2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guidelines

What's New in 2023

• SGLT2 Inhibitors & GLP-1 RA: Recommended for CCD with type 2 diabetes, heart failure, or CKD—cardio-renal protection proven
• ISCHEMIA Trial Impact: Routine invasive PCI does NOT improve survival in moderate-severe ischemia vs. GDMT alone; reserved for refractory symptoms
• Lipid Therapies: Inclisiran (PCSK9 siRNA), bempedoic acid, and combination strategies for very high-risk patients
• Rivaroxaban 2.5mg BID: Dual pathway inhibition (aspirin + rivaroxaban) for COMPASS-eligible high-risk patients
• Social Determinants of Health: Integrated screening and management throughout CCD care pathway
• Team-Based Care Emphasis: Multidisciplinary approach with physicians, pharmacists, nurses, dietitians, behavioral health specialists

CCD Definition & Patient Categories

Chronic coronary disease encompasses obstructive and nonobstructive CAD with or without prior MI or revascularization:

• Stable Angina: Reproducible symptoms or ischemic equivalents; medically managed or positive imaging
• Post-ACS (>12 months): Discharged after ACS or coronary revascularization with ischemic cardiomyopathy
• Ischemic Cardiomyopathy: Reduced LV systolic dysfunction with known/suspected CAD
• Prior Revascularization: History of PCI or CABG
• Vasospastic/Microvascular Angina: Symptoms with inducible ischemia on testing

Lifestyle Interventions

Nutrition & Diet

Class I LOE A

• Vegetables, fruits, legumes, nuts, whole grains, lean protein
• Saturated fat <6% of total calories; avoid trans fat
• Sodium <2,300 mg/day (target 1,500 mg/day)
• Minimize refined carbohydrates and sugar-sweetened beverages
• Mediterranean or DASH diet patterns recommended

Physical Activity

Class I LOE A

• 90–150 min/week moderate-intensity aerobic activity
• 2–3 days/week resistance training
• Reduce sedentary time; increase light activity
• Cardiac rehabilitation for symptom relief & outcomes

Weight Management

Class I LOE B

• 5–10% weight loss for overweight/obese; target BMI <25 kg/m²
• Structured programs combined with lifestyle intervention

Smoking Cessation

Class I LOE A

• Assessment at every visit; behavioral + pharmacotherapy (varenicline, bupropion, NRT)
• Short-term nicotine e-cigarettes may be considered; avoid long-term
• Secondhand smoke avoidance

Pharmacotherapy Overview

Guideline-directed medical therapy reduces MACE, manages symptoms, and improves quality of life in CCD. Organized by drug class:

Antiplatelet Therapy & Anticoagulants

Aspirin (Primary Prevention)

Class I LOE A

• 75–100 mg daily in established CCD reduces MACE

Dual Antiplatelet Therapy

Class 2b LOE B

• Short-term DAPT safe in high-risk CCD
• Rivaroxaban 2.5mg BID + aspirin for COMPASS-eligible (prior MI, PAD, diabetes + CAD risk)

Contraindication: Long-Term DAPT

Class I LOE C

• NOT recommended in CCD without MI within 12 months, LV EF <50%, or other indication

Lipid Management

High-Intensity Statin (First-Line)

Class I LOE A

• Goal LDL-C <70 mg/dL (1.8 mmol/L)
• Atorvastatin 80 mg or Rosuvastatin 20–40 mg daily
• Monitor fasting lipids 4–12 weeks after initiation/adjustment

Ezetimibe

Class 2a LOE B

• Add 10 mg daily for very high-risk with LDL-C ≥70 mg/dL on maximal statin
• ~20% additional LDL-C reduction

PCSK9 Monoclonal Antibodies

Class 2a LOE B

• Very high-risk with LDL-C ≥70 mg/dL on statin + ezetimibe
• Alirocumab/evolocumab: ~50% LDL-C reduction

Inclisiran (PCSK9 siRNA)

Class 2b LOE B

• Reduces LDL-C ~50% with twice-yearly subcutaneous dosing
• May improve adherence vs. monoclonal antibodies

Bempedoic Acid

Class 2b LOE B

• For statin-intolerant; ATP citrate lyase inhibitor
• ~15–25% LDL-C reduction; may combine with ezetimibe

Niacin & Omega-3

Class 3

• NOT recommended due to lack of benefit reducing CVD events

Blood Pressure Management

BP Goals & Nonpharmacologic Approach

Class I LOE B

• Target BP: <130/80 mm Hg
• First-line: Weight loss, DASH diet, reduced sodium, aerobic activity, alcohol moderation

Pharmacologic Therapy

Class I LOE B

• ACE inhibitors / ARBs: First-line (especially with LV dysfunction, diabetes, CKD)
• Beta-blockers: Indicated if prior MI, HF, or angina
• Calcium channel blockers: Dihydropyridines for symptom relief
• Thiazide diuretics, hydralazine, long-acting nitrates: If additional control needed

Anti-Anginal Medications

Beta-Blockers

Class I LOE B

• First-line for symptom relief; target HR 50–60 bpm at rest, <70 with activity

Calcium Channel Blockers

Class I LOE B

• Dihydropyridines (amlodipine, nifedipine) or non-DHP (verapamil, diltiazem)
• Especially effective in vasospastic angina

