American Guidelines Sour on Beta-Blockers for Chronic Coronary Disease

New American guidelines for chronic coronary disease (CCD) modify management considerations for a heterogeneous group that includes people with or without angina, a history of coronary revascularization, and previous acute coronary syndrome.

For one, the American Heart Association (AHA) and American College of Cardiology (ACC) say that outpatients with CCD should no longer initiate beta-blockers — based on recent observational studies, a class III statement of non-recommendation has been issued for long-term beta-blocker therapy in the absence of myocardial infarction (MI) in the past year, left ventricular ejection fraction ≤50%, or another primary indication for beta-blocker therapy.

“This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care,” according to the writing committee chaired by Salim Virani, MD, PhD, of the Aga Khan University in Karachi City, Pakistan, and Texas Heart Institute, Houston.

Published in Circulation, the new recommendations replace the 2012 guideline and 2014 focused guideline update on stable ischemic heart disease.

Virani and colleagues noted that CCD covers conditions of obstructive and nonobstructive coronary artery disease (CAD) with or without previous MI or revascularization, ischemic heart disease diagnosed only by noninvasive testing, and chronic angina syndromes with varying underlying causes. Approximately 20.1 million people live with CCD in the U.S., they said.

In patients with CCD who are already on beta-blockers for previous MI without a history of or current left ventricular ejection fraction (LVEF) ≤50%, angina, arrhythmias, or uncontrolled hypertension, guideline authors deem it “may be reasonable” to reassess the indication for long-term use of beta-blocker therapy for reducing major adverse cardiovascular events, in a class IIb recommendation.

Meanwhile, modified recommendations now put a class I endorsement for revascularization to improve symptoms in patients with lifestyle-limiting angina despite guideline-directed medical therapy and with coronary stenoses amenable to revascularization; or to improve survival in patients with significant left main disease, or multivessel disease with severe left ventricular (LV) dysfunction in whom bypass surgery plus medical therapy is recommended over medical therapy alone.

The AHA and ACC continue to recommend healthy diet and exercise. Statins remain the first-line therapy for lipid lowering; this leaves ezetimibe (Zetia), PCSK9 inhibitors, inclisiran (Leqvio), and bempedoic acid (Nexletol) as adjunctive therapies with weaker class II endorsements.

Meanwhile, SGLT-2 inhibitors are strongly recommended for those with CCD and type 2 diabetes or heart failure with reduced LVEF, and GLP-1 receptor agonists are similarly endorsed in CCD with type 2 diabetes.

Routine periodic anatomic or ischemic testing should be limited to people who have had a change in clinical or functional status, not for risk stratification or to guide therapeutic decision-making in patients with CCD.

“There is no role for routine stress testing or coronary angiography in patients who are stable,” agreed Sunil Rao, MD, and two colleagues at NYU Langone Health System in New York City, in an accompanying editorial.

“Although not specifically mentioned in the guidelines, as a pragmatic approach, periodic assessment of LV function might be considered for patients with LVEF near the qualifying value for an implantable cardioverter-defibrillator, even without a change in clinical status. Otherwise, there is no role for routine assessment of LV function,” the editorialists wrote.

As for the soured attitude toward beta-blockers, Rao and colleagues noted that this is based on observational data and that several ongoing randomized trials are assessing how well beta-blockers work in the context of contemporary secondary prevention in a range of CCD patient types.

“Importantly, the guidelines exist to provide guidance, and are meant to complement, not supplant, clinical judgment. As the evidence for the management of CCD continues to evolve, the guidelines will need to be a ‘living document’ to ensure that clinicians and patients can achieve their shared therapeutic goals of reducing mortality and improving quality of life,” they urged.

The new guidelines had been developed in collaboration with and were endorsed by the American College of Clinical Pharmacy, American Society for Preventive Cardiology, National Lipid Association, and Preventive Cardiovascular Nurses Association; and were endorsed by the Society for Cardiovascular Angiography and Interventions.