What is the recommended management for patients with coronary artery disease?

Management of Patients with Coronary Artery Disease

The comprehensive management of coronary artery disease requires a combination of guideline-directed medical therapy, lifestyle modifications, and selective revascularization based on symptom severity and risk stratification to reduce mortality, prevent heart failure, and improve quality of life.

Risk Stratification and Diagnosis

• Initial evaluation should include:

  • Assessment of symptoms (angina, dyspnea)
  • Resting echocardiography to quantify left ventricular function 1
  • Risk stratification preferably using stress imaging or coronary CTA 1

• For symptomatic patients with high-risk clinical profile:

  • Invasive coronary angiography (ICA) with invasive physiological guidance (FFR/iFR) is recommended, particularly when symptoms inadequately respond to medical treatment 1
  • For patients with mild or no symptoms but high event risk on non-invasive testing, ICA with physiological guidance is also recommended 1

Medical Therapy

Anti-ischemic/Antianginal Medications

1. First-line therapy:

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

2. Additional options for persistent symptoms:

   • Long-acting nitrates
   • Ranolazine for patients with persistent angina despite optimal therapy

Antithrombotic Therapy

• For patients in sinus rhythm:

  • Aspirin 75-100 mg daily for patients with previous MI or revascularization 1
  • Clopidogrel 75 mg daily as alternative in aspirin-intolerant patients 1

• Post-PCI patients:

  • Aspirin 75-100 mg daily following stenting 1
  • Clopidogrel 75 mg daily in addition to aspirin for 6 months after coronary stenting 1

• For patients with atrial fibrillation:

  • NOAC preferred over VKA when oral anticoagulation is initiated 1
  • Concomitant use of proton pump inhibitor recommended in patients at high risk of gastrointestinal bleeding 1

Lipid-Lowering Therapy

• Statins recommended for all patients with CCS 1
• If goals not achieved with maximum tolerated statin dose, add ezetimibe 1
• For very high-risk patients not achieving goals on statin plus ezetimibe, add PCSK9 inhibitor 1

Heart Failure Management in CAD Patients

• For patients with HFrEF:

  • ACE inhibitor, MRA, SGLT2 inhibitor (dapagliflozin or empagliflozin), and beta-blocker are recommended to reduce heart failure hospitalization and death 1
  • Sacubitril/valsartan recommended as replacement for ACE-I or ARB 1
  • Diuretics for patients with signs/symptoms of congestion 1

• For patients with HFmrEF or HFpEF:

  • SGLT2 inhibitor (dapagliflozin or empagliflozin) recommended to reduce HF hospitalization or cardiovascular death 1

Device Therapy for CAD with Heart Failure

• ICD recommended for:

  • Patients with symptomatic HF (NYHA class II-III) of ischemic etiology with LVEF ≤35% despite ≥3 months of optimized GDMT 1
  • Patients recovered from ventricular arrhythmia causing hemodynamic instability 1

• CRT recommended for:

  • Symptomatic HF patients with sinus rhythm, LVEF ≤35% despite GDMT, and QRS duration ≥150 ms with LBBB QRS morphology 1
  • Patients with HFrEF requiring ventricular pacing for high-degree AV block 1

Revascularization

Left Main or Multivessel Disease

• CABG recommended for patients with left main or three-vessel disease 1
• For patients with complex multivessel disease and diabetes, CABG preferred over PCI 1

Single- or Double-Vessel Disease

• For single- or double-vessel disease involving proximal LAD with insufficient response to medical therapy, CABG or PCI recommended over medical therapy alone 1
• For complex single- or double-vessel disease involving proximal LAD less amenable to PCI, CABG recommended over PCI 1
• For symptomatic patients with single- or double-vessel disease not involving proximal LAD and insufficient response to medical therapy, PCI recommended to improve symptoms 1

Non-obstructive Coronary Artery Disease

• For persistently symptomatic patients with suspected ANOCA/INOCA despite medical treatment, invasive coronary functional testing is recommended 1
• For suspected vasospastic angina:
  • 12-lead ECG recording during angina recommended 1
  • Calcium channel blockers recommended for treatment 1

Lifestyle Management

• Exercise-based cardiac rehabilitation recommended 1
• Cognitive behavioral interventions to help achieve healthy lifestyle 1
• Annual influenza vaccination, especially in elderly patients 1
• Multidisciplinary healthcare involvement (cardiologists, GPs, nurses, dieticians, physiotherapists, psychologists, pharmacists) 1

Special Considerations

Older Adults (≥75 years)

• Particular attention to drug side effects, intolerance, drug-drug interactions, overdosing, and procedural complications 1
• Diagnostic and revascularization decisions based on symptoms, extent of ischemia, frailty, life expectancy, comorbidities, and patient preferences 1

Women

• Similar guideline-directed cardiovascular preventive therapy as in men 1
• Systemic post-menopausal hormone therapy not recommended 1

Follow-up

• Periodic visits to cardiovascular healthcare professional to reassess risk status, lifestyle modifications, adherence to targets, and development of comorbidities 1
• For symptomatic patients:
  • Reassessment of CAD status recommended in patients with deteriorating LV systolic function 1
  • Risk stratification recommended for patients with new or worsening symptoms 1
  • Expeditious referral for evaluation in patients with significant worsening of symptoms 1