2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease

Authors, Journal, Affiliations, Type, DOI

• Authors: Virani SS (Chair), Newby LK (Vice-Chair), Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS
• Journal: Circulation. 2023;148:e9–e119
• Affiliations: Multisociety — AHA, ACC, ACCP, ASPC, NLA, PCNA; endorsed by SCAI
• Type: Clinical practice guideline — full revision replacing 2012 ACCF/AHA Stable Ischemic Heart Disease guideline and 2014 focused update
• DOI: 10.1161/CIR.0000000000001168
• Published: August 29, 2023

Overview

This guideline provides a comprehensive, evidence-based, patient-centred framework for the management of chronic coronary disease (CCD), defined as stable outpatient coronary disease including post-ACS, ischaemic cardiomyopathy, stable angina syndromes, and INOCA. It replaces the 2012 stable ischaemic heart disease guideline and its 2014 focused update. Key new positions include: beta blockers do not reduce MACE in CCD without prior MI or LVEF ≤50% (COR 3); SGLT2 inhibitors and GLP-1 receptor agonists are now COR 1/A for CCD + T2DM; routine revascularisation does not improve survival in stable CCD (ISCHEMIA paradigm); and short DAPT (6 months) is default post-PCI with P2Y12 monotherapy as a Class 2a option. The guideline incorporates social determinants of health, shared decision-making, team-based care, and cost-value assessments.

Keywords

Chronic coronary disease, secondary prevention, angina, dual antiplatelet therapy, aspirin, beta blockers, SGLT2 inhibitors, GLP-1 receptor agonists, colchicine, statins, PCSK9 inhibitors, cardiac rehabilitation, revascularisation, PCI, CABG, FFR, INOCA, SCAD, diabetes, social determinants of health, shared decision-making

Key Takeaways

1. Scope and Definition of CCD

• CCD applies to patients in the outpatient setting: (1) post-ACS/revascularisation after stabilisation; (2) LV systolic dysfunction with known/suspected CAD; (3) stable angina on medical therapy; (4) coronary vasospasm or microvascular angina; (5) coronary disease identified on screening imaging
• ~20.1 million Americans have CCD; 11.1 million have stable angina; 25% of MIs in the US occur in the 8.8M persons with known prior MI
• The writing committee explicitly acknowledges the continuum from post-ACS to chronic outpatient management

2. Diagnostic Evaluation and Risk Stratification

• Stress PET/SPECT/CMR/echo (COR 1/B-NR): In patients with CCD and change in symptoms or functional capacity despite GDMT — to detect ischaemia, estimate MACE risk, guide decisions
• ICA (COR 1/B-R): For change in symptoms/functional capacity despite GDMT to guide revascularisation for symptom improvement
• PET preferred over SPECT (COR 2a/B-R): If available — better diagnostic accuracy and fewer non-diagnostic results
• MBFR (COR 2a/B-NR): Addition to stress PET/CMR improves risk stratification by detecting microvascular dysfunction
• Routine ICA (COR 3 No Benefit/A): Not routinely recommended for asymptomatic patients with stable chest pain controlled on GDMT — COURAGE, BARI-2D, ISCHEMIA all show no MACE reduction from routine revascularisation
• Risk categories: low (<1%), intermediate (1–3%), high (>3%) annual risk for CV death or nonfatal MI — integrate noninvasive/invasive results with clinical and social variables

