What are the management options for coronary artery disease (CAD)?

Management of Coronary Artery Disease

The management of coronary artery disease requires comprehensive risk profiling and multidisciplinary treatment, including lifestyle modifications, pharmacological therapy, and revascularization when appropriate to reduce morbidity and mortality. 1

Risk Assessment and Diagnosis

Initial Evaluation

• A stepwise approach is recommended for patients with suspected CAD:
  1. General clinical evaluation (symptoms, signs, 12-lead ECG, basic blood tests)
  2. Cardiac examination including echocardiography to assess LV function and rule out valvular disease
  3. Diagnostic testing to confirm CAD and determine risk
  4. Implementation of treatment strategy 1

Diagnostic Testing

• For patients with suspected CAD and pre-test likelihood >5%, either CCTA or non-invasive functional imaging is recommended as initial diagnostic test 1
• CCTA is preferred for patients with low to moderate (>5%-50%) pre-test likelihood to rule out obstructive CAD 1
• Functional imaging is recommended if CCTA shows CAD of uncertain functional significance 1
• Invasive coronary angiography with functional assessment is recommended when non-invasive testing is inconclusive 1

Treatment Strategies

Lifestyle Modifications

• Smoking cessation, physical activity, healthy diet, weight management, and stress reduction are essential components 1
• Exercise-based cardiac rehabilitation is recommended to improve outcomes and quality of life 1
• Annual influenza vaccination is recommended, especially in older patients 1
• Psychological interventions should be implemented to address depression and improve quality of life 1

Pharmacological Management

Anti-ischemic Therapy

• First-line treatment includes beta-blockers and/or calcium channel blockers to control heart rate and symptoms 1
• Short-acting nitrates are recommended for immediate relief of effort angina 1
• Amlodipine can be used for symptomatic treatment of chronic stable angina, vasospastic angina, and to reduce risk of hospitalization for angina and revascularization procedures in patients with documented CAD 2

Disease-Modifying Therapy

• Lipid-lowering therapy:

  • Statins are recommended for all CAD patients with a goal to reduce LDL-C by ≥50% from baseline and achieve LDL-C <1.4 mmol/L (<55 mg/dL) 1
  • If LDL-C goals are not achieved after 4-6 weeks with maximum tolerated statin dose, add ezetimibe 1
  • If goals still not achieved, consider adding a PCSK9 inhibitor 1

• Antithrombotic therapy:

  • Low-dose aspirin (75-100 mg daily) is recommended for secondary prevention 1
  • Consider proton pump inhibitor in patients at high risk of gastrointestinal bleeding 1

• Other medications:

  • ACE inhibitors (or ARBs if intolerant) are recommended for patients with heart failure with reduced LVEF (<40%), diabetes, or CKD 1
  • Beta-blockers are recommended for patients with systolic LV dysfunction or heart failure with reduced LVEF (<40%) 1
  • Mineralocorticoid receptor antagonists (MRAs) are recommended for heart failure with reduced LVEF (<40%) 1

Revascularization

• Myocardial revascularization is recommended when angina persists despite treatment with antianginal drugs 1
• In patients with mild or no symptoms receiving medical treatment, in whom non-invasive risk stratification indicates high risk, invasive coronary angiography (with FFR when necessary) is recommended 1
• The ISCHEMIA trial showed that an early revascularization strategy did not yield short-term survival benefit in patients without left main disease or reduced LVEF who had moderate-severe ischemia, suggesting most such patients should initially be treated conservatively with optimized medical therapy 1

Special Considerations

Hypertension Management

• Target office BP: 120-130 mmHg systolic in general, 130-140 mmHg in older patients (>65 years) 1
• In hypertensive patients with recent MI, beta-blockers and RAS blockers are recommended 1
• In patients with symptomatic angina, beta-blockers and/or calcium channel blockers are recommended 1

Diabetes Management

• All patients with NSTE-ACS should be screened for diabetes and have blood glucose levels monitored if diagnosed with diabetes or admission hyperglycemia 1
• Avoid hypoglycemia 1

Older Patients

• The same diagnostic and interventional strategies should be applied to older patients as for younger patients, with medication dosages adapted to renal function and specific contraindications 1

Follow-up Care

• Periodic visits to a cardiovascular healthcare professional are recommended to reassess risk status, evaluate lifestyle modifications, adherence to targets of cardiovascular risk factors, and development of comorbidities 1
• Risk stratification is recommended for patients with new or worsening symptoms, preferably using stress imaging or exercise stress ECG 1

Common Pitfalls to Avoid

• Focusing only on obstructive lesions while neglecting non-obstructive plaques that may cause acute coronary syndromes 3
• Using invasive coronary angiography solely for risk stratification without clinical indication 1
• Combining ACE inhibitors and ARBs (not recommended) 1
• Neglecting to assess and treat comorbidities that affect CAD outcomes 1
• Underutilizing cardiac rehabilitation programs despite their proven benefits 1

By implementing this comprehensive approach to CAD management, clinicians can effectively reduce morbidity and mortality while improving patients' quality of life.