Ranolazine

Class 2b LOE B

• 500–1000 mg BID; useful for recurrent angina despite BB & CCB
• No mortality benefit; improves exercise tolerance

Long-Acting Nitrates

Class 2b LOE B

• Symptom relief when BB insufficient
• Require 10–12 hour nitrate-free interval daily to prevent tolerance
• Avoid with PDE5 inhibitors (severe hypotension)

Ivabradine

Class 2b LOE B

• If-channel inhibitor; reduces HR without negative inotropic effects
• Consider if HR >70 bpm on beta-blockers

SGLT2 Inhibitors & GLP-1 Receptor Agonists

SGLT2 Inhibitors

Class I LOE A

• Indication: CCD + type 2 diabetes → reduce MACE
• Agents: Empagliflozin, dapagliflozin (empagliflozin 10mg preferred if HFrEF)
• Benefits: Glycemic control, HF risk reduction, cardiorenal protection

GLP-1 Receptor Agonists

Class I LOE A

• Indication: CCD + type 2 diabetes + additional CVD risk or HF
• Agents: Semaglutide, liraglutide, dulaglutide (proven MACE reduction)
• Benefits: Weight loss, BP reduction, CVD risk reduction, renal protection

Combination SGLT2i + GLP-1 RA

Class 2a LOE B

• Recommended for CCD + diabetes + HF or CKD; complementary cardio-renal mechanisms

Revascularization in Chronic Coronary Disease

ISCHEMIA Trial: Key Findings

5,179 stable CAD patients with ≥50% stenosis and moderate-severe ischemia:

• No mortality benefit of routine invasive PCI vs. GDMT alone over ~3.3 years
• Invasive arm: more procedures (ICA, PCI, CABG) but no survival advantage
• Implication: Invasive revascularization NOT routinely indicated for moderate-severe ischemia in stable CCD

Indications for Revascularization

Class I LOE B

• Refractory Angina: Persistent symptoms despite optimized GDMT; PCI or CABG for symptom relief
• Hemodynamically Significant Lesions: If anatomically suitable and shared decision-making favors invasive approach
• ACS: Warranted (outside stable CCD scope)

Noninvasive vs. Invasive Strategy

Class 2b LOE A

• Shared decision-making essential for angina on GDMT with ischemia on testing
• Discuss risks/benefits of ICA and revascularization
• Many patients managed effectively with GDMT alone

Noninvasive Testing for Ischemia

Stress Testing

Class I LOE B

• Exercise ECG, stress nuclear imaging (SPECT), or stress echocardiography
• Risk stratification and revascularization guidance

Coronary Computed Tomography Angiography (CCTA)

Class I LOE B

• Noninvasive coronary imaging; evaluates anatomy and stenosis severity
• High sensitivity; negative study excludes significant CAD

Positron Emission Tomography (PET)

Class 2b LOE B

• Myocardial blood flow and reserve measurement for indeterminate cases

Cardiac Magnetic Resonance (CMR)

Class 2b LOE B

• Stress CMR for ischemia detection and risk stratification

Routine Periodic Testing

Class 3

• NOT recommended without clinical change or symptom recurrence

Cardiac Rehabilitation & Secondary Prevention

Cardiac Rehabilitation Programs

Class I LOE A

• Components: Aerobic exercise, resistance training, education, behavioral counseling, nutrition
• Duration: 12 weeks minimum; 2–3 sessions/week
• Benefits: Reduced mortality, improved QOL, better GDMT adherence, symptom relief
• Strongly encouraged: All CCD, especially post-ACS and post-revascularization

Mental Health Integration

Class 2a LOE B

• Screen for depression and anxiety (PHQ-9, GAD-7)
• Integrated treatment (pharmacologic + psychotherapy) improves outcomes
• Mindfulness and cognitive-behavioral therapy beneficial

Special Populations

Women With CCD

• Higher microvascular angina prevalence; similar GDMT approach
• Symptoms may differ (dyspnea, fatigue, atypical presentations)
• Pregnancy counseling; most CCD medications compatible

Diabetes & CCD

• Higher MACE risk; more aggressive lipid and BP targets
• SGLT2i and GLP-1 RA strongly recommended
• Glycemic target: HbA1c 7–8% (individualize for hypoglycemia risk)

Chronic Kidney Disease (CKD)

• eGFR <30: careful medication dosing (ACEi/ARB, SGLT2i, GLP-1 RA, statins)
• Higher MACE risk; intensive BP and lipid management
• SGLT2i protective for renal function; consider in all CCD + CKD

Elderly (≥75 years)

• Individualize targets; avoid aggressive BP/lipid reduction if frailty
• Address polypharmacy; deprescribe where appropriate
• Shared decision-making for revascularization; symptom-focused approach often preferred

Prior CABG Surgery

• Graft patency concerns; GDMT optimization essential
• Limited revascularization options; PCI for native or graft disease considered
• Aspirin + beta-blocker for graft patency maintenance

HFrEF (<40% LVEF) With CCD

• Quadruple therapy: ACEi/ARB + beta-blocker + aldosterone antagonist + SGLT2i
• Consider ICD/CRT for arrhythmia prevention and resynchronization
• Aggressive revascularization NOT routinely indicated (ISCHEMIA trial relevance)

Do's and Don'ts

Clinical Calculators & Risk Tools

Validated tools for risk stratification, treatment decisions, and patient communication: