Chronic Coronary Disease Guideline E2: Risk Assessment and Lifestyle Factors
Chronic Coronary Disease Guideline E2: Risk Assessment and Lifestyle Factors
Risk assessment is the foundation that treatment decisions are built upon. In this episode, Dr. Virani and Newby discuss the guideline’s detailed recommendations when it comes to evaluation and risk assessment, including the encouragement to defer testing in certain patients due to its inherent risks and costs. They also go into the lifestyle factors that play an important role in managing CCD, including optimal nutrition and exercise. And they emphasize the guideline’s recommendations on how to best counsel patients about drug and alcohol use. Learn more about the guideline: bit.ly/3K3qSMt
0:00 Intros
1:30 Assessing risk
7:30 Therapy and nutritional recommendations
11:59 Cumulative physical activity
14:22 Tobacco and substance use
18:17 Controlling blood pressure
19:56 Sexual health
Content
0 -> foreign
0.51 -> [Music]
3.14 -> to the American Heart Association
5.339 -> statements and guidelines podcast where
7.74 -> we'll discuss clinical practice
9.059 -> guidelines and scientific statements on
11.28 -> various cardiovascular disease and
13.139 -> stroke topics
18.18 -> hello everyone I'm Celine varani and I'm
20.699 -> a vice verse for research as well as a
23.22 -> professor of Cardiology at the AG Khan
25.68 -> University I work as a preventive
28.019 -> cardiologist and I was honored to serve
30.18 -> as a chair for the 2023 American Heart
33.48 -> Association American College of
34.98 -> Cardiology guideline on the management
36.899 -> of chronic coronary disease
40.02 -> and I'm Krista Newby I'm a professor of
42.6 -> medicine in the division of Cardiology
44.46 -> and a faculty member at the Duke
47.219 -> Clinical Research Institute at Duke
48.96 -> University School of Medicine and I
51.36 -> served as the co-chair for The Chronic
53.7 -> coronary disease guidelines
56.579 -> so this is our second podcast episode
58.68 -> discussing the major takeaways from the
61.02 -> 2023 American Heart Association American
63.3 -> College of Cardiology guideline for the
65.7 -> management of patients with chronic
67.619 -> coronary disease
69.06 -> in the first episode we talked about
71.1 -> what patient-centered care and
73.38 -> team-based care mean in addition to a
75.78 -> general overview of this guideline as
77.7 -> well as what does a Class 1 Class 2
80.159 -> class 3 recommendation means
82.259 -> in this episode which is the second
84.36 -> episode we will talk about lifestyle
87.06 -> recommendations and how do we assess
90.84 -> risk when it comes to patients with
93.299 -> chronic coronary disease with that I'll
95.46 -> turn it over to uh uh Kristen to talk
98.4 -> about what are some general principles
100.259 -> when it comes to risk assessment of
102.06 -> patients with CCD
104.22 -> yeah so we'll we'll start here with risk
106.5 -> assessment and that's really the
107.82 -> foundation upon which we build to make
110.759 -> our decisions about treatment if we
113.159 -> don't understand
114.439 -> risk we can't understand treatment
116.939 -> benefit and appropriately select therapy
120.24 -> so this is a really important part of
122.759 -> what we do the guidelines has a really
126.42 -> well developed section with a lot of
128.459 -> details about evaluation and risk
132 -> assessment and we're going to cover the
133.92 -> highlights of that we won't go into
135.72 -> detail
136.86 -> um on everything but just for example
140.28 -> for patients with chronic coronary
142.08 -> disease if there's an opportunity to do
144.9 -> so clinicians should first intensify
148.44 -> guideline directed medical therapy and
151.08 -> defer testing for risk assessments so
154.14 -> that's one of the key principles and and
156.599 -> why do we say defer testing well testing
159.84 -> is expensive testing has its own
162.72 -> built-in risk there's there's the
165.68 -> possibility that we get false positive
168.3 -> testing that we then have to deal with
170.16 -> so there are a lot of reasons to not
172.98 -> only assess risk but also if appropriate
177.72 -> to defer any testing while intensifying
