What medications are used to treat Coronary Artery Disease (CAD)?

Medications for Coronary Artery Disease (CAD)

The cornerstone medications for treating coronary artery disease include aspirin, statins, beta-blockers, and ACE inhibitors, which together significantly reduce mortality and morbidity in CAD patients. These medications address different pathophysiological aspects of CAD, from platelet aggregation to lipid management and blood pressure control.

Antiplatelet Therapy

Aspirin

• First-line antiplatelet therapy for all CAD patients (75-160 mg daily) 1, 2
• Reduces risk of cardiovascular events and death in secondary prevention
• Contraindications: active bleeding, aspirin allergy
• For aspirin-intolerant patients, clopidogrel 75 mg daily is recommended 1, 2

Dual Antiplatelet Therapy (DAPT)

• Recommended after Acute Coronary Syndrome (ACS) or percutaneous coronary intervention (PCI)
• Typically aspirin plus a P2Y12 inhibitor (ticagrelor, prasugrel, or clopidogrel) 1, 2
• Duration: 12 months after ACS; 6 months after elective PCI with stent placement
• Consider proton pump inhibitor for patients at high risk of gastrointestinal bleeding 1

Lipid-Lowering Therapy

Statins

• High-intensity statins recommended for all CAD patients 1, 2
• Target LDL-C <1.4 mmol/L (55 mg/dL) and ≥50% reduction from baseline
• Atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily are preferred options 3
• Monitor for side effects: myalgia, liver enzyme elevations

Additional Lipid-Lowering Agents

• If target LDL-C not achieved with maximum tolerated statin dose:
  1. Add ezetimibe 1, 2
  2. For very high-risk patients still not at goal, add PCSK9 inhibitor 1, 2

Renin-Angiotensin-Aldosterone System Inhibitors

ACE Inhibitors

• Recommended for all CAD patients, especially those with:
  • Heart failure
  • Hypertension
  • Diabetes
  • Previous myocardial infarction 1, 2
• Reduces cardiovascular death, MI, and stroke even in patients without heart failure

ARBs

• Alternative for patients who cannot tolerate ACE inhibitors (e.g., due to cough) 1, 2

Aldosterone Antagonists

• Recommended in patients with LVEF ≤40% who have either diabetes or heart failure
• Avoid in patients with significant renal dysfunction or hyperkalemia 2

Beta-Blockers

• First-line therapy for symptom control and secondary prevention 1
• Particularly beneficial in patients with:
  • Prior myocardial infarction
  • Heart failure with reduced ejection fraction
  • Angina symptoms

Nitrates and Calcium Channel Blockers

Nitrates

• Sublingual nitroglycerin for immediate angina relief 1
• Long-acting nitrates for prevention of angina symptoms
• Caution: tolerance may develop with continuous use

Calcium Channel Blockers

• Alternative or adjunct to beta-blockers for symptom control 1
• Particularly useful when beta-blockers are contraindicated or not tolerated
• Dihydropyridines (e.g., amlodipine) preferred with heart failure
• Non-dihydropyridines (e.g., diltiazem, verapamil) useful for rate control in atrial fibrillation

Special Populations

Diabetic Patients with CAD

• SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin) recommended to reduce CV events 1
• GLP-1 receptor agonists (liraglutide, semaglutide, dulaglutide) recommended to reduce CV events 1
• Empagliflozin and liraglutide specifically recommended to reduce mortality 1

Patients with Heart Failure and CAD

• ACE inhibitors, beta-blockers, and MRAs are indicated for symptomatic patients with HFrEF 1
• Sacubitril/valsartan is indicated instead of ACEIs for patients who remain symptomatic despite standard therapy 1

Treatment Algorithm

1. All CAD patients should receive:

   • Aspirin 75-160 mg daily (or clopidogrel if aspirin-intolerant)
   • High-intensity statin therapy
   • ACE inhibitor (or ARB if intolerant)
   • Beta-blocker (especially post-MI or with heart failure)

2. For symptom control:

   • First-line: Beta-blockers and/or long-acting nitrates
   • Second-line: Add or substitute calcium channel blockers

3. For patients not at LDL-C goal on statins:

   • Add ezetimibe
   • Consider PCSK9 inhibitor if still not at goal

4. For diabetic patients:

   • Consider adding SGLT2 inhibitor and/or GLP-1 receptor agonist

5. For patients with heart failure:

   • Optimize guideline-directed medical therapy for heart failure

Common Pitfalls and Caveats

• Underutilization of evidence-based therapies: Many eligible patients do not receive all recommended medications
• Inadequate dosing: Particularly with statins and ACE inhibitors, suboptimal dosing is common
• Drug interactions: Be aware of potential interactions, especially with multiple medications
• Medication adherence: Poor adherence significantly impacts outcomes; simplify regimens when possible
• Monitoring for side effects: Regular monitoring of renal function, electrolytes, and liver enzymes is essential

By implementing this comprehensive medication regimen tailored to individual risk factors and comorbidities, CAD patients can achieve significant reductions in morbidity and mortality.