Take a team approach to coronary disease

In the first major update on diagnosing and managing chronic coronary disease (CCD) in over a decade, a guideline from the American Heart Association/American College of Cardiology (AHA/ACC) highlights the importance of team-based, patient-centered care and makes new recommendations on drug and lifestyle therapies. (Hint: It's not just about writing prescriptions.)

“One of the biggest messages is that managing chronic coronary disease is a team sport involving primary care physicians, cardiologists, nurses, and anyone else who touches the patient, including their family,” said Kristin Newby, MD, vice chair of the guideline's writing committee and professor of medicine at Duke University School of Medicine in Durham, N.C. “We also highlight the impact of social determinants of health on how we deliver care and acknowledge that some decisions will be based on factors like patient preferences, affordability, or geography.”

The guideline, which was published in July 2023 in Circulation and the Journal of the American College of Cardiology, encompasses patients with chronic coronary heart disease. Notably, it puts team-based, patient-centered care at the forefront of management and highlights the role of healthy diet and exercise habits in reducing cardiovascular risk and improving overall quality of life.

In a shift from past guidance, the committee also recommends stopping beta-blockers in patients with stable disease. Pointing to evidence from multiple studies, the experts conclude that beta-blocker therapy is not necessary in patients without primary indications, such as myocardial infarction in the past year or left ventricular ejection fraction of 50% or less.

“We previously advised leaving all patients on beta-blockers for three years or more,” said Dr. Newby. “But there's now strong evidence that long-term use doesn't benefit most patients unless they have other indications, such as heart failure.”

Putting patients at the center

While concepts like shared decision making and patient-centered care aren't new, they're given significantly more weight than in past guidelines, experts said.

“The guideline committee considered the whole disease experience,” said Clyde W. Yancy, MD, MSc, MACP, chief of the division of cardiology at Northwestern University's Feinberg School of Medicine in Chicago. “There's a strong emphasis on prevention, lifestyle, and secondary prevention and a major focus on collaboration among a team of professionals, with the patient at the center.”

The prominent inclusion of social determinants of health—a concept that wasn't even mentioned in previous guidelines—is a welcome addition, noted Dr. Yancy.

“It's become evident that certain community-based issues, such as housing or transportation, have great bearing on patient outcomes; we need to pause and consider those factors,” he said. “If we can identify a need or void and address it, patient outcomes will improve.”

Social determinants of health, including access to care, are key drivers of persistent health disparities and inequities, the guideline states. Care teams should conduct routine screening of patients with CCD to identify potential barriers to effective treatment, such as mental health issues, poor health literacy, or lack of insurance coverage, and connect patients with “tangible and practical community-based resources and services.”

Providing such services can be challenging in a busy primary care office, especially in remote or under-resourced areas, Dr. Newby acknowledged. That's why it's so important to work in teams that include physicians and other clinicians throughout the community.

“Primary care offices can extend what they do by cultivating relationships with other service providers,” she said. “Connecting with people in the community who can help, such as social workers, case managers, and nutritionists, is a really important part of managing these patients.”

Still, translating such recommendations into practice can be challenging, even with adequate staffing, said Robert O. Roswell, MD, FACP, a cardiologist at Northwell Health Zucker School of Medicine in Uniondale, N.Y. For example, the guideline urges physicians to talk with patients about cost, but it's difficult to fit that conversation into a 20-minute visit.

“It's quite time-consuming to look up and compare the side effects and costs of all the various statin medications during an office visit,” he said. “Even if I have a care navigator, the patient might have to come back to me if the copay for the statin I prescribed is very high and they want to discuss other options.”

Although it may be out of reach for some practices, having a staff nurse act as patient navigator or care coordinator is ideal, said David L. Fischman, MD, FACP, a cardiologist at Jefferson Health in Philadelphia. A coordinator can follow up on issues covered during the office visit and act as a resource for patients on implementing elements of their care plan.

For example, he said, if the physician stresses the importance of daily exercise, the coordinator can follow up with resources and details on what types of activities are most beneficial. They can also advise patients on dietary habits and other home health issues.

Managing medications

It's impossible to thoroughly cover all aspects of CCD management in one office visit, noted ACP Member Lauren Weber, MD, a cardiologist at Confluence Health in Wenatchee, Wash. During the first follow-up appointment, the cardiologist typically focuses on reviewing patients' symptoms and medications, including documenting goals of therapy.

That documentation is an important guide for primary care physicians, who handle ongoing follow-up care throughout the year, she said. Once patients have stable angina symptoms, primary care physicians focus on reaching recommended targets for blood pressure and cholesterol control.

“Ideally, the relationship between the cardiologist and primary care physicians is very collaborative,” she said. “With good communication, patients don't necessarily have to come back to see me in order to change a dose or stop or start a medication.”

According to the updated guideline, statins remain the first-line drug therapy for lipid-lowering. Ezetimibe and PCSK9 monoclonal antibodies may supplement statins if patients on a maximally tolerated dose are not reaching the recommended target of at least a 50% reduction in low-density lipoprotein (LDL) cholesterol levels.

“Everyone with chronic coronary disease should be on a statin,” said Dr. Fischman. “It's important to take the time to explain to patients why they're so important.”

That includes encouraging patients to stick with therapy and contact you about any concerns or side effects, he said. Otherwise, a patient might discontinue therapy on their own based on a perceived side effect, such as muscle aches, that turns out to be unrelated to the statin.

