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Interpretation on the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guidelines for the Management of Patients with Chronic Coronary Disease
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摘要: 近期，美国心脏协会(American Heart Association，AHA)、美国心脏病学会(American College of Cardiology，ACC)等六大学会联合发布了《2023 AHA/ACC/ACCP/ASPC/NLA/PCNA慢性冠状动脉疾病患者管理指南》，该指南强调了“以患者为中心，以团队为基础”的总体管理理念和重视生活方式改善对慢性冠状动脉疾病患者预后的影响，并对主要心血管不良事件风险评估及新型药物推荐等作出了新的阐述，指南内容的更新对于指导我国临床医生为慢性冠状动脉疾病患者提供高质量管理具有重要指导意义。Abstract: In July 2023, the American Heart Association (AHA), the American College of Cardiology (ACC), and four other professional societies jointly released the updated version of the AHA/ACC/ACCP/ASPC/NLA/PCNA Guidelines for the Management of Patients with Chronic Coronary Artery Disease. This guideline emphasizes a patient-centered and team-based approach to the overall management of chronic coronary artery disease (CCD), highlights the impact of lifestyle improvements on the prognosis of CCD patients, and provides new insights into risk assessment for major adverse cardiovascular events (MACE) and recommendations for novel medications. These updates hold significant guiding value for health care professionals in China to provide high-quality management for CCD patients.
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Key words:
- chronic coronary artery disease /
- diagnosis /
- treatment /
- management /
- guidelines
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表 1 新版指南对于药物治疗预防心血管事件和症状管理的推荐意见
Table 1. The updated guidelines recommendations for pharmacological treatment in the prevention of cardiovascular events and management of symptoms
推荐意见 推荐强度 证据等级 对于同时患有高血压、糖尿病、LVEF≤40% 或CKD的CCD患者，建议使用ACEI或ARB(若ACEI不耐受)以减少CVD 1类推荐 A级证据 对于同时患有高血压、糖尿病、LVEF＞40% 或CKD的CCD患者，建议使用ACEI或ARB(若ACEI不耐受)以减少CVD 2b类推荐 B级证据 对于CCD患者，可考虑添加秋水仙碱进行二级预防，以减少复发性ASCVD事件 2b类推荐 B级证据 对于CCD患者，建议每年接种流感疫苗，以减少心血管发病率、心血管死亡率和全因死亡率 1类推荐 A级证据 对于CCD患者，建议根据公共卫生指南接种COVID-19疫苗，以减少COVID-19并发症 1类推荐 C级证据 对于CCD患者，肺炎球菌疫苗可合理降低心血管发病率和死亡率以及全因死亡率 2a类推荐 B级证据 对于患有CCD和心绞痛的患者，建议使用β受体阻滞剂、CCB或长效硝酸盐进行抗心绞痛治疗，以缓解心绞痛或类似症状 1类推荐 B级证据 对于初次治疗后仍有症状的CCD和心绞痛患者，建议添加不同治疗类别的第二种抗心绞痛药物(β受体阻滞剂、CCB、长效硝酸盐)，以缓解心绞痛或类似症状 1类推荐 B级证据 对于CCD患者，尽管使用β受体阻滞剂、CCB或长效硝酸酯疗法治疗，但症状仍存在的患者，建议使用雷诺嗪 1类推荐 B级证据 对于CCD患者，建议舌下含服硝酸甘油或硝酸甘油喷雾剂，以立即短期缓解心绞痛或类似症状 1类推荐 B级证据 对于CCD和左室功能正常的患者，在标准抗心绞痛治疗中添加伊伐布雷定，可能有害 3类推荐 B级证据 对于患CCD、难治性心绞痛且无其他治疗选择的患者，可考虑增强体外反搏，以缓解症状 2b类推荐 B级证据 LVEF(left ventricular ejection fractions)：左心室射血分数；CKD(chronic kidney disease)：慢性肾脏病；CCD(chronic coronary artery disease)：慢性冠状动脉疾病；ACEI(angiotensin converting enzyme inhibitors)：血管紧张素转化酶抑制剂；ARB(angiotensin receptor blocker)：血管紧张素Ⅱ受体阻滞剂；ASCVD(atherosclerotic cardiovascular disease)：动脉粥样硬化性心血管疾病；COVID-19(corona virus disease 2019)：新型冠状病毒感染；CCB(calcium channel blocker)：钙通道阻滞剂 
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表 2 新版指南关于CCD特殊人群管理的推荐意见
Table 2. The updated guidelines recommendations for the management of specific populations with CCD
推荐意见 推荐强度 证据等级 对于年轻的CCD患者，在优化传统心血管危险因素后，对非传统心血管危险因素进行综合评估和治疗，有利于降低CVD的发生风险 2a类推荐 C级证据 对于患有CCD和癌症的患者，建议建立包括心脏病学和肿瘤学专业的多学科团队，以改善长期CVD结局 1类推荐 C级证据 对于考虑怀孕或已怀孕的CCD患者，应对孕产妇、产科和胎儿不良结局的发生风险进行风险分层，并提供相关咨询 1类推荐 C级证据 对于计划怀孕或已怀孕的CCD患者应在受孕前接受多学科心脏产科团队的护理，并持续整个孕期、分娩和产后，以改善母婴结局 1类推荐 C级证据 对于女性CCD患者，可考虑怀孕期间继续使用他汀类药物 2b类推荐 C级证据 对于女性CCD患者，不应接受全身绝经后激素治疗，因对MACE和死亡率无益处，且静脉血栓栓塞的风险增加 3类推荐 A级证据 对于CCD和CKD患者，应采取措施尽量减少治疗相关的急性肾损伤发生风险 1类推荐 C级证据 对于患有CCD和HIV感染的成年人，抗逆转录病毒治疗有助于降低CVD的发生风险 1类推荐 B级证据 对于患有CCD和HIV感染的成年人，考虑药物相互作用，应选择有利于降低血脂和心血管风险状况的抗逆转录病毒治疗方案 2a类推荐 B级证据 对于患有CCD和HIV感染的成年人，洛伐他汀或辛伐他汀不应与蛋白酶抑制剂共同服用，因其可能对患者造成伤害 3类推荐 C级证据 对于患有CCD和类风湿关节炎的患者，若有替代疗法，则不建议长期使用大剂量糖皮质激素，因其增加心血管风险 3类推荐 C级证据 对于心脏同种异体移植的血管病变患者，建议使用他汀类药物进行二级预防，以减少MACE 1类推荐 C级证据 对于心脏同种异体移植的血管病变患者，阿司匹林有助于二级预防，减少MACE 2a类推荐 C级证据 对于患有严重同种异体心脏移植血管病的患者，若具有合适的解剖结构，血运重建是合理的，其可潜在减轻同种异体心脏移植血管病的长期不良后果 2a类推荐 C级证据 CCD、CKD: 同表 1；CVD(cardiovascular disease)：心血管疾病；MACE(major adverse cardiovascular events)：主要心血管不良事件；HIV(human immunodeficiency virus)：人类免疫缺陷病毒
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[1] Fihn S D, Gardin J M, 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 Associa-tion for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons[J]. Circulation, 2012, 126(25): e354-e471. [2] Fihn S D, Blankenship J C, Alexander K P, 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]. Circulation, 2014, 130(19): 1749-1767. doi: 10.1161/CIR.0000000000000095 [3] Virani S S, Newby L K, Arnold S V, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the manage-ment of patients with chronic coronary disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines[J]. Circulation, 2023, 148(9): e9-e119. [4] Knuuti J, Wijns W, Saraste A, et al. 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes[J]. Eur Heart J, 2020, 41(3): 407-477. doi: 10.1093/eurheartj/ehz425 [5] Patel K K, Spertus J A, Arnold S V, et al. Ischemia on PET MPI May identify patients with improvement in angina and health status post-revascularization[J]. J Am Coll Cardiol, 2019, 74(13): 1734-1736. doi: 10.1016/j.jacc.2019.06.074 [6] Patel K K, Spertus J A, Chan P S, et al. Myocardial blood flow reserve assessed by positron emission tomography myocardial perfusion imaging identifies patients with a survival benefit from early revascularization[J]. Eur Heart J, 2020, 41(6): 759-768. doi: 10.1093/eurheartj/ehz389 [7] Heitner J F, Kim R J, Kim H W, et al. Prognostic value of vasodilator stress cardiac magnetic resonance imaging: a multicenter study with 48 000 patient-years of follow-up[J]. JAMA Cardiol, 2019, 4(3): 256-264. doi: 10.1001/jamacardio.2019.0035 [8] Kwong R Y, Ge Y, Steel K, et al. Cardiac magnetic resonance stress perfusion imaging for evaluation of patients with chest pain[J]. J Am Coll Cardiol, 2019, 74(14): 1741-1755. doi: 10.1016/j.jacc.2019.07.074 [9] Al-Lamee R, Thompson D, Dehbi H M, et al. Percutane-ous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial[J]. Lancet, 2018, 391(10115): 31-40. doi: 10.1016/S0140-6736(17)32714-9 [10] REYNOLDS H R, SHAW L J, MIN J K, et al. Correction to: outcomes in the ISCHEMIA trial based on coronary artery disease and ischemia severity[J]. Circulation, 2022, 146(1): 1024-1038. [11] Rees K, Takeda A, Martin N, et al. Mediterranean-style diet for the primary and secondary prevention of cardiova-scular disease[J]. Cochrane Database Syst Rev, 2019, 3(3): CD009825. [12] Tapsell L C, Neale E P. The effect of interdisciplinary interventions on risk factors for lifestyle disease: a literature review[J]. Health Educ Behav, 2016, 43(3): 271-285. doi: 10.1177/1090198115601092 [13] Hall K S, Hyde E T, Bassett D R, et al. Systematic review of the prospective association of daily step counts with risk of mortality, cardiovascular disease, and dysglycemia[J]. Int J Behav Nutr Phys Act, 2020, 17(1): 78. doi: 10.1186/s12966-020-00978-9 [14] Ference B A, Ginsberg H N, Graham I, et al. Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel[J]. Eur Heart J, 2017, 38(32): 2459-2472. doi: 10.1093/eurheartj/ehx144 [15] Kosiborod M, Cavender M A, Fu A Z, et al. Lower risk of heart failure and death in patients initiated on sodium-glucose cotransporter-2 inhibitors versus other glucose-lowering drugs: the CVD-REAL study (comparative effectiveness of cardiovascular outcomes in new users of sodium-glucose cotransporter-2 inhibitors)[J]. Circulation, 2017, 136(3): 249-259. doi: 10.1161/CIRCULATIONAHA.117.029190 [16] Sattar N, Lee M M Y, Kristensen S L, et al. Cardiovascular, mortality, and kidney outcomes with GLP-1 receptor agonists in patients with type 2 diabetes: a systematic review and meta-analysis of randomised trials[J]. Lancet Diabetes Endocrinol, 2021, 9(10): 653-662. doi: 10.1016/S2213-8587(21)00203-5 [17] Yoshida Y, Cheng X, Shao H, et al. A systematic review of cost-effectiveness of sodium-glucose cotransporter inhibitors for type 2 diabetes[J]. Curr Diab Rep, 2020, 20(4): 12. doi: 10.1007/s11892-020-1292-5 [18] Gaziano J M, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial[J]. Lancet, 2018, 392(10152): 1036-1046. doi: 10.1016/S0140-6736(18)31924-X [19] Lopes R D, Hong H, Harskamp R E, et al. Optimal antithrombotic regimens for patients with atrial fibrillation undergoing percutaneous coronary intervention: an updated network meta-analysis[J]. JAMA Cardiol, 2020, 5(5): 582-589. doi: 10.1001/jamacardio.2019.6175 [20] Lopes R D, Hong H, Harskamp R E, et al. Safety and efficacy of antithrombotic strategies in patients with atrial fibrillation undergoing percutaneous coronary intervention: a network meta-analysis of randomized controlled trials[J]. JAMA Cardiol, 2019, 4(8): 747-755. doi: 10.1001/jamacardio.2019.1880 [21] Bonaca M P, Bhatt D L, Cohen M, et al. Long-term use of ticagrelor in patients with prior myocardial infarction[J]. N Engl J Med, 2015, 372(19): 1791-1800. doi: 10.1056/NEJMoa1500857 [22] Bhatt D L, Eikelboom J W, Connolly S J, et al. Role of combination antiplatelet and anticoagulation therapy in diabetes mellitus and cardiovascular disease: insights from the COMPASS trial[J]. Circulation, 2020, 141(23): 1841-1854. doi: 10.1161/CIRCULATIONAHA.120.046448 [23] Steffel J, Eikelboom J W, Anand S S, et al. The COMPASS trial: net clinical benefit of low-dose rivaroxaban plus aspirin as compared with aspirin in patients with chronic vascular disease[J]. Circulation, 2020, 142(1): 40-48. doi: 10.1161/CIRCULATIONAHA.120.046048 [24] Dargie H J. Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the Capricorn randomised trial[J]. Lancet, 2001, 357(9266): 1385-1390. doi: 10.1016/S0140-6736(00)04560-8 [25] Park C S, Yang H M, Ki Y J, et al. Left ventricular ejection fraction 1 year after acute myocardial infarction identifies the benefits of the long-term use of β-blockers: analysis of data from the KAMIR-NIH registry[J]. Circ Cardiovasc Interv, 2021, 14(4): e010159. doi: 10.1161/CIRCINTERVENTIONS.120.010159 [26] Sorbets E, Steg P G, Young R, et al. β-Blockers, calcium antagonists, and mortality in stable coronary artery disease: an international cohort study[J]. Eur Heart J, 2019, 40(18): 1399-1407. doi: 10.1093/eurheartj/ehy811 -
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