American societies associated with the clinical and therapeutic management of ischemic heart disease (American Heart Association [AHA], American College of Cardiology [ACC], American College of Clinical Pharmacy [ACCP], American Society for Preventive Cardiology [ASPC], National Lipid Association [NLA], and Preventive Cardiovascular Nurses Association [PCNA]) have released an updated version of the previous clinical guidelines from 2012 and 2014. Interestingly, earlier versions included endorsements from the Society of Thoracic Surgeons (STS) and the Society for Cardiovascular Angiography and Interventions (SCAI). However, in the 2023 edition, representatives of invasive therapies are not directly involved, with the SCAI merely endorsing the guidelines without mention of surgical society support.

These guidelines, developed by these societies, present a distinctly clinical focus in an extensive document spanning 111 pages, addressing various aspects such as epidemiology, early detection, diagnosis, lifestyle modifications, pharmacologic and non-pharmacologic treatments. Particularly, the latter covers patient assignment to interventional or surgical therapy, a topic that has generated considerable discussion on social networks (and likely contributed to the absence of STS endorsement). Although reactions in cardiothoracic journals have yet to appear, given the recent publication date, such discussions are expected imminently. Nonetheless, this extensive work provides numerous recommendations and insights applicable to our patients. It is within our control to either disengage from or actively participate as integral members of the care team managing this condition. Personally, I believe that the latter path affirms our role as surgeons, that is, physicians who operate—not merely technicians performing coronary bypasses.

COMMENTARY:

As previously mentioned, the document is comprehensive, but we will attempt to summarize the most relevant recommendations that can be directly applied to our surgical practice:

Epidemiology: In a globalized world, coronary disease prevalence exhibits notable regional differences, likely due to variations in dietary habits, lifestyle factors (such as smoking), demographics, and healthcare access. In descending order of prevalence, the regions affected include: the Maghreb, the Middle East; Russia and its neighboring states, Mongolia, and the Indian subcontinent; China, Indonesia, and Central America; the rest of Africa, South America, and Oceania, with the lowest prevalence found in most of Europe, Japan, and North America.

Diagnosis and Risk Stratification: Various recommendations are provided regarding additional studies to be performed when there is a change in symptom profile despite maximum medical treatment. However, our role in determining diagnostic testing is limited in this context. More importantly, a list of clinical characteristics and complementary findings that negatively impact prognosis is available. This information can guide decision-making in patient management. Key factors include demographic aspects (e.g., age, male sex, limited social support, and lower socioeconomic status); comorbidities (e.g., obesity, previous myocardial infarction or revascularization, heart failure, atrial fibrillation or flutter, diabetes mellitus, dyslipidemia, chronic kidney disease, active smoking, peripheral artery disease, depressive disorders, and poor medication adherence); cardiologic test results (e.g., inability to perform exercise testing, reduced functional capacity or left ventricular deterioration during stress testing, pharmacologically induced angina, ventricular hypertrophy or left bundle branch block on ECG, reduced ejection fraction or ventricular hypertrophy on echocardiography, high coronary calcium levels on cardiac CT angiography, poor ventricular function, particularly with hypertrophy or scars on MRI); and analytical findings (e.g., persistently elevated troponin and/or natriuretic peptide levels).

Therapeutic Management:

As mentioned earlier, optimal medical therapy is essential in managing these patients. The lack of symptom control or the occurrence of acute events often leads to additional studies aimed at recommending revascularization procedures, such as coronary artery bypass grafting (CABG). Surgery presents a valuable opportunity to update pharmacologic treatment and promote lifestyle changes that can improve patient outcomes. It is in our hands to be one of the initial links to catalyze this clinical change.

Throughout the clinical course, adherence to therapeutic prescriptions should be emphasized (class I).

In therapeutic decision-making, the guidelines highlight two aspects that steer our practice away from medical paternalism and the restrictions inherent in specialty silos:

1. Team-Based Care within a continuum that extends beyond cardiologists and surgeons. This includes the involvement of nurses, rehabilitation specialists, physiotherapists, pharmacists, dietitians, social workers, primary care physicians, and occupational health physicians (class I). This collaborative team aims to maximize patient understanding of disease progression, symptom awareness, adherence to therapeutic prescriptions and healthy lifestyle choices, self-care, and reintegration into an active life (class I).
2. Shared Decision-Making with Patients: This includes exploring treatment options, assessing associated risks and benefits, understanding patient preferences and attitudes toward each option, assessing cardiovascular risk and the impact on life expectancy and quality, and evaluating the symptom burden and current quality of life (class I). We must take responsibility—alongside cardiologists—for the information provided to the patient and the decisions made with them.

Dietary Aspects and Nutritional Supplements: We should recommend a diet rich in vegetables, fruits, legumes, whole grains, nuts, and lean protein (class I). Fats should be minimized, particularly saturated fats (<6% of total caloric intake), which should be replaced with monounsaturated and polyunsaturated fats (class 2a). Sodium intake should be limited to <1.5 g per day (class 2a). Highly processed foods, refined sugars, and sugary drinks should be minimized (class 2a), and trans fats should be avoided entirely (class 3). Omega-3 fatty acid supplements, as well as vitamins C, D, and F, beta-carotene, and calcium, have not shown a proven benefit and are therefore not recommended (class 3).

