What is the recommended approach for managing cardiac patients?

Management of Cardiac Patients: A Comprehensive Approach

For optimal management of cardiac patients, a multidisciplinary approach integrating guideline-directed medical therapy, lifestyle modifications, and appropriate risk stratification is strongly recommended to reduce morbidity, mortality, and improve quality of life. 1

Risk Assessment and Diagnosis

Initial Evaluation

• Perform risk stratification based on clinical assessment and diagnostic test results 1
• Resting echocardiography to quantify left ventricular function in all patients with suspected CAD 1
• For symptomatic patients, preferably use stress imaging or coronary CTA for risk stratification 1
• In patients with suspected vasospastic angina:
  • Obtain 12-lead ECG recording during angina episodes 1
  • For repetitive episodes of rest angina with ST-segment changes, invasive functional angiography is recommended 1

Risk Stratification Tools

• Use validated risk assessment tools:
  • PRECISE-DAPT score or ARC-HBR tool for bleeding risk 1
  • SCORE2 and SCORE-OP for cardiovascular event risk in asymptomatic individuals 1

Medical Therapy

Pharmacological Management

• First-line treatment for symptom control:

  • Beta-blockers and/or calcium channel blockers to control heart rate and symptoms 1
  • Short-acting nitrates for immediate relief of effort angina 1

• For vasospastic angina:

  • Calcium channel blockers are recommended to control symptoms and prevent ischemia 1

• Antithrombotic therapy:

  • Aspirin 75-100 mg daily for patients with previous MI or revascularization 1
  • Clopidogrel 75 mg daily as alternative in aspirin-intolerant patients 1
  • After stenting: DAPT (aspirin plus clopidogrel) for 6 months, unless bleeding risk necessitates shorter duration 1

• For patients with heart failure with reduced EF (<40%):

  • ACE inhibitors or ARBs 1
  • Beta-blockers 1
  • Mineralocorticoid receptor antagonists 1

• Lipid management:

  • Statins for all patients to reduce LDL-C by ≥50% from baseline and achieve LDL-C <1.4 mmol/L (<55 mg/dL) 1
  • Consider adding ezetimibe if LDL-C goals not achieved with maximum tolerated statin dose 1

Special Populations

• Older adults (≥75 years):

  • Pay particular attention to drug side effects, interactions, and dosing 1
  • Make diagnostic and revascularization decisions based on symptoms, ischemia extent, frailty, life expectancy, and comorbidities 1

• Women:

  • Apply same guideline-directed cardiovascular preventive therapy as in men 1
  • Avoid systemic post-menopausal hormone therapy due to thromboembolic risk 1

Lifestyle Modifications

Core Recommendations

• Exercise-based cardiac rehabilitation is strongly recommended 1

  • Exercise test-guided moderate intensity aerobic exercise at least five times per week 1
  • Medically supervised programs for high-risk patients 1

• Dietary modifications:

  • Diet based on low intake of salt and saturated fats 1
  • Regular intake of fruits, vegetables, and fish 1
  • Consider omega-3 fatty acid supplementation (1g) in patients with low intake of oily fish 1

• Smoking cessation:

  • Assess smoking status at each visit 1
  • Provide counseling to quit and avoid passive smoking 1
  • Consider bupropion and nicotine replacement therapy 1

• Weight management:

  • Weight reduction when BMI ≥30 kg/m² 1

Implementation Strategies

• Mobile health interventions (text messages, apps, wearable devices) to improve adherence 1
• Behavioral interventions to improve adherence 1
• Simplify medication regimens (e.g., fixed-dose combinations) 1
• Involve multiprofessional teams and family members 1

Follow-up and Monitoring

• Periodic visits (e.g., annual) to evaluate cardiovascular risk factor control and assess changes in risk status 1
• Reassessment of CAD status in patients with deteriorating LV function 1
• Risk stratification in patients with new or worsening symptoms, preferably using stress imaging 1
• For patients with refractory symptoms or at high risk, consider invasive coronary angiography with FFR/iFR 1

Disease Progression Management

• For patients with symptoms refractory to medical treatment, invasive coronary angiography (with FFR/iFR when necessary) is recommended 1
• In patients with non-obstructive coronary disease and poor quality of life, consider invasive coronary functional testing 1
• For patients with deteriorating LV function, reassess CAD status 1

Common Pitfalls to Avoid

1. Abrupt discontinuation of beta-blockers in patients with coronary artery disease can lead to severe exacerbation of angina, MI, and ventricular arrhythmias 2

2. Overlooking comorbidities - Comprehensive risk profiling and management of major comorbidities (hypertension, hyperlipidemia, diabetes) is essential 1

3. Focusing only on pharmacotherapy without addressing lifestyle factors - Both approaches are necessary for optimal outcomes 3, 4

4. Poor medication adherence - Simplifying regimens and using mobile health interventions can improve adherence 1

5. Inadequate risk stratification before determining treatment strategy - Risk assessment should guide management decisions 1

6. Neglecting special populations - Older adults, women, and patients with comorbidities require tailored approaches 1