Symptom relief and healthy habits are top goals for treating chronic heart disease

Guideline Highlights:

• Healthy lifestyle and dietary habits remain the foundation of management for the more than 20 million people in the U.S. diagnosed with heart conditions known collectively as chronic coronary disease (CCD), according to the first comprehensive guideline update on CCD in a decade from the American Heart Association and the American College of Cardiology.
• The guideline states the top priorities in therapy should be reducing a patient’s future risk of cardiovascular events and providing symptom relief and improved quality of life.
• The guideline also emphasizes collaboration among primary care clinicians and various members of the cardiology team for treating CCD and updates recommendations on follow-up screening, medications and dietary supplements.

Newswise — DALLAS and WASHINGTON, July 20, 2023 —

According to the latest joint guideline from the American Heart Association and the American College of Cardiology, individuals in the U.S. suffering from chronic coronary disease (CCD), which encompasses various long-term vascular and heart conditions resulting in inadequate blood flow to or from the heart, can significantly improve their health by adopting a heart-healthy diet and lifestyle.

The guideline, published in the American Heart Association's Circulation journal and the Journal of the American College of Cardiology, underscores the importance of maintaining a healthy diet, engaging in regular physical activity, and avoiding smoking to prevent the deterioration of their condition. Additionally, the guideline updates several medication recommendations based on the most recent scientific data.

For those with CCD, including individuals experiencing chronic, heart-related chest pain, those who have undergone heart attack, coronary stent, or bypass surgery, and those with evidence of reduced blood flow to the heart based on diagnostic testing, the guideline recommends considering the use of specific medications. These include SGLT-2 inhibitors, GLP-1 receptor agonists, beta blockers, bempedoic acid, and inclisiran.

With more than 20 million people in the U.S. affected by chronic coronary disease, adhering to these guidelines can significantly contribute to improving their overall health and quality of life.

Salim S. Virani, M.D., Ph.D., FAHA, FACC, who chairs the joint guideline writing committee for the American Heart Association and the American College of Cardiology, emphasized the significant advancements in the science guiding the management of care for individuals with chronic coronary disease (CCD) since the 2012 guideline and its subsequent 2014 update. Dr. Virani, also serving as vice provost for research at Aga Khan University in Pakistan and a cardiologist at the Texas Heart Institute and adjunct professor at Baylor College of Medicine in Houston, shared that the prognosis for CCD patients has greatly improved due to the combination of healthy lifestyle habits and the remarkable progress in medical therapy.

The management principles outlined by the American Heart Association and the American College of Cardiology for patients with CCD are as follows:

• 1.Prioritize treatment based on a patient's risk for future cardiovascular events.
• 2.Recognize the importance of symptom relief and maintaining a good quality of life.
• 3.Encourage team-based care, involving primary care clinicians working collaboratively with cardiology specialists, to provide comprehensive and effective management for individuals with CCD.

Considering the patient's perspective and ensuring a good quality of life are vital aspects when evaluating treatment options for chronic coronary disease (CCD), as highlighted in the guideline. To achieve this, clinicians are recommended to conduct a comprehensive risk assessment during annual follow-up visits. This assessment involves evaluating all medical and social factors related to heart health in CCD patients.

During these follow-up visits, clinicians should discuss the risk assessment findings with their patients and provide education on symptom management and available treatment options. The aim is to actively involve patients in the decision-making process regarding their care. In some cases, based on the risk assessment and patient discussions, clinicians may recommend therapies that primarily focus on relieving symptoms, even if they may not necessarily prolong life or reduce the risk of cardiovascular events.

According to L. Kristin Newby, M.D., MHS, co-chair of the guideline committee and professor of medicine at Duke University School of Medicine in Durham, NC, regular conversations between CCD patients and their healthcare professionals are essential. These discussions ensure that patients are adhering to the most up-to-date diet, physical activity, and lifestyle recommendations, as well as receiving all appropriate evidence-based therapies. This approach helps strike a balance between maintaining a good quality of life and minimizing the risk of future cardiovascular events.

