What is the management approach for non-coronary atherosclerotic disease?

From the Guidelines

The management of non-coronary atherosclerotic disease should focus on aggressive risk factor modification, antiplatelet therapy, and targeted interventions for specific vascular beds, with a primary goal of achieving an LDL cholesterol level of less than 70 mg/dL using high-intensity statin therapy, as recommended by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1. This approach is supported by the most recent and highest quality evidence, which emphasizes the importance of statin therapy in reducing the risk of major cardiovascular events in patients with non-coronary atherosclerotic disease. Key components of the management approach include:

• Lifestyle modifications, such as smoking cessation, regular exercise, and a heart-healthy diet
• Medical therapy, including antiplatelet agents like aspirin or clopidogrel, and high-intensity statin therapy with atorvastatin or rosuvastatin
• Blood pressure control, targeting levels below 130/80 mmHg using medications like ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics
• Diabetes management, with a target HbA1c below 7% and consideration of SGLT2 inhibitors or GLP-1 receptor agonists
• Targeted interventions for specific vascular beds, such as supervised exercise programs and revascularization for peripheral artery disease, and intervention for carotid artery disease and renal artery disease as needed. The 2022 ACC/AHA guideline 1 provides the most recent and highest quality evidence to support this approach, and should be prioritized in clinical decision-making. Additionally, the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines 1 and the 2011 ESC guidelines 1 provide further support for the importance of aggressive risk factor modification and targeted interventions in the management of non-coronary atherosclerotic disease. However, the 2022 ACC/AHA guideline 1 takes precedence due to its recency and high quality. Overall, the management of non-coronary atherosclerotic disease requires a comprehensive and multifaceted approach, with a focus on achieving an LDL cholesterol level of less than 70 mg/dL using high-intensity statin therapy, and prioritizing the most recent and highest quality evidence.

From the Research

Management Approach for Non-Coronary Atherosclerotic Disease

The management of non-coronary atherosclerotic disease involves a comprehensive approach that includes lifestyle modifications, risk factor management, and pharmacological therapy.

• The European Society Guidelines and AHA/ACC Guidelines on Peripheral artery diseases recommend an interdisciplinary approach to manage non-coronary atherosclerotic disease, emphasizing the importance of awareness and involvement of atherosclerosis at different levels 2.
• Risk assessment is crucial in managing atherosclerotic cardiovascular disease, and global risk scores based on standard office-based measures can be used to assess baseline risk 3.
• Pharmacological therapy, such as angiotensin-converting enzyme (ACE) inhibitors and statins, can be effective in reducing the risk of atherosclerotic cardiovascular disease events 4, 5.
• The combination of ACE inhibitors and statins has been shown to have synergistic actions in reducing the rate of atherosclerotic cardiovascular disease events in patients with hypertension and lipid disorders 5.
• Risk stratification is essential in guiding preventive medical therapy, and a dedicated risk scoring system can accurately predict prognosis in patients with non-obstructive coronary artery disease 6.

Lifestyle Modifications and Risk Factor Management

Lifestyle modifications, such as a healthy diet, regular physical activity, and smoking cessation, are essential in managing non-coronary atherosclerotic disease.

• Managing risk factors, such as hypertension, diabetes, and hypercholesterolemia, is critical in reducing the risk of atherosclerotic cardiovascular disease events 3, 4, 5.
• The use of risk-enhancing factors, including traditional risk factors and novel biomarkers, can further assess atherosclerotic cardiovascular disease risk, especially in those at borderline or intermediate risk 3.

Pharmacological Therapy

Pharmacological therapy plays a crucial role in managing non-coronary atherosclerotic disease.

• ACE inhibitors and angiotensin receptor blockers (ARBs) can effectively reduce the risk of atherosclerotic cardiovascular disease events by improving endothelial function, cardiac and vascular remodeling, and retarding the anatomic progression of atherosclerosis 4.
• Statins can reduce the risk of atherosclerotic cardiovascular disease events by lowering cholesterol levels and reducing inflammation 5, 6.
• The combination of ACE inhibitors and statins can be beneficial in high-risk patients, while aspirin can be harmful in low-risk patients 6.