What is the recommended management for coronary artery disease (CAD)?

Management of Coronary Artery Disease

The recommended management for coronary artery disease (CAD) includes a comprehensive pharmacological approach with antiplatelet therapy, statins, beta-blockers, and ACE inhibitors as first-line treatments, combined with lifestyle modifications and appropriate revascularization when indicated. 1

Pharmacological Management

First-Line Medications

1. Antiplatelet Therapy

   • Aspirin 75-100 mg daily is recommended for all patients with established CAD 2, 1
   • Clopidogrel 75 mg daily is an alternative for aspirin-intolerant patients 1
   • For post-ACS or post-PCI patients, dual antiplatelet therapy (DAPT) is recommended for 12 months after ACS and 6 months after elective PCI 2, 1

2. Lipid-Lowering Therapy

   • Statins are recommended for all CAD patients, targeting LDL-C <1.4 mmol/L (<55 mg/dL) and ≥50% reduction from baseline 2, 1
   • If target LDL-C is not achieved with maximum tolerated statin dose, add ezetimibe 2, 1
   • For very high-risk patients not reaching goals with statin plus ezetimibe, consider adding a PCSK9 inhibitor 2, 1

3. Beta-Blockers

   • Recommended as initial therapy for chronic stable angina for symptom control 2, 1
   • Particularly beneficial in patients with prior MI, heart failure, or angina symptoms 1

4. ACE Inhibitors/ARBs

   • Recommended for all CAD patients, especially those with heart failure, hypertension, diabetes, or previous MI 1
   • ARBs are recommended as alternatives for ACE inhibitor-intolerant patients 1

Second-Line/Symptom Relief Medications

1. Calcium Channel Blockers

   • Long-acting dihydropyridines (e.g., amlodipine) are effective for angina control 2, 1
   • Can be used in combination with beta-blockers 1
   • Non-dihydropyridines (diltiazem, verapamil) should be used with caution in heart failure with reduced ejection fraction 1

2. Nitrates

   • Short-acting nitrates recommended for immediate relief of effort angina 2
   • Long-acting nitrates can be added when beta-blockers and/or CCBs are insufficient 2
   • Contraindicated in patients with hypertrophic obstructive cardiomyopathy or when used with phosphodiesterase inhibitors 2

3. Additional Anti-Anginal Agents

   • Ranolazine, nicorandil, trimetazidine, or ivabradine can be considered for persistent symptoms 1

Diagnostic Approach

1. Initial Assessment

   • Risk stratification based on clinical assessment and diagnostic test results 2
   • Resting echocardiography to quantify LV function in all patients 2

2. Non-invasive Testing

   • Functional imaging for myocardial ischemia recommended if coronary CTA has shown CAD of uncertain functional significance 2
   • Exercise ECG recommended for assessment of exercise tolerance, symptoms, arrhythmias, BP response, and event risk 2

3. Invasive Assessment

   • Invasive angiography recommended for patients with high clinical likelihood, severe symptoms refractory to medical therapy, or high event risk 2
   • Invasive functional assessment (FFR) should be available to evaluate stenoses before revascularization 2

Revascularization

1. Percutaneous Coronary Intervention (PCI)

   • Drug-eluting stents (DES) are recommended over bare-metal stents for any PCI 2
   • Radial access is recommended as the standard approach 2

2. Coronary Artery Bypass Grafting (CABG)

   • Recommended over PCI in patients with multivessel CAD and acceptable surgical risk 2
   • For patients with multivessel CAD and SYNTAX score ≤22, PCI should be considered as an alternative to CABG 2

Special Populations

1. Diabetic Patients

   • Same antithrombotic treatment as in non-diabetic patients 2
   • SGLT2 inhibitors and GLP-1 receptor agonists recommended to reduce CV events 1

2. Elderly Patients

   • Should be considered for invasive strategy and revascularization after careful evaluation of risks/benefits 2
   • Adjusted dosing regimens of medications should be considered to prevent side effects 2

3. Chronic Kidney Disease

   • Assess kidney function by eGFR in all patients 2
   • Adjust doses of anticoagulants based on renal function 2
   • Hydration with isotonic saline and low/iso-osmolar contrast media recommended during invasive procedures 2

Lifestyle Management

1. Exercise and Cardiac Rehabilitation

   • Exercise-based cardiac rehabilitation is recommended 2
   • Multidisciplinary approach involving cardiologists, GPs, nurses, dieticians, physiotherapists, psychologists, and pharmacists 2

2. Risk Factor Modification

   • Smoking cessation
   • Weight management
   • Regular physical activity
   • Healthy diet
   • Annual influenza vaccination 2

Monitoring and Follow-up

1. Regular Assessment
   • Timely review of patient's response to medical therapies (e.g., 2-4 weeks after drug initiation) 2
   • Annual control of lipids, glucose metabolism, and creatinine 2

Common Pitfalls to Avoid

1. Medication-Related

   • Underuse of beta-blockers despite strong evidence for benefit 1
   • Inappropriate use of short-acting dihydropyridine CCBs 1
   • Using dipyridamole for antiplatelet therapy (not recommended) 2, 1
   • Combining ivabradine with non-dihydropyridine CCBs 1

2. Management-Related

   • Failure to adjust antiplatelet therapy after PCI or ACS 1
   • Performing coronary CTA when extensive coronary calcification, irregular heart rate, or obesity is present 2
   • Using ICA solely for risk stratification without therapeutic intent 2

The combination of aspirin, statin, and blood pressure-lowering agents has been shown to significantly reduce the risk of vascular events and total mortality in patients with CAD 3, supporting the importance of comprehensive pharmacological management.