Managing Chronic Coronary Disease: Key Perspectives

The following are key perspectives from a multisociety guideline for the management of patients with chronic coronary disease (CCD):

1. The CCD guideline emphasizes team-based, patient-centered care that considers social determinants of health along with associated costs while incorporating shared decision-making in risk assessment, testing, and treatment.
2. Lifestyle modification and nonpharmacologic therapies, including healthy dietary habits and exercise, are recommended for all patients with CCD.
3. Patients with CCD who are free from contraindications are encouraged to participate in habitual physical activity, including activities to reduce sitting time and to increase aerobic and resistance exercise. 
4. Cardiac rehabilitation for eligible patients provides significant cardiovascular benefits, including decreased morbidity and mortality outcomes.
5. Use of sodium glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists are recommended for select groups of patients with CCD, including groups without diabetes to improve outcomes.
6. Long-term beta-blocker therapy is not recommended to improve outcomes in patients with CCD in the absence of myocardial infarction in the past year, left ventricular ejection fraction ≤50%, or another primary indication for beta-blocker therapy. 
7. Either a calcium channel blocker or beta-blocker is recommended as first-line antianginal therapy.
8. Statins remain first line for lipid lowering in patients with CCD. Several adjunctive therapies (e.g., ezetimibe, proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors, inclisiran, bempedoic acid) may be used in select populations, although clinical outcomes data are not yet available for novel agents such as inclisiran and bempedoic acid.
9. 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 not high.
10. The use of nonprescription or dietary supplements, including fish oil and omega-3 fatty acids or vitamins, is not recommended in patients with CCD given the lack of benefit in reducing cardiovascular events.
11. Routine periodic anatomic or ischemic testing without a change in clinical or functional status is not recommended for risk stratification or to guide therapeutic decision-making in patients with CCD.
12. Although they increase the likelihood of successful smoking cessation, because of the lack of long-term safety data and risks of sustained use, e-cigarettes are not recommended as first-line therapy.
13. In patients with CCD and lifestyle-limiting angina despite guideline-directed management and therapy and with significant coronary artery stenoses amenable to revascularization, revascularization is recommended to improve symptoms.
14. In patients with CCD who require revascularization for multivessel coronary artery disease (CAD) with complex and diffuse CAD (e.g., SYNTAX score >33), it is reasonable to choose coronary artery bypass grafting over percutaneous coronary intervention to improve survival.
15. Finally, studies are needed to assess which interventions lead to effective guideline implementation in clinical practice. Similarly, research is needed to assess the effect of a new guideline release at the patient, clinic, hospital, health care system, and community levels.