182.28 -> guideline directive medical therapy
186.54 -> so you know when we talk about a risk
189.78 -> stratification in these patients I think
192.599 -> the important thing is to recognize that
196.2 -> when we talk about risk what I would say
199.62 -> there are four major buckets of of
202.2 -> information that we as clinicians need
204.36 -> that will allow us to identify which of
207.48 -> our patients is very high risk which
210.3 -> patient is not that high risk and these
212.459 -> include uh socio-demographic variables
215.64 -> that we all are aware of whether that's
217.5 -> sex whether that's social support
219.72 -> second is patients passed on concurrent
222.9 -> medical as well as history related to
225.239 -> mental health conditions because we know
226.799 -> that both medical conditions as well as
229.799 -> mental health affects prognosis in
232.68 -> patients with chronic coronary disease
234.48 -> we briefly talked about ancillary
237.12 -> cardiac testing or Imaging that of
239.28 -> course gives us some ideas about what
241.739 -> are high-risk features which patients
243.299 -> are going to have a high risk of
245.459 -> cardiovascular events and then last but
247.799 -> not the least if biomarkers are measured
250.439 -> on some of these patients for example
252.06 -> High sensitivity troponins as well as
255.079 -> BNB in the outpatient setting these
258.479 -> biomarkers can also be helpful when
261.239 -> we're doing risk stratification in these
263.94 -> patients and I would refer our listeners
265.979 -> to table five of the guideline which
268.199 -> really gets into the details of this the
270.72 -> other aspects of this risk
272.639 -> stratification is that
274.919 -> when we are evaluating these patients in
278.1 -> the outpatient setting we should get a
280.74 -> pretty good sense whether we are dealing
282.78 -> with a low risk patient and intermediate
285.72 -> risk patient or high risk patient and
288.24 -> this risk stratification is extremely
290.16 -> important it's actually a class one
291.54 -> recommendation because
293.82 -> we have a lot of options in terms of
296.46 -> therapies that we can use in these
298.38 -> patients with CCD so knowing which of
301.08 -> our patients with chronic coronary
302.639 -> disease are low risk intermediate risk
305.16 -> or high risk will allow us to intensify
307.68 -> those therapies and maximize the benefit
309.6 -> of those therapies so that's one
312.36 -> the second aspect of this is which is
314.94 -> extremely important that we have learned
316.68 -> from a lot of randomized control trials
318.86 -> is that optimization of guideline
321.6 -> directed medical therapy is extremely
324.18 -> important in these patients to reduce
326.46 -> cardiovascular events in fact most of
329.28 -> the re-vascularization procedures that
331.199 -> we perform
332.28 -> are only needed for symptom relief
335.34 -> except in some very important patient
339.479 -> groups that we will talk about so it is
341.88 -> extremely important that we look at
343.68 -> guideline directed medical therapy as an
346.259 -> important Cornerstone in patients with
348.6 -> chronic coronary disease and of course
350.3 -> throughout this podcast and the next
352.979 -> podcast we'll talk about what guideline
354.78 -> directed medical therapy means and then
357.24 -> the third aspect of this is that there
360.18 -> are some patients with chronic Corner
362.699 -> disease or suspected chronic coronary
364.74 -> disease where it might be important to
367.139 -> perform a coronary angiography to assess
370.74 -> coronary Anatomy for risk stratification
372.72 -> purposes these include patients with
375.539 -> newly reduced LV systolic function
378.18 -> those who have clinical heart failure or
381 -> both in these patients it is advisable
384.36 -> to perform a coronary angiography to
387.479 -> assess coronary anatomy and guide
389.94 -> potential revascularization at the same
392.819 -> time what our listeners will notice that
395.46 -> there is a class 3 recommendation that
398.039 -> there is no benefit of using coronary
400.919 -> angiography for risk stratification
402.66 -> routinely without any history of Elvis
