Coronary Artery Disease

Use an ACS pathway when the presentation is consistent with type 1 AMI, the plaque rupture, erosion, or dissection phenotype targeted by the ACS guideline. Do not extrapolate that pathway automatically to type 2 MI, myocardial infarction with nonobstructive coronary arteries (MINOCA), or spontaneous coronary artery dissection (SCAD), which are addressed separately. jacc+1jacc2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary SyndromesWileyClinical guideline highlights for the hospitalist: Updated ...

When parenteral unfractionated heparin is selected for initial ACS anticoagulation, use a 60 IU/kg loading dose (maximum 4,000 IU) followed by 12 IU/kg/h (maximum 1,000 IU/h), titrating to an aPTT of 60-80 seconds. For PCI in patients without prior anticoagulant therapy, use 70-100 U/kg to achieve an activated clotting time of 250-300 seconds; patients previously anticoagulated may receive additional UFH to the same ACT target. jaccjacc2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes

DAPT reduces recurrent ischemic events and stent thrombosis after ACS or PCI, but antithrombotic intensity must be balanced against bleeding. In patients with concomitant atrial fibrillation requiring oral anticoagulation after ACS or PCI, avoid assuming that prolonged triple therapy is necessary; randomized evidence and subsequent analyses compare oral anticoagulant plus a single antiplatelet agent with triple-antithrombotic strategies. NEJM+2NEJMAntithrombotic Therapy after Acute Coronary Syndrome or ...AHA Journals2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the ...AHA Journals2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the ...

In stable or recurrent anginal syndromes, use noninvasive testing when the result will change medical therapy, revascularization planning, or the diagnostic label. Routine screening for coronary heart disease in asymptomatic persons is unlikely to change management or the intensity of risk-factor reduction, so it should not substitute for direct preventive treatment. Annals of Internal MedicineAnnals of Internal MedicineShould We Screen for Coronary Heart Disease in ...

CCTA is useful when exclusion of obstructive CAD is the principal diagnostic objective. In intermediate-risk chest-pain populations, reported CCTA sensitivity is approximately 91%-99% and negative predictive value 93%-97% for CAD detection. A comparative meta-analysis found greater sensitivity for coronary CT than stress-testing strategies but substantial heterogeneity, supporting patient-specific modality selection rather than a universal first test. ScienceDirect+1ScienceDirectThe Significance of Equivocal Exercise Treadmill ECG for Intermediate Risk Chest Pain Assessment – Insight From Coronary CT Angiography Data - ScienceDirectScienceDirectCoronary CT Outperforms Stress Testing In Sensitivity For Coronary Artery Disease Diagnosis: Implications For Heart Failure Risk Stratification - A Meta-analysis

After an equivocal exercise treadmill ECG, CCTA can resolve uncertainty about coronary anatomy because the test has strong negative predictive performance for CAD. Conversely, functional testing provides an ischemia-focused answer; select it when documenting exercise-induced ischemia would direct management more clearly than anatomic exclusion alone. ScienceDirectScienceDirectThe Significance of Equivocal Exercise Treadmill ECG for Intermediate Risk Chest Pain Assessment – Insight From Coronary CT Angiography Data - ScienceDirect

Reserve invasive coronary angiography for patients in whom anatomy is needed to guide revascularization or to clarify an ischemic cause of heart failure. In chronic coronary disease with heart failure, noninvasive ischemia testing or CCTA may be appropriate in selected circumstances, while invasive angiography can identify coronary anatomy and direct subsequent treatment. AHA JournalsAHA Journals2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the ...

For chronic coronary disease without an indication for oral anticoagulation, prescribe low-dose aspirin 81 mg daily (acceptable range 75-100 mg) to reduce atherosclerotic events. The decision changes when long-term oral anticoagulation is required, because antithrombotic combinations after PCI or ACS require individualized bleeding-versus-thrombotic assessment. jacc+2jacc2023 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 GuidelinesNEJMAntithrombotic Therapy after Acute Coronary Syndrome or ...NEJMAntithrombotic Therapy for Atrial Fibrillation with Stable ...

After PCI for chronic coronary disease, use DAPT with aspirin and clopidogrel for 6 months, then continue single antiplatelet therapy. In selected patients with a drug-eluting stent who have completed 1-3 months of DAPT, P2Y12-inhibitor monotherapy for at least 12 months is reasonable when reducing bleeding risk is a priority. jaccjacc2023 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

Use statin-based lipid lowering as secondary prevention in obstructive CAD; randomized trials have demonstrated reductions in recurrent cardiovascular events and mortality. In post-ACS patients, adding ezetimibe 10 mg to simvastatin 40 mg reduced relative MACE risk by 6.4% versus simvastatin alone in IMPROVE-IT; benefit was similar among participants with baseline LDL-C of 50-70 mg/dL and those with LDL-C of at least 70 mg/dL. AHA Journals+1AHA JournalsStatin Use in Outpatients With Obstructive Coronary Artery DiseaseAHA Journals2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the ...

For patients with chronic coronary disease and symptoms suggestive of stable angina undergoing outpatient angiography, an hs-cTnI concentration above 10 ng/L identified a higher-risk group in a prospective cohort. Troponin was independently associated with MI or cardiovascular death over a median 2.4 years, but this observational risk marker should complement—not replace—clinical assessment, coronary anatomy, and standard secondary prevention. ScienceDirectScienceDirectHigh-Sensitivity Cardiac Troponin for Risk Assessment in Patients With Chronic Coronary Artery Disease - ScienceDirect

When chronic coronary disease coexists with ischemic cardiomyopathy, distinguish CABG-eligible disease from PCI-amenable disease before projecting a survival or heart-failure benefit. In evidence summarized by the chronic coronary disease guideline, an invasive treatment strategy reduced cardiovascular death or MI in a cited population, whereas REVIVED-BCIS2 found no reduction in all-cause death or heart-failure hospitalization with PCI plus medical therapy versus medical therapy alone among 700 patients with LVEF 35% or less and PCI-amenable chronic coronary disease. AHA JournalsAHA Journals2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the ...

For chronic coronary disease with heart failure, use invasive coronary angiography when it will establish revascularization suitability or clarify the cause of heart failure; otherwise, noninvasive ischemia evaluation or CCTA may answer the clinical question with less procedural exposure. AHA JournalsAHA Journals2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the ...

After PCI, align the antiplatelet plan with stent-related thrombotic risk and bleeding risk before discharge. DAPT lowers recurrent ischemic events and stent thrombosis, but abbreviated DAPT followed by P2Y12 monotherapy is an evidence-based bleeding-reduction option only for selected drug-eluting-stent recipients who have completed the initial 1-3-month DAPT course. NEJM+1NEJMAntithrombotic Therapy after Acute Coronary Syndrome or ...jacc2023 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

When symptoms persist despite nonobstructive epicardial anatomy, consider vasospastic angina rather than escalating therapy solely for fixed obstructive CAD. The chronic coronary disease guideline defines epicardial spasm as more than 90% reduction in coronary diameter after intracoronary acetylcholine compared with baseline resting diameter after intracoronary nitroglycerin. jaccjacc2023 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

If myocardial infarction occurs with nonobstructive coronary arteries or in the setting of suspected SCAD, classify the mechanism before assigning standard type 1 ACS secondary-prevention and revascularization assumptions. The ACS guideline explicitly identifies MINOCA and SCAD as conditions covered in separate guidance. jaccjacc2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes