SUMMARY: 

Chronic coronary disease (CCD) affects 20 million persons in the United States. CCD includes patients with obstructive and nonobstructive coronary artery disease with or without previous heart attacks or revascularization.  

• Evaluation of CCD 
• Lifestyle Interventions 
• Mental Health 
• Sexual Health 
• Weight Management 
• Physical Activity 
• Immunizations 
• Follow up 

EVALUATION OF CCD 

• In patients with CCD and a change in symptoms or functional capacity that persists despite guideline directed management and therapy (GDMT), image guided stress testing is recommended to detect the presence and extent of myocardial ischemia. This can help estimate risk of major cardiovascular events and guide decision making. Alternatively, invasive angiography is recommended with goal of improving anginal symptoms (not mortality) 
• GDMT: Pharmacological and procedural treatments aim to optimize Dyslipidemia| Hypertension| Hyperglycemia | Weight Management| Nutrition | Physical Activity  
• In patients with CCD with newly reduced LV systolic function or clinical heart failure, invasive angiography is recommended to assess coronary anatomy and guide revascularization as appropriate. 
• Invasive angiography is NOT recommended for patients without LV systolic dysfunction, heart failure, or stable chest pain. 

LIFESTYLE INTERVENTIONS 

Nutrition 

• Emphasize diet rich in vegetables, fruits, nuts, legumes, whole grains and lean protein 
• Reduce saturated fat (<6% of total calories) and avoid trans fat 
• Minimize sodium intake (<2 grams/day), sugar-sweetened beverages and processed meats 
• Mediterranean-type diet helps reduce cardiovascular risk factors and thus cardiovascular events.  

Tobacco use

• Assess tobacco use at every office visit and advise patients to quit utilizing behavioral interventions with combined pharmacotherapy to maximize successful cessation of use. 
• Pharmacotherapy includes varenicline, bupropion or combination long and short acting nicotine replacement therapy. 
• Tobacco cessation is associated with >30% reduction in death and heart attacks 

Alcohol and Substance Use: 

• Limit alcohol intake to ≤ 1 drink per day for women and ≤ 2 drinks per men 
• Not advised to consume alcohol for sole purpose of cardiovascular protection 
• Counsel against substance use specifically cocaine| amphetamines| opioids |marijuana  

MANAGEMENT OF COMORBIDITIES  

Mental Health

• 20-40% of patients with CCD have concomitant mental health conditions (i.e. depression and anxiety) 
• Screening for mental health disorders and referral as appropriate is advised 

Weight Management 

• Assess BMI routinely during office visits. Patients overweight or obese should be counseled on diet and lifestyle goals for weight loss.  
• Pharmacological therapy, specifically GLP-1 receptor agonist, semaglutide or liraglutide can be beneficial in addition to diet and physical activity to help patients lose weight. Bariatric surgery can be reasonable for those patients who meet criteria and unable to achieve weight loss goals with other interventions 
• Use of sympathomimetic (i.e. phentermine) weight loss drugs can be harmful 

Sexual Health 

• Risk of heart attack or sudden death resulting from sexual activity is very low. Patients with CCD who want to engage in sexual activity should undergo a medical evaluation. In general, sexual activity represents moderate physical activity at around 3-5 metabolic equivalents (METS) 
• Phosphodiesterase type 5 inhibitors should NOT be used concomitantly with nitrate medications due to risk of severe hypotension 

Immunizations

• Annual influenza vaccination is recommended to reduce cardiovascular death 
• SARS-CoV2 vaccination is recommended to reduce COVID-19 complications 
• Pneumococcal vaccine is reasonable to reduce mortality 

Physical Activity

• Aim to improve functional capacity, quality of life and reduce mortality. 
• Recommend ≥150 minutes/week of moderate intensity exercise or ≥75 minutes/week of high intensity exercise 
• Cardiac Rehabilitation: Refer all patients with CCD after recent heart attack| Percutaneous Coronary Intervention| CABG | Stable Angina   

FOLLOW UP  

• Clinical follow-up at least annually to assess for symptoms (using validated patient-reported health status measure if feasible, change in functional status, adherence to and adequacy of lifestyle and medical interventions and monitoring for complications of CCD therapy)  
• If no change in clinical or functional status on optimized GDMT, routine periodic stress testing, LV function assessment or invasive angiography is NOT recommended 

Learn More – Primary Sources: 

AHA/ACC Clinical Practice Guidelines Chronic Coronary Disease 2023