Coronary Artery Atherosclerosis Guidelines

Updated: Jul 20, 2023
  • Author: Sandy N Shah, DO, MBA, FACC, FACP, FACOI; Chief Editor: Yasmine S Ali, MD, MSCI, FACC, FACP  more...
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Guidelines Summary

2019 ACC/AHA primary prevention guidelines

In September 2019, the American College of Cardiology (ACC) and the American Heart Association (AHA) published joint guidelines on the primary prevention of cardiovascular disease. [102]

It is recommended that atherosclerotic cardiovascular disease (ASCVD)–related risk factors be controlled via a team-based approach.

For adults, health-care visits should routinely include counseling on optimization of a physically active lifestyle.

At least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity (or an equivalent combination of moderate and vigorous activity) is recommended for ASCVD risk reduction in adults.

Improvement of the ASCVD risk factor profile through weight loss is recommended for patients with overweight or obesity.

It is recommended that adults with overweight or obesity achieve and maintain weight loss with the aid of counseling and comprehensive lifestyle interventions (including calorie restriction).

Improvement of glycemic control, achievement of weight loss (if necessary), and improvement of other ASCVD risk factors, via a tailored nutrition plan aimed at providing a heart-healthy dietary pattern, is recommended for all adults with type 2 diabetes mellitus (T2DM).

Improvement of glycemic control, achievement of weight loss (if necessary), and improvement of other ASCVD risk factors, via at least 150 minutes per week of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity, is recommended for adults with T2DM.

If, as a result of a risk discussion, a decision is made to employ statin therapy, adults with high blood cholesterol with an intermediate ASCVD risk (≥7.5% to < 20% 10-year ASCVD risk) should be treated with a moderate-intensity statin.

In patients with high blood cholesterol who have an intermediate ASCVD risk (≥7.5% to < 20% 10-year ASCVD risk), reduction of low-density lipoprotein cholesterol (LDL-C) levels by at least 30% is recommended, while optimal ASCVD risk reduction can be targeted, particularly in high-risk patients (≥20% 10-year ASCVD risk), by reducing LDL-C levels by at least 50%.

Maximally tolerated statin therapy is recommended in patients aged 20-75 years with an LDL-C level of at least 190 mg/dL (≥4.9 mmol/L).

Among the nonpharmacologic interventions recommended for adults with elevated blood pressure (BP) or hypertension, including patients who need antihypertensive agents, are the following:

  • Weight loss

  • A heart-healthy dietary pattern

  • Sodium reduction

  • Dietary potassium supplementation

  • Increased physical activity with a structured exercise program

  • Limited alcohol

  • Primary prevention of cardiovascular disease (CVD) with BP-lowering medications is recommended for adults with an estimated 10-year ASCVD risk of at least 10% and an average systolic BP (SBP) of 130 mm Hg or higher or an average diastolic BP (DBP) of at least 80 mm Hg.

  • A BP target of below 130/80 mm Hg is recommended for adults with confirmed hypertension and a 10-year ASCVD event risk of at least 10%.

  • Treatment to a BP goal of below 130/80 mm Hg is recommended for adults with hypertension and chronic kidney disease.

  • Antihypertensive drug treatment should be administered to adults with T2DM and hypertension who have a BP of 130/80 mm Hg or higher, the aim being to reduce BP to below 130/80 mm Hg.

  • For adults, cessation of tobacco use should be facilitated by evaluation of such use at every health-care visit, with the status of a patient’s tobacco use recorded as a vital sign.

  • All adult tobacco users should be advised to quit.

  • In adult tobacco users, quit rates should be maximized by combining behavioral interventions with pharmacotherapy.

2018 ACC/AHA/HRS guidelines

The guideline on the evaluation and management of bradycardia and cardiac conduction delay was released in November 2018, by the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS). [103, 104]

The guideline’s top 10 key messages for assessing and treating patients with bradycardia or other disorders of cardiac conduction delay are provided below.

Sinus node dysfunction is most often related to age-dependent progressive fibrosis of the sinus nodal tissue and surrounding atrial myocardium leading to abnormalities of sinus node and atrial impulse formation and propagation and will therefore result in various bradycardic or pause-related syndromes.

Sleep disorders of breathing and nocturnal bradycardias are relatively common. Treatment of sleep apnea reduces the frequency of these arrhythmias and also may offer cardiovascular benefits. The presence of nocturnal bradycardias should prompt consideration for screening for sleep apnea, beginning with solicitation of suspicious symptoms. However, nocturnal bradycardia is not in itself an indication for permanent pacing.

The presence of left bundle branch block on electrocardiogram markedly increases the likelihood of underlying structural heart disease and of diagnosing left ventricular (LV) systolic dysfunction. Echocardiography is usually the most appropriate initial screening test for structural heart disease, including LV systolic dysfunction.

In sinus node dysfunction, there is no established minimum heart rate or pause duration where permanent pacing is recommended. It is important to establish a temporal correlation between symptoms and bradycardia when determining whether permanent pacing is needed.

In patients with acquired second-degree Mobitz type II atrioventricular (AV) block, high-grade AV block, or third-degree AV block not caused by reversible or physiologic causes, permanent pacing is recommended regardless of symptoms. For all other types of AV block, in the absence of conditions associated with progressive AV conduction abnormalities, permanent pacing should generally be considered only in the presence of symptoms that correlate with AV block.

In patients with an LV ejection fraction between 36% and 50% and AV block, who have an indication for permanent pacing and are expected to require ventricular pacing over 40% of the time, techniques that provide more physiologic ventricular activation (eg, cardiac resynchronization therapy [CRT], His bundle pacing) are preferred to right ventricular pacing to prevent heart failure.

Because conduction system abnormalities are common after transcatheter aortic valve replacement (TAVR), recommendations on postprocedure surveillance and pacemaker implantation are made in this guideline.

In patients with bradycardia who have indications for pacemaker implantation, shared decision-making and patient-centered care are endorsed and emphasized in this guideline. Treatment decisions are based on the best available evidence and on the patient’s goals of care and preferences.

Using the principles of shared decision-making and informed consent/refusal, patients with decision-making capacity or his/her legally defined surrogate have/has the right to refuse or request withdrawal of pacemaker therapy, even if the patient is pacemaker dependent, which should be considered palliative, end-of-life care, and not physician-assisted suicide. However, any decision is complex, should involve all stakeholders, and will always be patient specific.

Identifying patient populations that will benefit the most from emerging pacing technologies (eg, His bundle pacing, transcatheter leadless pacing systems) will require further investigation as these modalities are incorporated into clinical practice.

2013 ACC/AHA guidelines

The ACC/AHA released their recommendations on the treatment of blood cholestrol to reduce atherosclerotic cardiovascular risk in adults in November 2013. [57] See the table below.

Table. Four Statin Benefit Groups and Major Recommendations (Open Table in a new window)

  Group Recommendation
1. Age ≥21 years with clinical ASCVD (including history of or current acute coronary syndrome, myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, PAD presurmed to be of atherosclerotic origin)

1.For patients age >75 years, high-intenstiy statin(or moderate-intensity statinif not candidate for high-intensity due to safety concerns)

2. For patients age >75 years, moderate-intensity statin

2. Adults aged ≥21 years with LDL-C ≥190 mg/dl (not due to modifiable

1. High-intensity statin therapy to achieve ≥50% reduction in LDL-C statin (or moderate-intenstiy if not a candidate for high-intensity statin due to safety concerns)

2. May consider combining statin and non-statin therapy to further reduce LDL-C

3. Cascade screeing of close biologic relatives should be performed to identify others with the disease who would benefit from treatment.

3. Adults aged 40-75 years without ASCVD but with diabetes and with LDL-C 70-189 mg/dL

1. Moderate-intensity statin

2. If 10-year ASCVD risk ≥7.5%, consider high-intensity statin.

4. Adults aged 40-75 years without ASCVD or diabetes, and with LDL-C 70-189 mg/dL and an estimated 10 year risk for ASCVD of ≥7.5%

1. Estimate 10-year ASCVD risk using Pooled Cohort Equations

a. if ≥7.5%, moderate- or high-intensity statin;

b. If ≥to < 7.5%, consider moderate-intensity statin.

2. If selected individuals with 10-year ASCVD risk < 5%, or age < 40 or > 75 years, individualize decisions based on presence of other high-risk features.

3. Before initiation of statin therapy for primary prevention, it is reasonable for clinicians and patients to engage in a discussion that considers the potential for ASCVD risk-reduction benefits and for adverse effects and drug-drug interactions, as well as patient preferences for treatment.

ASCVD = atherosclerotic cardiovascular disease; LDL-C = low-density lipoprotein cholesterol; PAD = peripheral artery disease; TIA = transient ischemic attack.


