What medications are used to treat coronary artery disease (CAD)?

Medication Management for Coronary Artery Disease

The cornerstone of coronary artery disease (CAD) treatment includes antiplatelet therapy, statins, beta-blockers, ACE inhibitors, and additional symptom-controlling medications, all of which significantly reduce morbidity and mortality. 1, 2

First-Line Medications

Antiplatelet Therapy

• Aspirin 75-100 mg daily is recommended for all CAD patients, particularly those with previous MI or revascularization 1, 2
• Clopidogrel 75 mg daily is the alternative for aspirin-intolerant patients 1, 2
• Dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel is recommended for:
  • 6 months after coronary stenting (standard duration) 1
  • Shorter duration (1-3 months) if high bleeding risk 1
  • Longer duration for specific high-risk patients 2

Lipid-Lowering Therapy

• High-intensity statins (e.g., atorvastatin 40-80 mg) are recommended for all CAD patients 1, 2, 3
• Target LDL-C <1.4 mmol/L (55 mg/dL) and ≥50% reduction from baseline 2
• Monitor for side effects including myalgia and liver enzyme elevations 3
• If targets not achieved with maximum tolerated statin dose:
  • Add ezetimibe 1, 2
  • For very high-risk patients still not at goal, add a PCSK9 inhibitor 1, 2

Beta-Blockers

• First-line therapy for symptom control and secondary prevention 1, 2
• Particularly beneficial for patients with:
  • Prior myocardial infarction
  • Heart failure with reduced ejection fraction
  • Angina symptoms 2

ACE Inhibitors/ARBs

• ACE inhibitors (e.g., lisinopril) recommended for all CAD patients, especially those with:
  • Heart failure
  • Hypertension
  • Diabetes
  • Previous myocardial infarction 2, 4
• ARBs recommended as alternatives for patients who cannot tolerate ACE inhibitors 2

Second-Line and Adjunctive Medications

Calcium Channel Blockers (CCBs)

• Recommended when beta-blockers are contraindicated or not tolerated 1, 2
• Can be used in combination with beta-blockers for persistent symptoms 1
• Use with caution in heart failure with reduced ejection fraction 2

Nitrates

• Short-acting nitrates (sublingual nitroglycerin) recommended for immediate angina relief 1, 2
• Long-acting nitrates for prevention of angina symptoms 2
• Caution: Avoid in patients with hypertrophic obstructive cardiomyopathy or when used with phosphodiesterase inhibitors 1

Additional Medications for Special Populations

For Diabetic CAD Patients

• SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin) 1, 2
• GLP-1 receptor agonists (liraglutide, semaglutide) 1, 2

For CAD Patients with Atrial Fibrillation

• NOACs preferred over vitamin K antagonists 1, 2
• Triple therapy (dual antiplatelet plus anticoagulant) requires careful consideration of bleeding risk 1
• Avoid ticagrelor or prasugrel as part of triple therapy 1

For Patients at High Risk of GI Bleeding

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

Clinical Pearls and Pitfalls

1. Combination therapy is crucial: The combined use of aspirin, statins, and blood pressure-lowering agents is associated with significantly lower risk of cardiovascular events and mortality compared to using fewer components 5

2. Aspirin dosing: Lower doses (75-100 mg) provide similar efficacy with less bleeding risk compared to higher doses 6, 7, 8

3. Medication adherence: Poor adherence is a major cause of treatment failure; consider fixed-dose combinations when appropriate 2, 5

4. Elderly patients: Require careful dose adjustment and monitoring for side effects 1, 2

5. Renal function: Assess eGFR in all patients and adjust medication doses accordingly, particularly for anticoagulants 2

6. Avoid drug interactions: Be cautious with concomitant medications that may interact with antiplatelet agents (e.g., ibuprofen can block aspirin's antiplatelet effects) 2

7. Regular monitoring: Review patient response to medications within 2-4 weeks of initiation and perform annual monitoring of lipids, glucose, and renal function 2

By implementing this comprehensive medication regimen and addressing potential pitfalls, clinicians can significantly reduce morbidity and mortality in patients with coronary artery disease.