In the past, patients also stayed on beta-blockers indefinitely but experts now advise discontinuing them after a year in the absence of worsening symptoms.

“Cardiologists have been questioning the long-term use of beta-blockers for years, and large studies have shown that chronic use isn't beneficial,” said Dr. Roswell. “We can now say to patients that it might only be a year, depending on how they're doing.”

Patients are usually relieved to hear that they don't have to be chained to a medication indefinitely, especially since beta-blockers can contribute to depression and reduced libido, he said. Drugs that lower heart rate also make it harder to gauge exercise intensity.

“There are probably scores of patients with no symptoms who have been on a beta-blocker for 20 years or more,” said Dr. Roswell. “This is a great time for primary care physicians to do an inventory of patients who are taking beta-blockers and have conversations about whether they could be discontinued.”

The guideline also updates recommendations on dual antiplatelet therapy—typically aspirin and clopidogrel or another blood thinner. Discontinuing therapy is now considered safe and effective for most patients, especially those with high risk of bleeding and low to moderate ischemic risk.

“Many patients with chronic coronary disease have had a previous coronary intervention and are on antiplatelet therapies,” said Dr. Fischman. “The data show that we can now shorten that duration based on a patient's risk of bleeding or having an ischemic event.”

Physicians can use validated risk scores to determine bleeding risk, the guideline states, such as PRECISE DAPT (Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy) and PARIS (Patterns of Non-Adherence to Antiplatelet Regimen in Stented Patients).

Dr. Fischman recommends keeping an open dialogue with the cardiologist about whether and when to change antiplatelet therapy. The decision can be difficult for primary care physicians to make without knowing details of the complexity of the patient's coronary disease and placement of a stent or stents.

“If you have a patient who underwent PCI [percutaneous intervention] six or more months ago, consider reaching out to their cardiologist to discuss going down to a single antiplatelet agent,” Dr. Weber said. “For most patients who are on dual antiplatelet therapy due to acute coronary syndrome, we will still continue DAPT for a year.”

The guideline also includes two newer diabetes and lipid management therapies. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists are recommended for CCD patients with type 2 diabetes and reduced ejection fraction (with or without diabetes).

However, the committee notes that the benefits of SGLT-2 inhibitors and GLP-1 receptor agonists may not justify the high prices of such drugs in patients with preserved ejection fraction, with or without diabetes.

“Cost is an issue with newer, brand-name drugs,” said Dr. Fischman. “However, studies show that they can be effective and have a significant mortality benefit, particularly in [patients with diabetes].”

The update endorses revascularization for patients who experience lifestyle-limiting angina despite adhering to recommended medications and other therapies.

“When symptoms are present, revascularization in conjunction with medical therapy gives patients the best possible outcomes,” said Dr. Yancy. “We know that percutaneous coronary intervention and surgery relieve angina, but we have less evidence that revascularization extends life expectancy.”

Lifestyle and prevention

The importance of implementing healthy diet and exercise habits is among the top take-home messages in the new guideline. Patients should be encouraged to participate in cardiac rehab, if eligible, and adopt daily exercise habits, including aerobic and resistance training, to reduce time spent sitting.

“In addition to cardiac rehab, we're now seeing recommendations for walking and resistance training, for all activities that get people up and moving,” said Dr. Weber. “We should encourage any type of exercise that people want to do. I tell patients to pick something they enjoy because it's more likely to be sustainable.”

The cardiologist may go over recommendations for cardiac rehab, diet, and exercise in initial follow-up visits and yearly check-ins thereafter, said Dr. Weber. However, primary care offices can monitor patients throughout the year, along with handling annual checkups for patients who have been stable for many years.

“Lifestyle is such an important part of CCD management,” said Dr. Newby. “Physicians should be addressing diet, exercise, weight loss, and smoking cessation at every visit.”

She recommends using checklists to ensure that all medications and lifestyle issues are covered. Additionally, she said, resist glossing over issues that may seem obvious, such as the significance of losing weight or quitting smoking.

“We often underestimate how important it is to have a physician tell a patient to do something,” she said. “But it's been shown that the smoking quit rate can be as high as 15% if a doctor instructs a patient to do it. It's important to raise issues and state clearly what needs to be done.”

Routine testing is no longer recommended in patients with stable disease, she added. Annual stress testing or echocardiography is not needed unless new symptoms emerge or the patient is experiencing issues, such as difficulty breathing.

That's a change from current practice, said Dr. Weber.

“We're used to doing an annual echocardiogram or stress test, but based on the new recommendations we may have to have conversations with patients to reset expectations,” she said. “The patient is really in the driver's seat in terms of what they're feeling. If they're doing well, we don't necessarily need to routinely check in.”

Patients may feel overwhelmed by the need to make multiple changes to their routines, especially if they are extremely overweight or haven't exercised regularly in the past, said Dr. Fischman. It's important to start with simple, practical suggestions.

“I talk to patients about how they can build up their exercise over time,” he said. “Start with as little as [walking] a couple of blocks and add more every day, or take the stairs instead of the elevator. Any exercise counts.”

As the latest recommendations stress, lifestyle interventions can mitigate the need for long-term use of medications, which can be motivating for patients with chronic conditions.

“I tell patients that if they lose weight, their numbers will get better and we may not have to add another medication to control their cholesterol or high blood pressure,” said Dr. Fischman. “That physician-patient partnership is very important. Management isn't just about doctors writing prescriptions.”