2020 ACC Guidelines on CV Disease Risk Reduction in T2D

In July 2020, the American College of Cardiology (ACC) published clinical recommendations regarding cardiovascular disease risk reduction using sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists (GLP-1RAs) in patients with type 2 diabetes. [105, 106] Their recommendations are outlined below.

It is recommended that for patients with type 2 diabetes (T2D) who have or are at very high risk for clinical atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and/or diabetic kidney disease, a patient-clinician discussion be initiated, at a clinical follow-up visit, regarding the use of a sodium-glucose cotransporter 2 (SGLT2) inhibitor and/or a glucagon-like peptide 1 receptor agonist (GLP-1RA), with demonstrated cardiovascular (CV) benefit.

Recommendations regarding the choice of an SGLT2 inhibitor or a GLP-1RA

Many SGLT2 inhibitors and GLP-1RAs have shown CV benefit in patients with T2D, so patient-clinician discussions regarding their use must involve consideration of which agent is most appropriate.

In patients with impaired renal function, clinical judgement must be employed when initiating an SGLT2 inhibitor if the patient will be starting or up-titrating an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB).

It is suggested that in patients with a history of peripheral artery disease, severe peripheral neuropathy, lower extremity diabetic ulcers, or soft tissue infections, caution be exercised when starting an SGLT2 inhibitor, even though questions remain regarding the association of these agents with an increased amputation risk.

A GLP-1RA alternative to semaglutide SQ should be considered in patients with active proliferative retinopathy (especially those with high HbA1c and in whom significant rapid reduction is expected).

Owing to a lack of research on the use of GLP-1RAs in individuals with active gallbladder disease or a history of pancreatitis, it is suggested that these agents be employed cautiously in such patients.

Diabetes control and the initiation of SGLT2 inhibitors and GLP-1RAs

Because evidence indicates that the CV effects of SGLT2 inhibitors and GLP-1RAs are not influenced by HbA1c or background antidiabetic agent use, the decision to initiate an SGLT2 inhibitor (for CV or kidney risk reduction) or a GLP-1RA (for CV risk reduction) should not depend on HbA1c levels.

Even so, the addition of an SGLT2 or a GLP-1RA to the regimen of a patient with well-controlled T2D may require dose adjustment of background medications to avoid hypoglycemia in the context of insulin, sulfonylurea, or glinide therapy, particularly in patients in whom glycemic goals have or nearly have been reached.

Continue full efforts to achieve glycemic and blood pressure targets and to adhere to lipid, antiplatelet, antithrombotic, and smoking cessation guidelines after the addition of an SGLT2 inhibitor or a GLP-1RA to therapy.

Concomitant use of SGLT2 inhibitors and GLP-1RAs

It appears reasonable that an SGLT2 inhibitor and a GLP-1RA, with demonstrated CV benefit, be used together, if clinically indicated, despite a lack of research regarding the employment of such combination therapy for CV risk reduction.

Patient monitoring in SGLT2 inhibitor therapy

Inform patients starting an SGLT2 inhibitor about the higher risk of genital mycotic infections, as well as the ability to lower such risk through careful attention to personal hygiene of the perineum.

Patients should understand the potential risk of developing hyperglycemic or euglycemic diabetic ketoacidosis and learn prevention strategies. In addition, they should be told to seek immediate care if symptoms potentially associated with diabetic ketoacidosis arise (eg, nausea, vomiting, abdominal pain, generalized weakness).

It may be reasonable to use home monitoring with urine ketone test strips in some higher-risk patients.

Precipitation of diabetic ketoacidosis should be avoided by steering clear of initial reductions in total daily insulin dose of over 20%.

Initiation of an SGLT2 inhibitor should be made in collaboration with the clinician managing the patient’s diabetes, for those individuals on a complex insulin regimen or with a history of labile blood glucose.

Inform patients taking insulin or an insulin secretagogue (ie, a sulfonylurea or glinide) of the risk of hypoglycemic events when an SGLT2 inhibitor is added for CV benefit, particularly in cases where HbA1c is already well-controlled at baseline. The hypoglycemia risk in these patients could be reduced by discontinuing or weaning the sulfonylurea or glinide or reducing total daily insulin dose by up to 20%. However, dose adjustments should hinge on clinical judgment and be customized to each patient’s needs and requirements.

Coordinate management of complex insulin regimens or “brittle” diabetes with the patient’s diabetes care provider. Following the initiation of SGLT2 inhibitors, patients should self-monitor blood glucose levels closely during the first 3-4 weeks.