3. Lifestyle: Nutrition, Physical Activity, Weight

• Diet (COR 1/B-R): Mediterranean-type — vegetables, fruits, legumes, nuts, whole grains, lean protein — reduces CVD events; avoid trans fat (COR 3 Harm); reduce saturated fat to <6% of total calories (COR 2a/B-NR)
• Physical activity (COR 1/A): ≥150 min/wk moderate-intensity OR ≥75 min/wk vigorous aerobic + resistance training ≥2 days/wk (COR 1/B-R)
• Dietary supplements (COR 3 No Benefit/B-NR): Omega-3 fatty acids, vitamin C, D, E, beta-carotene, calcium — no reduction in CVD events; consistent with ACC/AHA 2026 lipid guideline
• Weight management: GLP-1 receptor agonist COR 2a/B-R when pharmacotherapy warranted for overweight/obesity; semaglutide preferred over liraglutide (COR 2a/B-R); sympathomimetics COR 3 Harm
• Cardiac rehabilitation (COR 1/A after MI/PCI/CABG; COR 1/B-R for stable angina): Reduces all-cause/cardiovascular mortality, rehospitalisation, and improves QOL; home-based CR is acceptable alternative
• Tobacco: Behavioural + pharmacotherapy combined — COR 1/A; varenicline preferred (COR 2b); e-cigarettes not recommended as first-line (COR 2b)
• Alcohol: No alcohol recommendation for cardiovascular protection (COR 3 No Benefit); limit to ≤2 drinks/d men, ≤1 drink/d women (COR 2a)
• Mental health (COR 2a/B-R): Screen and treat depression/anxiety — associated with poor CCD outcomes; escitalopram reduced MACE after ACS (EsDEPACS)

4. Lipid Management in CCD

• High-intensity statin COR 1/A: Aim ≥50% LDL-C reduction; generic formulations are cost-saving (high value)
• Monitor lipids: 4–12 weeks after initiation/dose change, then every 3–12 months
• Very high risk definition (Table 10): Multiple major ASCVD events OR 1 major event + ≥2 high-risk conditions (age ≥65, FH, prior CABG/PCI, DM, HTN, CKD eGFR 15–59, smoking, LDL ≥100 on max statin+ezetimibe, HF)
  • Major ASCVD events: recent ACS ≤12 mo, MI, ischaemic stroke, symptomatic PAD
• Ezetimibe add-on (COR 2a/B-R): Very high risk + LDL ≥70 mg/dL on max statin; generic ezetimibe is high value (<$50K/QALY); IMPROVE-IT: 7% relative RRR; higher benefit in TRS2P ≥3 high-risk features
• PCSK9 mAb (COR 2a/A): Very high risk + LDL ≥70 or non-HDL ≥100 on max statin + ezetimibe; FOURIER (evolocumab), ODYSSEY OUTCOMES (alirocumab) — each reduced MACE by 15%; uncertain economic value at current US prices
• Icosapent ethyl (COR 2b/B-R): LDL <100 + TG 150–499 mg/dL on statin — REDUCE-IT: 25% MACE RRR (mineral oil placebo caveat acknowledged); incident AF more common
• Bempedoic acid / inclisiran (COR 2b): When ezetimibe and PCSK9 mAb are insufficient or not tolerated; no MACE outcome data at time of guideline publication (CLEAR Outcomes not yet reported)
• Niacin, fenofibrate, dietary omega-3 (COR 3 No Benefit): No CV event reduction when added to background statin

5. Blood Pressure Management

• Target <130/<80 mmHg — COR 1/B-R (25% reduction in CVD complications)
• ACEi/ARB or beta blockers: COR 1/B-R as first-line for compelling indications (recent MI, angina, LVEF ≤40%)
• Add dihydropyridine CCB, long-acting thiazide, and/or MRA as needed

6. SGLT2 Inhibitors and GLP-1 Receptor Agonists

• COR 1/A: SGLT2 inhibitor OR GLP-1 receptor agonist (with proven CV benefit) for CCD + T2DM to reduce MACE
• GLP-1 RA primarily reduce atherosclerotic events; SGLT2i primarily reduce HF hospitalisation and progression of CKD
• SGLT2i for HFrEF (LVEF ≤40%) — COR 1/A: Regardless of diabetes status — reduces CV death/HF hospitalisation; improves QOL (DAPA-HF, EMPEROR-Reduced, EMPEROR-Preserved)
• SGLT2i for HFpEF (LVEF >40%) — COR 2a/B-R: Reduces HF hospitalisation + improves QOL regardless of diabetes status (EMPEROR-PRESERVED, DELIVER)
• GLP-1 RA for weight management (COR 2a/B-R): semaglutide 2.4 mg weekly > liraglutide 3.0 mg daily for weight loss (STEP 8 trial)
• No data on CV benefit in CCD without T2DM or HF for either class

7. Antiplatelet Therapy in CCD

• Aspirin 81 mg daily — COR 1/A for CCD without OAC indication; 81 mg = 325 mg (ADAPTABLE trial)
• DAPT 6 months post-PCI → SAPT — COR 1/A (meta-analysis n=31,666: similar MACE, lower bleeding vs 12-month DAPT)
• P2Y12 monotherapy after 1–3 months DAPT — COR 2a/A: Reduces bleeding; trials: SMART CHOICE, STOP-DAPT2, TWILIGHT, GLOBAL LEADERS (35–62% stable patients)
• Extended DAPT >12 months (up to 3 years) for previous MI, low bleeding risk — COR 2b/A: PEGASUS-TIMI 54 — ticagrelor 60 mg BID: 16% reduction in CV death/MI/stroke; NNT ~91 to prevent 1 MACE over 31 months; increased major bleeding
• Low-dose rivaroxaban 2.5 mg BID + aspirin 81 mg — COR 2a/B-R: High ischaemic risk + low-moderate bleeding risk without OAC or DAPT indication — COMPASS: cardiovascular death/stroke/MI reduced 4.1% vs 5.4% with aspirin alone (terminated early for benefit); higher major bleeding (3.1% vs 1.9%)
• Vorapaxar (PAR-1 inhibitor) — COR 2b/B-R: Previous MI without stroke/TIA/ICH; reduces CV death/MI/stroke; COR 3 Harm if prior stroke/TIA/ICH (TRAP 2P-TIMI 50)
• PPI add-on — COR 2a/B-R to reduce GI bleeding on DAPT; avoid omeprazole/esomeprazole with clopidogrel (CYP2C19 interaction; no ischaemic impact in COGENT)
• No DAPT without recent ACS/PCI — COR 3 No Benefit/A: Clopidogrel + aspirin no better than aspirin alone in CCD without active indication
• NSAIDs — COR 3 Harm/B-R: Increase MACE, HF hospitalisation (all NSAIDs); coxibs and diclofenac also increase vascular events
• CCD with OAC (elective PCI) — COR 1/B-R: DAPT 1–4 weeks → clopidogrel + DOAC × 6 months; aspirin continuation for ≤1 month in high thrombotic risk (COR 2a); DOAC monotherapy COR 2b after 1 year post-PCI
• AFIRE trial: In stable CCD + AF >1 year post-PCI or CABG, rivaroxaban monotherapy non-inferior to rivaroxaban + antiplatelet for efficacy and superior for safety

8. Beta Blockers — Key Change

• COR 1/A: LVEF ≤40% with or without prior MI — reduces future MACE and CV death; benefits extend to HFmrEF (LVEF 40–49%)
• COR 1/A (sustained-release agents preferred): LVEF <50% — metoprolol succinate, carvedilol, bisoprolol titrated to target doses
• COR 2b/B-NR: Prior MI, preserved LVEF, ≤1 year ago — reasonable to reassess indication for long-term (>1 year) beta-blocker use; ongoing RCTs (REBOOT-CNIC, REDUCE-SWEDEHEART, BETAMI, DANBLOCK)
• COR 3 No Benefit/B-NR: No prior MI, LVEF >50%, no angina/arrhythmia/HTN — beta blockers not beneficial for MACE reduction; REACH registry, NCDR CathPCI registry, CHARISMA post-hoc analysis all consistently negative