Mental Health: Mental health considerations must be actively addressed (class 2a) to identify the need for pharmacologic or non-pharmacologic support. Adequate patient information and education help reduce stress, improve self-management, and prevent complications. In terms of smoking cessation, repeated encouragement to quit smoking should be given at each patient evaluation, with both pharmacologic and non-pharmacologic options offered (class 1). For pharmacologic support, varenicline may be preferable to bupropion (class 2b), and the replacement of cigarettes with electronic alternatives or similar products is not recommended as a smoking cessation strategy, as they pose similar risks. Regarding alcohol consumption, it is advised to systematically assess alcohol intake during anamnesis and recommend abstinence (class 1); if the patient already consumes alcohol, it should be limited to one serving for women and two for men of wine or beer (class 2a). No form of alcohol consumption, including wine, should be recommended to reduce cardiovascular risk (class 3). Finally, regarding sexual activity, it should be adjusted to the patient’s exercise capacity both pre- and postoperatively (class 2a). In patients enrolled in cardiac rehabilitation programs involving regular exercise, sexual activity is recommended as a measure to reduce cardiovascular risk (class 2a). The use of phosphodiesterase type 5 inhibitors should be avoided in patients treated with nitrates due to the risk of severe hypotension (class 3).

Physical Exercise, Rehabilitation, and Vaccination: All patients with stable clinical conditions, whether or not they have undergone previous revascularization, should be encouraged to participate in cardiac rehabilitation programs and to establish a routine of physical activity (class I). This includes 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of high-intensity aerobic activity. For patients without contraindications, muscle-strengthening exercises (low load, high repetitions) twice a week are also recommended. These activities are preferable to merely incorporating more active lifestyle habits, such as walking for transportation or reducing sedentary behavior (class 2a). Routine vaccination against influenza (class I), SARS-CoV-2 (class I), and pneumococcus (class 2a) is recommended.

Pharmacologic Treatment: The guidelines provide recommendations for the various pharmacologic groups in the therapeutic spectrum of ischemic heart disease:

• Antiplatelet Therapy: Recommendations suggest a less aggressive approach to antiplatelet therapy, including shortening the duration of dual antiplatelet therapy even in cases with drug-eluting stents (a maximum of six months, class I). For patients requiring concomitant oral anticoagulation, this dual therapy is limited to one month, after which a single antiplatelet agent, preferably clopidogrel, should continue (class I). Notably, in stable cases, once a year has passed since the last acute event, adding a second antiplatelet agent does not prevent major ischemic events and may lead to hemorrhagic complications (class 3). Regarding coronary surgery, dual antiplatelet therapy for 3–6 months is recognized as class 2b to reduce the incidence of saphenous vein graft thrombosis.
• Beta-Blockers: Their indication has been narrowed to patients with left ventricular dysfunction (<40%) to improve survival (class I) and for one year following a myocardial infarction (class I). Outside these indications, they offer no clinical benefit (class 2b). Recommended agents include metoprolol, atenolol, and carvedilol, with other beta-blockers less favored (class I).
• Renin-Angiotensin-Aldosterone System Inhibitors (RAASi): ACE inhibitors or ARBs are recommended for patients with hypertension, diabetes, chronic kidney disease, and/or left ventricular dysfunction (<40%) (class I). Outside these situations, they provide no clinical benefit (class 2b).
• Lipid-Lowering Agents: Statins remain the cornerstone of lipid management (class I), with the goal of reducing LDL levels by at least 50%. The highest tolerated dose should be used, and for more aggressive LDL targets (<70 mg/dL), ezetimibe is recommended as an adjunct therapy (class 2a). In cases where these targets are not met, particularly in familial hypercholesterolemia, PCSK9 inhibitors are considered (class 2a/2b). New agents like bempedoic acid and inclisiran lack clear recommendations (class 2b), and niacin, fibrates, or omega-3 supplements are not advised alongside statins. The most potent agents are atorvastatin and rosuvastatin, followed by simvastatin, lovastatin, and pitavastatin; all are lipophilic with dose-dependent effects, as well as corresponding tolerability and side effect profiles. The hydrophilic statins pravastatin and rosuvastatin, while less potent, are generally better tolerated.
• SGLT2 Inhibitors (-gliflozins) and GLP-1 Receptor Agonists (-glutides): These are new additions to heart failure pharmacotherapy, now integral to ischemic heart disease management. Both are recommended for diabetic patients (class I). In patients with left ventricular dysfunction (<40%), SGLT2 inhibitors are indicated even in the absence of diabetes (class I).
• Hormone Replacement Therapy in Postmenopausal Women with Coronary Disease is not recommended due to increased thromboembolic risk and lack of clinical benefit (class 3).

Revascularization Therapy: This is the most controversial aspect. The recommendations adhere to the 2021 revascularization guidelines from American societies, with a simplified approach to coronary anatomy indications and a focus on the SYNTAX score, where only a score of >33 remains a decisive point. Key indications are summarized into three categories:

1. Intermediate-Low Surgical Risk Non-Diabetic Patients: Surgery is class I recommended for left main coronary artery disease. A notable point is that CABG remains superior for SYNTAX scores >33 (class 2a), though intermediate and low scores are not explicitly addressed.
2. High Surgical Risk Patients: Percutaneous intervention is class 2a recommended to improve symptoms and outcomes in patients deemed unsuitable for surgery.
3. Diabetic Patients: Revascularization for multivessel disease is a class I indication. For left main coronary disease, percutaneous intervention is class 2b recommended for SYNTAX scores <33, while intermediate and low scores are not mentioned.

These guidelines provide an update on optimal therapeutic management of patients with stable ischemic heart disease. Their application is especially relevant in the postoperative setting, following revascularization surgery, as they allow for the appropriate prescription of both medications and lifestyle changes to enhance patient survival and quality of life from the time of hospital discharge.

REFERENCE:
Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, 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 Jul 20. doi: 10.1161/CIR.0000000000001168.