The guideline places significant emphasis on the importance of coordinated care between cardiovascular and primary care professionals for individuals with chronic coronary disease (CCD). This collaborative approach is essential because the care team interacts with CCD patients multiple times over an extended period, and treatment needs to be continually assessed and adjusted as necessary.

According to Virani, "Management of CCD is a team sport." It is crucial for both primary and specialty care clinicians to fully utilize the expertise and skills of all members of the cardiovascular care team. This includes physicians, nurse practitioners, physician assistants, nurses, nursing assistants, pharmacists, dietitians, exercise physiologists, physical, occupational, and speech therapists, psychologists, and social workers. By leveraging the collective capabilities of the care team, the aim is to maximize the benefits and outcomes for patients with CCD, ensuring they receive comprehensive and well-rounded care throughout their journey.

The guideline provides additional medication and lifestyle recommendations for individuals with chronic coronary disease (CCD), which are as follows:

• 1. Glucose-lowering medicines: Two classes of medications traditionally used for Type 2 diabetes, namely SGLT-2 inhibitors and GLP-1 receptor agonists, offer potential cardiovascular benefits in addition to controlling blood sugar. They aid in weight loss, reduce the progression of kidney disease, and lower the risk of cardiovascular events, even in CCD patients without Type 2 diabetes.
• 2. Beta-blocker medications: Beta-blockers are medications that decrease heart rate and the force of heart contractions, effectively reducing blood pressure. The guideline advises against routine long-term use of beta-blockers for CCD patients who haven't had a heart attack within the past year or whose left ventricular ejection fraction is at or above 50% (indicating effective blood pumping).
• 3. New cholesterol-lowering medicines: Statins are the primary choice for lowering cholesterol levels. However, for CCD patients with persistent high cholesterol or those who can't tolerate statins, alternative medicines like ezetimibe, PCSK9 inhibitors, bempedoic acid, and inclisiran may be considered.
• 4. Less time on antiplatelet medicine: Antiplatelet medication helps prevent clotting in cardiovascular conditions. The guideline recommends shorter durations of dual antiplatelet therapy, which involves adding a second antiplatelet to the treatment regimen for some patients.
• 5. Supplements not recommended: There isn't enough evidence to support the use of non-prescription nutrition or dietary supplements (e.g., omega-3 fatty acids, vitamins C, D, or E, beta-carotene, or calcium) for CCD patients.
• 6. When tests are not needed: Routine follow-up screening with stress testing or computed tomography is not recommended for CCD patients on guideline-directed therapies without changes in symptoms or functional status.
• 7. Smoking cessation: Behavioral interventions combined with nicotine replacement therapy are recommended for CCD patients who smoke regularly to aid in quitting. In select cases, short-term use of e-cigarettes for smoking cessation may be considered in consultation with a medical professional.
•  8. However, CCD patients using e-cigarettes for smoking cessation should be warned about potential long-term dependence and encouraged to quit promptly to avoid risks. E-cigarettes are not recommended as the first-line therapy for smoking cessation due to lack of long-term safety data and potential risks of sustained use.

"We have seen significant advancements in our understanding of the role of social determinants of health, shared decision-making, and the importance of a team-based approach to care, thanks to new evidence," stated Virani. "The latest guideline incorporates this new information, providing evidence-based recommendations to enhance care for individuals with chronic coronary disease (CCD)."

For over 40 years, the American Heart Association and the American College of Cardiology have worked together to translate scientific evidence into clinical practice guidelines, aiming to improve cardiovascular health. This particular guideline was developed in collaboration with and endorsed by esteemed organizations such as the American College of Clinical Pharmacy, the American Society for Preventive Cardiology, the National Lipid Association, and the Preventive Cardiovascular Nurses Association. Additionally, it has gained endorsement from the Society for Cardiovascular Angiography and Interventions. The writing group comprised representatives from each of these collaborating organizations.

The manuscript includes a list of co-authors and disclosures.

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