Insight into the Updated AHA/ACC Guidelines on Treating Chronic Heart Disease

In July 2023, the American Heart Association and the American College of Cardiology released an updated guideline on the management of chronic coronary disease (CCD), in collaboration with several other professional organizations.¹ The previous recommendations on the topic were published more than a decade ago.

“This guideline provides a much-needed update to the 2012 guideline on the management of stable ischemic heart disease, so there are a lot of changes,” said one of the guideline authors, Dave L Dixon, PharmD, the Nancy L and Ronald H McFarlane Professor of Pharmacy and professor of internal medicine in the division of cardiology at Virginia Commonwealth University in Richmond, Virginia, and member of the ACC Prevention of Cardiovascular Disease Council. 

Along with recommendations on new medication classes and updated recommendations on the use of beta blockers in patients with CCD, some of the most notable additions to the new guideline include “several concepts regarding the importance of social determinants of health and how we leverage a team-based approach to care” for this patient population, according to the lead author of the guideline, Salim S. Virani, MD, PhD, professor in the sections of cardiology and cardiovascular research at Baylor College of Medicine in Houston, Texas. Available evidence on the relationship between environmental exposures in patients with CCD are also discussed. 

Selected highlights from the new guideline are summarized below.

Multidisciplinary, Team-Based Approach

Patients with CCD should be seen for follow-ups at least once per year for assessment of symptoms, functional status, adherence to medications and lifestyle interventions, and complications of disease or treatments.

Long-term CCD management should be based on a patient-centered, multidisciplinary team-based approach that emphasizes shared decision-making between clinicians and patients (class of recommendation [COR], 1; level of evidence [LOE], A). This approach has been linked to improved health outcomes, patient self-efficacy, health-related quality of life (QOL), health service utilization, and management of atherosclerotic cardiovascular disease (ASCVD) risk factors in CCD patients.

To facilitate the shared decision-making process, the care team should routinely assess for social determinants of health (SDOH), which affect all aspects of CCD management (COR, 1; LOE, B-R).

“Routine SDOH screening in patients with CCD… should encompass assessment of mental health, psychosocial stressors, health literacy, sociocultural influences (language, religious affiliation, body image), financial strain, transportation, insurance status, barriers to adherence to a heart healthy diet (food security), neighborhood or environmental exposures, and viable options for regular physical activity and social support,” as explained in the guideline. “Based on identified barriers or needs, collaborative cardiovascular care teams can provide tangible and practical community-based resources and services to patients.”

Nonpharmacologic Strategies

Guidance on nonpharmacologic approaches to CCD management includes nutritional recommendations such as adherence to a diet emphasizing fruits and vegetables, legumes, nuts, whole grains, and lean proteins (COR, 1; LOE, B-R) and minimizing intake of saturated fat, sodium, refined carbohydrates, and processed meats (COR, 2a; LOE, B-NR).

In addition, consumption of trans fat, such as those found in certain baked goods and fried foods, should be avoided due to evidence linking trans fat to increased rates of morbidity and mortality in patients with CCD and the general population (COR, 3: Harm; LOE, B-NR).

The guideline also noted the lack of evidence supporting the use of dietary supplements such as omega-3 fatty acids, calcium, and vitamin D in reducing the risk of acute CV events (COR, 3: No benefit; LOE, B-NR).

Other recommendations in the area of nonpharmacologic strategies include regular assessment and cessation interventions for tobacco use, and guidance on minimizing alcohol intake to reduce CV mortality and all-cause death. 

In terms of physical activity, an exercise regimen consisting of at least 150 minutes of moderate-intensity aerobic activities or at least 75 minutes of higher-intensity aerobic activities per week is recommended to improve functional capacity, QOL, hospital admission rates, and mortality rates in patients with CCD who do not have contraindications to such a regimen (COR, 1; LOE, A).