9. RAASi (ACEi/ARB)

• COR 1/A: HTN + DM + LVEF ≤40% + CKD — reduces CV events and HF
• COR 2b/B-R: Without HTN, DM, CKD, and LVEF >40% — uncertain benefit (PEACE, QUIET, CAMELOT, IMAGINE trials: inconsistent)

10. Colchicine

• COR 2b/B-R: Secondary prevention — 0.5 mg daily to reduce recurrent ASCVD events
• LoDoCo2: colchicine vs placebo — 6.8% vs 9.6% primary MACE endpoint (P<0.001) in stable ASCVD; trend toward increased noncardiovascular death in colchicine group
• COLCOT: 5.5% vs 7.1% primary MACE (P=0.02) in recent ACS — driven by stroke and urgent hospitalisation for angina
• Avoid in eGFR <30 mL/min/m²; CYP3A4 substrate — drug interactions; narrow therapeutic index

11. Immunisations

• Influenza vaccination — COR 1/A: Annual — reduces CV death, MACE, all-cause death in CCD
• COVID-19 vaccination — COR 1/C-EO
• Pneumococcal vaccine — COR 2a/B-NR: Reduces ACS events and all-cause mortality

12. Antianginal Therapy

• First-line: beta blocker OR CCB OR long-acting nitrate — COR 1/B-R (equal evidence for CCB vs beta blocker for angina relief; no difference in death/MI)
• Combine agents if persistent angina — COR 1/B-R (non-DHP CCB + beta blocker: caution for bradycardia/LV dysfunction)
• Ranolazine (COR 1/B-R): Persistent angina despite beta blocker/CCB/nitrate — CARISA, ERICA trials
• Sublingual NTG — COR 1/B-NR: Immediate relief; spray superior to sublingual for speed/headache
• Ivabradine — COR 3 Harm/B-R: In CCD with normal LV function — BEAUTIFUL trial: increase in primary endpoint of CV death/MI (7.6% vs 6.5%; P=0.02)
• Enhanced external counterpulsation (COR 2b/B-R): Refractory angina with no other options only
• Phosphodiesterase type 5 inhibitors + nitrates — COR 3 Harm: Severe hypotension; sildenafil/vardenafil: hold nitrates ≥24 h; tadalafil ≥48 h

13. Revascularisation

• Symptom relief (COR 1/A): Revascularisation for lifestyle-limiting angina despite GDMT — ISCHEMIA, COURAGE, ORBITA confirm symptom improvement; no survival benefit in most patients
• CABG for ischaemic cardiomyopathy (LVEF ≤35%) — COR 1/B-R: STICH trial (n=1,212) — CABG + medical therapy vs medical therapy alone: CV death lower (28% vs 33%; P=0.05); all-cause death lower at 10-year follow-up. PCI for LVEF ≤35% did NOT improve survival — REVIVED-BCIS2: no difference in death/HF hospitalisation
• CABG for left main + high-complexity disease (SYNTAX >33) — COR 1/B-R: SYNTAX trial — lower MACE at 5 and 10 years with CABG
• CABG vs PCI for multivessel CAD (SYNTAX >33) — COR 2a/B-R: SYNTAX 10-year: 40% higher mortality with PCI in triple-vessel disease
• CABG for diabetes + multivessel CAD + LAD involvement — COR 1/A: FREEDOM trial: lower all-cause death and MACE with CABG vs PCI at 5 and 8 years (HR 1.36 for PCI)
• FFR or iFR before PCI for intermediate stenoses — COR 1/A: FAME-2: FFR-guided PCI superior to medical therapy for MACE (urgent revascularisation reduction); FFR-CT and iFR are reasonable alternatives
• Heart Team — COR 1/B-NR: Required for complex 3-vessel or left main disease
• No routine revascularisation for MACE reduction — COR 3/A: COURAGE, BARI-2D, ISCHEMIA — no improvement in composite MACE or all-cause death with routine revascularisation vs GDMT in most stable patients; ISCHEMIA: benefit at 7-year follow-up in CV mortality only