406.38 -> systolic dysfunction heart failure or
409.5 -> patients who have stable chest pain who
412.139 -> really are are are symptom-free on
414.419 -> guideline directed medical therapy so in
416.34 -> these patients or patients where there
418.5 -> is not a high risk based on non-invasive
421.5 -> testing of left main disease in these
424.259 -> patients
425.16 -> invasive coronary and geography is not
428.639 -> recommended for further risk
430.8 -> stratification so those are very
432.36 -> important consideration when we are
434.34 -> looking at risk stratification these
436.319 -> patients based on social demographic
438.419 -> variables based on Imaging as well as in
441.84 -> some cases the use of invasive coronary
444.479 -> geography
446.099 -> so now once we have performed a risk
447.9 -> stratification of course it is now time
450.66 -> to start talking about therapies and the
453.599 -> first and the foremost out of that is
455.28 -> lifestyle recommendations and in that
457.08 -> nutrition is extremely important so I'll
460.02 -> pass it over to you Kristin to tell us a
461.759 -> little bit more about what nutrition
463.259 -> recommendations that we have in the
464.58 -> guideline
465.599 -> so nutrition is one of those
468.539 -> um you know foundational components of
471.539 -> managing chronic coronary disease so
474 -> it's so important to augment
476.84 -> pharmacologic therapies with
479.3 -> non-pharmacologic approaches which means
481.5 -> a healthy diet exercise this you know I
485.52 -> think is probably under emphasized in a
488.639 -> world where we have so many
490.02 -> interventions and medications that we
493.319 -> can use to treat patients with chronic
495 -> coronary disease so we felt it was
496.56 -> really important to include this and
499.08 -> emphasize it in this guidelines so we
502.379 -> want to encourage patients to eat a
504.78 -> heart-healthy diet and that means a diet
506.94 -> that includes fruits and vegetables
508.86 -> legumes nuts whole grains lean protein
512.599 -> complex carbohydrates and dietary fiber
516.779 -> we want them to avoid bad fats or
521.039 -> replace bad fats with good fats reduce
524.219 -> the percentage of calories overall that
526.56 -> come from saturated fat and use
528.98 -> monounsaturated and polyunsaturated fats
532.38 -> like olive oil as an example
535.62 -> we also want to encourage minimizing
538.019 -> dietary sodium to at least less than
540.959 -> 2300 milligrams per day and optimally
543.839 -> closer to 1500 milligrams per day we
547.86 -> recommend minimizing processed foods
550.2 -> like cured bacon hot dogs that transmit
554.459 -> a lot of these unhealthy fats to the
557.88 -> individual and then for carbohydrates we
561.3 -> want to again look for complex
563.399 -> carbohydrates to avoid the refined
565.86 -> carbohydrates that we find in processed
568.62 -> foods like ready to eat breakfast
570.6 -> cereals white bread
573.66 -> white rice so think about natural grain
577.14 -> long grain Rices and then really
580.2 -> importantly the emphasis on avoiding
582.48 -> sugar-sweetened beverages like soft
585.24 -> drinks energy drinks fruit drinks that
588.12 -> have added sugars we also have some
591.839 -> emphasis on trans fats and trans fats
595.08 -> are the hydrogenated vegetable oils
597.899 -> they're the things that have
600.12 -> um been added to help stabilize many of
603.839 -> our baked goods and other processed
605.76 -> foods to increase shelf life they're
608.279 -> also found in uh restaurant food that
611.76 -> involves deep frying so understanding
615.54 -> the sources of these I think we can
617.76 -> really help our our patients avoid these
621.839 -> bad things but we have to have these
623.399 -> conversations then we have to make it
625.44 -> part of our our culture in treating
628.92 -> chronic coronary disease patients that
630.839 -> this is something we review at every
633.72 -> Clinic visit
635.16 -> we also have a recommendation regarding
638.22 -> nutritional supplements specifically
640.32 -> that we do not recommend nutritional
643.32 -> supplements because there's no evidence
645.839 -> that they provide benefit for preventing
649.44 -> heart disease and stroke events
654.14 -> so uh in addition to nutrition another
657.42 -> really important lifestyle component
659.399 -> when we are trying to prevent uh or
662.579 -> treating chronic coronary disease is is
664.86 -> physical activity and as a lot of you
667.86 -> will notice the guidelines have actually
669.66 -> stopped using the term exercise it's
672.6 -> cumulative physical activity so as long
675.54 -> as our patients with chronic coronary
677.88 -> disease are free from contraindications
679.68 -> and those would include unstable angina
682.62 -> decompensated heart failure uncontrolled
685.14 -> arrhythmias or acute thromboembolic
687.839 -> disease
688.92 -> a good physical activity regimen is
691.98 -> recommended for all patients with
694.5 -> chronic coron disease so when we talk
696.66 -> about physical activity there are four
699.36 -> recommendations that are extremely
700.86 -> important for us to follow as
702.36 -> connections and recommend very actively
705.06 -> to our patients first is that we
707.88 -> recommend more than or equal to 150
710.82 -> minutes of moderate intensity aerobic
713.16 -> activity or more than or equal to 75
715.92 -> minutes per week of higher intensity
718.44 -> aerobic activities for every patient now
720.36 -> this is the same across all the
722.459 -> guidelines where we have in terms of
724.32 -> physical activity or exercise so that's
726.12 -> number one
727.2 -> second it is extremely important for
729.42 -> patients with chronic colon disease to
731.82 -> actually supplement this aerobic
733.32 -> activity with exercise that improves
737.1 -> strength and functional capacity and
739.38 -> then those exercises have also shown to
741.839 -> improve risk factor control so a
744.36 -> combination of aerobic activity and
747.54 -> muscle strengthening exercises is
749.94 -> extremely important we also have a class
752.7 -> 2 recommendation
754.38 -> for patients to reduce sedentary
757.32 -> Behavior now we know that 150 minutes is
759.959 -> really where you get good amount of
762.18 -> benefit in fact there is just a steep
764.459 -> curve up to 300 minutes but what we know
767.1 -> is that for a person who is very
768.72 -> sedentary they can gain benefit even up
771.899 -> to 150 minutes even if they increase
773.519 -> their physical activity by 10 minutes 20
775.74 -> minutes 30 minutes so we have a class
777.899 -> two recommendations for patients who are
779.94 -> very sedentary to increase their
783.26 -> non-sedentary time or reduce what we
785.7 -> would call a sedentary Behavior now last
788.7 -> but not the least a class one
791.04 -> recommendation that is extremely
792.839 -> important and we know that this is a
795.36 -> problem in taking care of patients with
797.1 -> chronic coronary disease is
799.079 -> recommendation related to cardiac rehab
801.62 -> we know that in patients who've had a
804.6 -> recent MI BCI or who've undergone
808.38 -> reality bypass grafting patients who
811.26 -> have stable angina patients who have had
813.72 -> heart transplant or patients who
816.3 -> recently had spontaneous coronary artery
818.639 -> dissection related event in all of these
821.7 -> patients we have class one
823.74 -> recommendation for cardiac rehab and
827.04 -> this is extremely important because we
829.079 -> know that referral as well as
831.36 -> continuation of cardiac rehab is
833.82 -> extremely low in these patients and we
835.74 -> know that it improves control of risk
838.68 -> factors it reduces symptom burden it
841.92 -> improves quality of life and for some of
844.44 -> these conditions it reduces mortality as
848.339 -> well so we would highly recommend that
851.16 -> we all as clinicians pay attention and
853.98 -> identify our patients who are good
855.779 -> candidates for cardiac rehab and then
858.12 -> refer them for cardiac rehab
861.959 -> so let's talk a little
863.94 -> tobacco substitute
867.06 -> smoking and use of tobacco is a major
870.42 -> cause of cardiovascular disease and
873.3 -> certainly important that we eliminate
876.54 -> that in our patients who already have
878.519 -> chronic coronary disease so we have
880.56 -> several updates to the guidelines
882.72 -> regarding tobacco use and screening for
885.72 -> tobacco use so if we don't ask patients
888.18 -> at every visit whether they're smoking
890.639 -> or not we can't help them stop smoking
893.459 -> so it's a class one recommendation now
896.04 -> to assess tobacco use at every
898.44 -> Healthcare visit that's not just at the
900.48 -> cardiologist's office that's every
902.459 -> Health Care visit across the health care
905.1 -> Spectrum
906.72 -> again to help us identify patients who
909.779 -> could benefit from interventions to help
911.88 -> them stop smoking we also have a class
914.82 -> one recommendation to use behavioral
917.04 -> intervention so counseling coaching peer
920.76 -> coaching to help maximize secession
923.699 -> rates in addition to pharmacotherapy
927.06 -> that may include things like bupropion
929.22 -> or variniclin in combination with long
932.579 -> and short-acting nicotine replacement
934.56 -> therapy
936.18 -> another updated addition to this
939.06 -> guideline that we talked a bit about
941.76 -> um
942.48 -> it is uh to avoid second-hand smoke
946.8 -> exposure so secondhand smoke almost
950.88 -> um equally toxic from a cardiovascular
953.82 -> perspective as primary cigarette smoking
957.12 -> so things you know that one might
960 -> consider as counseling family members so
962.579 -> this is where the environment and the
965.339 -> social determinants come in we know that
967.74 -> there are rules and regulations now in
970.92 -> in many places about public smoking to
974.339 -> help reduce the second hand exposure but
976.56 -> there's still a fair bit that occurs at
978.54 -> the home and we have to be aware and
981.42 -> assessing this to help our our patients
984.48 -> we also have added a an update with
987.779 -> regard to e-cigarettes
990.06 -> and we know that e-cigarettes increase
992.1 -> the likelihood of successful smoking
994.68 -> secession compared with nicotine
996.839 -> replacement therapy
998.94 -> but we don't really have long-term
1001.759 -> safety data and understand the risks of
1004.519 -> sustained e-cigarette use so we do not
1007.759 -> recommend e-cigarettes as first line
1010.279 -> therapy for smoking secession
1013.339 -> foreign
1016.839 -> topic we also have recommendations
1019.699 -> related to alcohol as well as uh
1022.759 -> substance use now we have a class 2
1025.699 -> recommendation to advise women with CCD
1028.579 -> to have one drink or less per day and
1031.579 -> for men with CCD to have two uh drinks
1034.16 -> or less per day and then we also have a
1036.439 -> recommendation not to recommend alcohol
1039.579 -> uh used for patients with CCD just for
1042.199 -> cardiovascular disease prevention
1043.22 -> because we have a lot of data now that
1044.78 -> that may not be the case so the message
1047.299 -> is not to recommend alcohol for
1049.7 -> cardiovascular disease risk reduction in
1051.74 -> patients with CCD but at the same time
1053.96 -> those patients who are using alcohol to
1056.6 -> limit the use of alcohol the other
1059 -> aspect of this is that we know that
1061.58 -> certain substances are not good for
1064.039 -> cardiovascular health and they become
1065.66 -> even more important in patients with CCD
1068.419 -> and these include the use of cocaine
1071.539 -> marijuana and opioids so again
1074.419 -> these are substances that we should
1076.82 -> routinely ask about when we are
1079.039 -> evaluating our patients and then counsel
1081.62 -> against the use of these substances
1083.299 -> because they could be harmful in
1086.299 -> patients with chronic coronary disease
1088.1 -> now we're talking about lifestyle in
1090.5 -> general so the other aspect of this
1092.84 -> where lifestyle becomes extremely
1094.64 -> important is when we are trying to talk
1097.16 -> about control of blood pressure and that
1099.14 -> again is an area where non-pharmacologic
1102.98 -> interventions become extremely important
1104.66 -> so for example weight loss healthy diet
1107.32 -> reducing the intake of dietary sodium
1110.14 -> increasing the intake of dietary
1112.22 -> potassium increasing physical activity
1114.26 -> as well as a moderation of alcohol
1117.02 -> intake are extremely important when we
1119.36 -> are trying to look for a
1121.539 -> non-pharmacologic ways of lowering blood
1124.16 -> pressure and our clinicians will find a
1126.98 -> very useful table table 12 in the
1129.26 -> guideline document that actually talks
1131.12 -> about these non-pharmalogical means of
1133.88 -> reducing blood pressure which is adapted
1136.34 -> from the hypertension guideline by the
1138.2 -> American Heart Association American
1139.46 -> College of Cardiology so once that's
1141.679 -> done then of course we can use
1144.44 -> medications for hypertension once
1146.419 -> lifestyle is instituted and then that
1149.059 -> that probably is very clear to
1150.799 -> clinicians when to use beta blockers
1152.6 -> when somebody has had recent ACS has LV
1155.9 -> dysfunction or continued angina when
1158.72 -> somebody has LV dysfunction concomitant
1161.48 -> diabetes with CKD then those are the
1164.12 -> patients with ACE inhibitors and arbs
1166.22 -> can be used similarly patients with LV
1169.039 -> dysfunction one would use aldosterone
1171.559 -> antagonist so those could be
1173.299 -> individualized based on patients
1175.88 -> clinical condition as well as whether or
1178.28 -> not they have LV dysfunction or
1180.38 -> continued symptoms of angina but first
1183.26 -> and foremost it is extremely important
1185.84 -> to try out lifestyle therapies when it
1189.14 -> comes to even management of blood
1191.6 -> pressure in these patients
1195.44 -> so sexual
1198.5 -> sexual of quality of life in our
1200.419 -> patients with chronic coronary disease
1202.34 -> so we've added some recommendations
1204.5 -> about counseling patients around sexual
1207.62 -> activity so first to to kind of equate
1211.76 -> sexual activity to other activities
1215.48 -> sexual activity is about three to five
1217.88 -> metabolic equivalents
1220.16 -> we have a class 2 recommendation that
1223.94 -> resumption of sexual activity should be
1226.48 -> individualized based on type of sexual
1229.16 -> activity their overall Exercise capacity
1232.16 -> and The Exercise capacity are related to
1234.5 -> that sexual activity and any
1237.22 -> post-procedural healing issues
1240.38 -> cardiac Rehabilitation and regular
1243.02 -> exercise reduces the risk of
1245.539 -> cardiovascular complications with sexual
1247.94 -> activities so we want to encourage
1249.799 -> regular exercise and engagement in
1252.799 -> cardiac Rehabilitation as a part of
1256.1 -> expanding that aspect of quality of life
1259.52 -> for CCD patients
1261.74 -> so one important thing that that we want
1265.58 -> to highlight is that the Foster
1267.38 -> diasterase type 5 Inhibitors or pde5
1270.679 -> Inhibitors should not be used
1273.44 -> concomitantly with nitrate medications
1275.78 -> and the reason for this is because of
1277.82 -> the risk for severe hypotension when
1280.46 -> these medications are used concurrently
1285.26 -> so that's it for the second of the three
1288.08 -> episodes that we have for the chronicorn
1290.78 -> disease guideline from the American
1292.46 -> Heart Association and American College
1294.5 -> of Cardiology
1295.82 -> in our last and third episode we'll get
1299.24 -> into some of the major updates in the
1301.1 -> guideline regarding Statin therapy and
1303.44 -> tablet therapy weight loss
1305.5 -> revascularization as well as
1307.64 -> recommendations related to special
1309.919 -> populations we hope to see you again
1312.44 -> thank you for listening
1316.11 -> [Music]
1318.38 -> the data and statistics presented in
1320.24 -> this podcast are from the official
1321.679 -> guideline being released by the American
1323.48 -> Heart Association any and all personal
1325.7 -> stories and testimonies are that of the
1327.74 -> talent hosts and volunteers and are not
1330.08 -> reflective of any statements or position
1331.82 -> of the American Heart Association for a
1334.4 -> full manuscript of the guideline
1335.84 -> released please visit the official
1337.64 -> American Heart Association website at
1339.919 -> professional.heart.org
Source: https://www.youtube.com/watch?v=dNrDY__jrxY