What medications should a person with coronary artery disease (CAD) be started on?

Medications for Coronary Artery Disease Management

Patients with coronary artery disease should be started on aspirin 75-100 mg daily, a statin, a beta-blocker, and an ACE inhibitor as the cornerstone of medical therapy to reduce mortality and morbidity. 1

Core Medications for CAD

1. Antiplatelet Therapy

• First-line: Aspirin 75-100 mg daily for all CAD patients 2, 1
  • Reduces vascular events by approximately 20% 2
  • No additional benefit from doses higher than 150 mg daily 2
• Alternative: Clopidogrel 75 mg daily if aspirin intolerant 2, 1
• Post-PCI/ACS: Dual antiplatelet therapy (DAPT) with aspirin plus P2Y12 inhibitor:
  • 6 months after elective PCI with stenting 2
  • 12 months after ACS 1
  • Return to single antiplatelet therapy after DAPT period 1

2. Lipid-Lowering Therapy

• First-line: High-intensity statin for all CAD patients 2, 1
  • Target LDL-C <1.4 mmol/L (55 mg/dL) and ≥50% reduction from baseline 2
• If target not achieved: Add ezetimibe 2, 1
• For very high-risk patients not at goal: Add PCSK9 inhibitor 2
• If statin intolerant: Consider bempedoic acid 2

3. Beta-Blockers

• First-line for symptom control and mortality benefit 2, 1
• Particularly beneficial for:
  • Post-myocardial infarction patients 2
  • Patients with heart failure 2
  • Patients with angina symptoms 1
• Not contraindicated in diabetes; diabetic patients may benefit more 2

4. Renin-Angiotensin System Blockers

• ACE inhibitors recommended for all CAD patients, especially those with:
  • Heart failure or LV dysfunction 2, 1
  • Hypertension 2, 1
  • Diabetes 2, 1
  • Previous MI 2, 1
• ARBs recommended as alternative if ACE inhibitors not tolerated 2, 1

Symptom-Relief Medications

1. Nitrates

• Short-acting: Sublingual nitroglycerin for acute angina relief 1
• Long-acting: For chronic angina symptom control 1
  • Not shown to reduce mortality 2

2. Calcium Channel Blockers (CCBs)

• Long-acting dihydropyridines (e.g., amlodipine) 3
  • Effective for angina control 2
  • Indicated for CAD with chronic stable angina 3
  • Can be used in combination with beta-blockers 2
• Non-dihydropyridines (diltiazem, verapamil)
  • Use with caution in heart failure with reduced ejection fraction 2

3. Additional Anti-anginal Agents

• Consider for persistent symptoms despite beta-blockers and/or CCBs:
  • Ranolazine 1
  • Nicorandil 2
  • Trimetazidine 2
  • Ivabradine (if heart rate elevated) 2

Additional Considerations

For Diabetic Patients with CAD

• SGLT2 inhibitors recommended to reduce cardiovascular events 2, 1
• GLP-1 receptor agonists (particularly semaglutide) should be considered for patients with obesity 2

Anti-inflammatory Therapy

• Low-dose colchicine (0.5 mg daily) should be considered to reduce MI, stroke, and need for revascularization 2

Bleeding Risk Management

• Proton pump inhibitors recommended for patients on antiplatelet therapy with high bleeding risk 2, 1

Common Pitfalls and Caveats

1. Underuse of beta-blockers despite strong evidence for benefit 2
2. Inappropriate use of short-acting dihydropyridine CCBs, which can increase adverse cardiac events 2
3. Dipyridamole should not be used as an antiplatelet agent in CAD as it can enhance exercise-induced myocardial ischemia 2
4. Combination of ivabradine with non-dihydropyridine CCBs is contraindicated 2
5. Failure to adjust antiplatelet therapy after PCI or ACS, leading to inadequate protection or excessive bleeding risk 2

Remember that medication selection should prioritize reducing mortality and morbidity first, followed by symptom control. The evidence strongly supports the use of aspirin, statins, beta-blockers, and ACE inhibitors as the foundation of CAD management.