14. Special Populations

• SCAD: Conservative management preferred acutely; CR (COR 1); beta blockers (COR 2b) — 64% reduction in recurrent SCAD in observational study; evaluate for fibromuscular dysplasia/extracoronary arteriopathies (COR 2a)
• INOCA (COR 2a/B-R): Invasive coronary physiology-guided stratified medical therapy (CFR/IMR/FFR + acetylcholine vasoreactivity testing) — CorMicA trial: +11.7 units Seattle Angina Questionnaire at 6 months; endotype-specific antianginal therapy
• CKD: RAASi reduces CKD progression; SGLT2i beneficial; lipid management follows CCD guidelines; statin in dialysis: no benefit from two negative RCTs
• HIV (age 40+): Both SGLT2i/GLP-1 RA and lipid management apply (pitavastatin per REPRIEVE; see Dyslipidemia-Management)
• Diabetes + CCD: SGLT2i + GLP-1 RA both COR 1/A; CABG preferred over PCI for multivessel + LAD
• Cancer survivors: Continue CCD management; statins may reduce anthracycline cardiotoxicity
• Women/pregnancy: Evaluate adversarial pregnancy outcomes as CCD risk factors; hormonal therapy not cardioprotective
• Cardiac allograft vasculopathy: CR, lipid management, and HR reduction recommended

Limitations of the Document

• Literature search concluded May 2022 with additional studies through November 2022 — does not capture 2023 trial data (eg, CLEAR Outcomes for bempedoic acid published March 2023; results of SELECT trial for semaglutide in non-DM ASCVD; DANBLOCK etc.)
• High crossover rates in revascularisation RCTs (21–42% of GDMT patients underwent revascularisation); limits interpretation of null MACE effect
• Evidence for beta-blocker de-escalation is observational; RCTs (REBOOT-CNIC, REDUCE-SWEDEHEART, BETAMI, DANBLOCK) were ongoing at guideline publication
• INOCA recommendations largely based on single CorMicA trial with 6-month follow-up
• Cost-value assessments based on US prices and may not generalise globally

Key Concepts Mentioned

• concepts/DAPT-Strategies — CCD-phase antiplatelet management; SAPT as default post-6 months; P2Y12 monotherapy; extended DAPT; rivaroxaban low-dose
• concepts/ASCVD-Risk-Assessment — PREVENT equations; very high risk definition; risk-based lipid targets
• concepts/Dyslipidemia-Management — CCD lipid algorithm; high-intensity statin; ezetimibe; PCSK9 mAb; icosapent ethyl; nonstatin options
• concepts/LV-Diastolic-Function — HFpEF diagnosis; SGLT2i for HFpEF
• concepts/Right-Heart-Catheterization — INOCA endotyping; ischaemic cardiomyopathy haemodynamics

Key Entities Mentioned

• entities/Chronic-Coronary-Disease — primary entity; full management framework
• entities/Acute-Coronary-Syndrome — continuum from ACS to CCD; chronic phase transition
• entities/Heart-Failure — SGLT2i in HFrEF/HFpEF; CABG for ischaemic cardiomyopathy; beta blockers for LVEF ≤40%
• entities/Atrial-Fibrillation — anticoagulation strategy in CCD + AF; AFIRE trial

Wiki Pages Updated

• Created: wiki/entities/Chronic-Coronary-Disease.md
• Updated: wiki/concepts/DAPT-Strategies.md (CCD-phase antiplatelet section)
• Updated: wiki/entities/Heart-Failure.md (CCD + HF section: CABG/PCI for ischaemic cardiomyopathy, SGLT2i)
• Updated: wiki/concepts/Dyslipidemia-Management.md (CCD lipid management section)
• Updated: wiki/entities/Acute-Coronary-Syndrome.md (chronic phase transition cross-link)
• Updated: wiki/sourceindex.md, wiki/wikiindex.md, log.md