary disease and an ejection fraction of less than 50%, dosages of metoprolol succinate, up to 200 mg per day, carvedilol (Coreg), up to 25 mg twice per day, or bisoprolol, up to 10 mg per day, should be targeted to decrease major adverse cardiovascular events and death. Beta-blocker therapy is useful in the first year after MI; however, it is not beneficial in patients with an ejection fraction of 50% or greater.
Renin-Angiotensin-Aldosterone Inhibitors
For patients with chronic coronary disease and chronic kidney disease, hypertension, diabetes, or an ejection fraction of less than 40%, ACE inhibitors are recommended to improve quality of life and decrease hospitalizations and death. Angiotensin receptor blockers may be used if patients are unable to tolerate ACE inhibitors.
Colchicine
For patients who have had previous cardiovascular events, colchicine (Colcrys), 0.5 mg per day, may be considered based on evidence of a reduction in subsequent cardiac events and strokes. Colchicine should be avoided if estimated glomerular filtration rate is less than 30 mL per minute per 1.73 m2. Drug-drug interactions are common with colchicine.
RELIEF OF ANGINA
Medical Therapy
Beta blockers, calcium channel blockers, or long-acting nitrates can improve angina and quality of life in patients with chronic coronary disease and angina. Adding a second class of medication should be considered if the benefit of one is insufficient, and ranolazine (Ranexa) may be considered if patients remain symptomatic despite multiple medications. Calcium channel blockers should be avoided if ejection fraction is reduced to prevent further reduction. The role of ivabradine (Corlanor) is uncertain, but it is harmful if ejection fraction is normal. Sublingual nitroglycerin is recommended for acute angina treatment.
Revascularization
In patients with angina, revascularization improves symptoms and quality of life more than pharmacotherapy alone. For patients with ongoing symptoms despite maximal medical therapy, revascularization should be considered. Coronary artery bypass graft surgery is recommended if ejection fraction is less than 35% or the patient has multivessel disease or diabetes.
SPONTANEOUS CORONARY ARTERY DISSECTION
Spontaneous coronary artery dissection is an underrecognized cause of MI. Following initial dissection, patients should be counseled on avoiding intense physical activity and distress, and testing for arteriopathies and connective tissue disorders should be considered. Beta-blocker therapy may reduce recurrence.
PREGNANCY
Patients with chronic coronary disease who are considering pregnancy should receive care from a multidisciplinary team before pregnancy. Continuing the use of statins during pregnancy should be considered, but ACE inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors, and aldosterone antagonists should be avoided.
| Score | Criteria |
|---|---|
| Yes | Focus on patient-oriented outcomes |
| Yes | Clear and actionable recommendations |
| Yes | Relevant patient populations and conditions |
| Yes | Based on systematic review |
| Yes | Evidence graded by quality |
| Yes | Separate evidence review or analyst in guideline team |
| Yes | Chair and majority free of conflicts of interest |
| Yes | Development group includes most relevant specialties, patients, and payers |
| Overall – useful |
Editor’s Note: This guideline is innovative because it focuses on the outpatient care of any patient with known coronary disease. New items include the shifting from LDL cholesterol goals to percentage reductions and consideration of daily colchicine for patients with previous cardiac events. This guideline covers treatment for most patients who we would define as having a positive cardiac history.
—Michael J. Arnold, MD, Assistant Medical Editor
The views expressed are those of the authors and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences, U.S. Navy, U.S. Department of Defense, U.S. Department of Veterans Affairs, or U.S. government.
Guideline source: American College of Cardiology/American Heart Association
Published source: Virani SS, Newby LK, Arnold SV, et al. 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. Circulation. 2023;148(9):e9–e119.
