Annika Skogg, PharmD, M Health Fairview
Background: The new 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease provides an evidenced-based and patient-centered update to the 2012 Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. The guideline received a focus update in 2014, but has not been updated since. Therefore, the 2023 guidelines are consolidating information from the 2012 guidelines, the 2014 focus update, and any new evidence established in literature.
This new guideline recommends using the term chronic coronary disease (CCD) rather than “stable ischemic coronary disease” to reflect the dynamic process of coronary artery disease (CAD) along with the potential for acute and chronic management of coronary disease. CCD is a heterogeneous term that includes obstructive and nonobstructive CAD with or without previous myocardial infarction (MI) or revascularization, ischemic heart disease diagnosed only by noninvasive testing, and chronic angina syndromes with varying underlying causes.
In addition to an updated recommendation to use sodium-glucose cotransporters-2 (SGLT-2) inhibitors in CCD regardless of diabetes status, there are new recommendations for the use of beta-blockers in patients without left ventricular (LV) dysfunction.
Evidence: The strongest evidence for major adverse cardiovascular events (MACE) reduction with beta-blockers continues to be in patients with LV systolic dysfunction (left ventricular ejection fraction (LVEF) <50%). The evidence for those without LV dysfunction has been challenged in a new era of revascularization, antithrombotic therapy, and lipid-lowering therapy. The 2012 guidelines recommended that beta-blocker therapy should be started and continued for three years in all patients with normal LV function after MI or acute coronary syndrome (ACS) (Level of Evidence B). In the 2023 guidelines, primary indications for beta-blockers still include angina, uncontrolled hypertension, and arrhythmias; however, it may be reasonable to reassess the long-term (>1 year) use of beta-blockers in patients with CCD who were initiated on beta-blocker therapy following a previous MI and currently have LVEF >50% with no history of uncontrolled hypertension, angina, or arrhythmias (Class 2b recommendation, Level of Evidence B).
The guidelines call out that long-term use of beta-blockers in patients without uncontrolled hypertension, angina, or arrhythmias may put patients at risk of fatigue, depression, and drug-drug interactions without additional clinical benefit. Observational studies have shown inconsistent results regarding the clinical benefit of long-term use of beta-blockers. Both the REACH and CHARISMA trials displayed no benefit of a beta blocker in patients with preserved LVEF and no previous MI. There are several ongoing large randomized controlled trials to evaluate the efficacy, safety, and quality of life associated with beta-blocker therapy in patients with preserved LV systolic function following an MI including REBOOT-CNIC (Treatment with Beta-blockers after MI without Reduced Ejection Fraction), REDUCE-SWEDEHEART (Evaluation of Decreased Usage of Beta-blockers After MI in the Swedeheart Registry), BETAMI (Beta-blocker Treatment after Acute MI in Revascularized Patients without Reduced LVEF), and DANBLOCK (Danish Trial of Beta-blocker Treatment after MI Without Reduced LVEF).
Discussion/Clinical impact: Beta-blockers remain a first-line option for the treatment of hypertension in patients with CCD. In patients with LVEF >50% and no hypertension, angina, or arrhythmias, consider evaluating for adverse effects from the long-term use of beta-blockers and discontinuing the beta-blocker. Results from ongoing trials will help assess the efficacy of the long-term use of beta-blockers beyond one year in patients without left systolic dysfunction, hypertension, angina, or arrhythmias.
References:
1. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):e354-e471.
2. Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014;64(18):1929-1949.
3. Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2023;148(9):e9-e119.
4. Chronic Coronary Syndrome – a new era for the diagnosis and management of stable coronary artery disease? BCS. Published March 6, 2020. Accessed December 15, 2023. https://www.britishcardiovascularsociety.org/resources/editorials/articles/chronic-coronary-syndrome-a-new-era-for-the-diagnosis-and-management-of-stable-coronary-artery-disease