In the absence of contraindications, strength training exercises on 2 or more days per week are also recommended (COR, 1; LOE, B-R), as well as non-exercise activities–such as gardening and taking walking breaks at work–to reduce sedentary time (COR, 2a; LOE, B-NR).

For eligible patients, cardiac rehab may reduce CV morbidity and mortality.

Minimization of environmental exposures, including ambient air pollution (COR, 2a; LOE, B-NR) as well as extreme temperatures and wildfire smoke (COR, 2b; LOE, B-NR), is recommended to reduce the risk of CV events in patients with CCD.

Pharmacologic Therapies

SGLT2 inhibitors and GLP-1 receptor agonists. The use of an SGLT2 inhibitor or a GLP-1 receptor agonist with proven CV benefit is recommended for patients with CCD and type 2 diabetes to reduce the risk for major adverse cardiac events (MACE; COR, 1; LOE, A).

Regardless of diabetes status, the use of an SGLT2 inhibitor is recommended for patients with CCD and heart failure with a left ventricular ejection fraction (LVEF) of 40% or less, to reduce the risk of CV death and hospitalization due to heart failure and improve QOL (COR, 1; LOE, A). The use of an SGLT2 inhibitor may also reduce heart failure hospitalizations and improve QOL in those with heart failure with an LVEF of more than 40%, regardless of diabetes status (COR, 2a; LOE, B-R).

Beta blockers. The use of beta blockers is recommended for patients with CCD and an LVEF of 40% or less, regardless of myocardial infarction (MI) history, to reduce the risk for future MACE (COR, 1; LOE, A).

The use of sustained release metoprolol succinate, carvedilol, or bisoprolol with titration to target doses is recommended over other beta blockers for patients with CCD and an LVEF of less than 50% (COR, 1; LOE, A).

In those who were previously initiated on beta blocker therapy after MI and with no history of or current LVEF of 50% or less, angina, uncontrolled hypertension, or arrhythmias, the guideline states that “it may be reasonable to reassess the indication for long-term ([more than] 1 year) use of beta blocker therapy for reducing MACE” (COR, 2b; LOE, B-NR).

As a new addition to the guideline, the use of beta blockers is not recommended for reducing MACE in patients without previous MI or LVEF of 50% or less or another primary indication for beta blocker therapy (COR, 3: No benefit; LOE, B-NR).

Antiplatelet therapy and oral anticoagulants. Other key updates in the new guideline include a “shift toward shorter durations for dual antiplatelet therapy in select patients,” Dr Dixon said.

Among the evidence supporting this shift, a meta-analysis of 10 RCTs with a combined total of 31,666 patients, a shorter duration of dual antiplatelet therapy (DAPT) was associated with lower all-cause mortality compared to a longer duration of DAPT after drug-eluting stent implantation.² While rates of mortality, MI, and stent thrombosis were similar between patients treated with DAPT for 6 months or less and those treated with 1-year DAPT, rates of major bleeding were lower in patients treated with DAPT for 6 months or less compared to 1 year.²

Another large meta-analysis found that short-term DAPT (less than 6 months) followed by P2Y12 inhibitor monotherapy was associated with a reduced risk for major bleeding compared to 12-month DAPT after drug-eluting stent implantation.³

“Shorter durations of dual antiplatelet therapy are safe and effective in many circumstances, particularly when the risk of bleeding is high and the ischemic risk is low to moderate,” according to the guideline.

Dr Virani advised that clinicians review the guideline and determine “how their current practice patterns align with these recommendations, whether they need to make any changes and what evidence supports these changes, and then utilize the excellent resources available on the ACC and AHA websites.”^4,5

He noted that the recommendations can be implemented over time and suggested that clinicians initially focus on Class 1 and Class 3 recommendations—what should be done and what should be avoided, respectively—before aiming to incorporate recommendations of a lower class, such as 2a and 2b.

In sum, “This is an essential guideline for clinicians because it encompasses aspects of multiple guidelines into one to provide a comprehensive guide on managing patients with chronic coronary disease,” Dr Dixon stated.