Advise patients that SGLT2 inhibitors may lead to a diuretic effect and that administration of SGLT2 inhibitors with loop diuretics has potentially additive natriuretic effects.

Patients should monitor themselves for signs of volume depletion such as orthostatic lightheadedness and, if these arise, should contact their clinician. If these symptoms occur in patients on concomitant loop diuretics who are starting an SGLT2 inhibitor, a reduction in the diuretic dose may be warranted.

In the first few weeks of treatment, it is reasonable to monitor renal function, especially in patients with impaired baseline renal function.

When patients with a history of amputations, severe peripheral neuropathy, severe peripheral artery disease, or active lower-extremity soft tissue ulcers or infections are being prescribed an SGLT2 inhibitor, consider alternatives to canagliflozin.

All patients should undergo regular foot exams in accordance with the American Diabetes Association’s Standards of Medical Care in Diabetes.

Patient monitoring in GLP-1RA therapy

The same strategy used to reduce hypoglycemic events with SGLT2 inhibitors is employed with GLP-1RAs.

Inform patients initiating a GLP-1RA that transient nausea is a relatively common side effect.

Minimization of nausea and vomiting can be achieved by starting with the lowest dose, up-titrating gradually according to the label recommendations, and ceasing up-titration when the nausea becomes uncomfortable, as well as by having the patient consume smaller food portions. A low-fat diet can also be useful.

In patients who have suffered problems with clinically significant gastroparesis, use GLP-1RAs with caution. In cases of treatment suspension, therapy should be reinitiated at the lowest dose, with recurrent nausea and vomiting avoided via gradual up-titration.

Since GLP-1RAs and dipeptidyl peptidase-4 (DPP-4) inhibitors each work through GLP-1 signaling and have not been studied for combined use, do not coadminister these two agents.

Semaglutide has been associated with an increased risk of diabetic retinopathy complications, primarily in patients with a history of proliferative retinopathy. Therefore, regular eye examinations should be administered to these patients.


2018 ACC Expert Consensus Decision Pathway on Novel Therapies for CV Risk Reduction in TD2 and ASCVD

The expert consensus decision pathways on the use of two major new classes of diabetes drugs—sodium-glucose cotransporter type 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists (GLP-1RAs)—for cardiovascular (CV) risk reduction in patients with type 2 diabetes (TD2) and atherosclerotic CV disease (ASCVD) were released in November 2018 by the American College of Cardiology (ACC). [107, 108] The main focus of management is in the outpatient ambulatory setting.

The SGLT2 inhibitors appear to reduce major adverse CV events (MACE) and the risk of heart failure (HF) but increase the risk for genital mycotic infections, whereas GLP-1RAs offer reductions in MACE but are associated with transient nausea and vomiting. Both classes of agents have benefits in reducing blood pressure and weight, and they have a low risk for hypoglycemia.

For CV risk reduction, initiate agents with demonstrated CV benefit from either drug class at the lowest doses; no uptitration is necessary for SGLT2 inhibitors, whereas the GLP-1RAs should be slowly uptitrated (to avoid nausea) to the maximal tolerated dose.

At the initiation of an SGLT2 inhibitor or a GLP-1RA agent, clinicians should avoid hypoglycemia in patients by monitoring those with A1C levels near or below target, particularly when patients’ existing diabetes therapies include sulfonylureas, glinides, or insulin.

In addition to reducing MACE and CV death, SGLT2 inhibitors are also suitable for preventing hospitalization for HF.

Empagliflozin is the preferred SGLT2 inhibitor based on the available evidence and overall benefit-risk balance.

Liraglutide should be the preferred agent among the GLP-1RAs for CV event risk reduction.

Two SGLT2 inhibitors (ie, canagliflozin, ertugliflozin) appear to be associated with an increased risk of amputation. It is unclear whether or not this is a class effect; therefore, clinicians should closely monitor patients on these agents who have a history of amputation, peripheral arterial disease, neuropathy, or diabetic foot ulcers.

Patients with T2D and clinical ASCVD on metformin therapy (or in whom metformin is contraindicated or not tolerated) should have an SGLT2 inhibitor or GLP-1 RA with proven CV benefit added to their treatment regimen. For patients not on background metformin therapy, practitioners may use their clinical judgment to prescribe an SGLT2 inhibitor or GLP-1RA for CV risk reduction.

It appears reasonable to concomitantly use an SGLT2 inhibitor and a GLP-1RA with demonstrated CV benefit if clinically indicated, although such combination therapy has not been studied for CVD risk reduction.