What are the life-saving drugs in coronary artery disease (CAD)?

Life-Saving Drugs in Coronary Artery Disease

Antiplatelet agents, statins, beta-blockers, and ACE inhibitors are the cornerstone life-saving medications in coronary artery disease, with each demonstrating significant reductions in mortality and cardiovascular events. These medications form the foundation of pharmacological management for CAD patients and should be prescribed to all eligible patients.

Primary Life-Saving Medications

1. Antiplatelet Therapy

• Aspirin (75-100 mg daily) - First-line antiplatelet therapy for all CAD patients

  • Reduces risk of cardiovascular events and death in secondary prevention 1
  • Should be used routinely in all patients with acute and chronic ischemic heart disease without contraindications 2
  • Low-dose (75-150 mg) is as effective as higher doses (160-325 mg) with fewer side effects 2

• Clopidogrel (75 mg daily)

  • Alternative for aspirin-intolerant patients 1
  • In the CURE trial, clopidogrel plus aspirin reduced relative risk of cardiovascular death, MI, or stroke by 20% compared to aspirin alone 3
  • Particularly beneficial after acute coronary syndrome or percutaneous coronary intervention 1

2. Statins

• High-intensity statins (e.g., atorvastatin 40-80 mg)
  • Recommended for all CAD patients 2, 1
  • Significantly reduce mortality and coronary events 2
  • In the TNT trial, atorvastatin 80 mg reduced major cardiovascular events by 22% compared to 10 mg dosing 4
  • Should be initiated without delay after acute coronary syndromes 2

3. Beta-Blockers

• Strongly recommended as initial therapy for chronic stable angina 2
• Improve prognosis in patients after myocardial infarction 2
• Reduce cardiac events when used as secondary prevention in post-infarction patients 2
• Essential component of treatment due to efficacy in both relieving angina and reducing morbidity and mortality 2
• Particularly beneficial in patients with prior MI, heart failure with reduced ejection fraction, or angina symptoms 1

4. ACE Inhibitors

• Recommended for all CAD patients, especially those with:
  • Heart failure
  • Hypertension
  • Diabetes
  • Previous myocardial infarction 1
• Reduce cardiovascular death, MI, and stroke even in patients without heart failure 1
• The HOPE trial showed a reduction of cardiovascular death from 8.1% to 6.1% over 4-6 years 2
• Beneficial effects extend beyond blood pressure control 2

Additional Life-Saving Therapies

1. Dual Antiplatelet Therapy (DAPT)

• Combination of aspirin with a P2Y12 inhibitor (ticagrelor, prasugrel, or clopidogrel)
• Recommended after Acute Coronary Syndrome (ACS) or percutaneous coronary intervention (PCI) 1
• Duration: 12 months after ACS and 6 months after elective PCI with stent placement 1

2. Additional Lipid-Lowering Agents

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

3. Aldosterone Blockers

• Recommended in patients with LVEF ≤0.40 who have either diabetes or heart failure 1
• Should be used without significant renal dysfunction or hyperkalemia 1

4. Nitrates

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

Special Considerations

Medication Combinations

• When two different therapeutic strategies are equally effective in alleviating symptoms of angina, the therapy with an advantage in preventing death should be recommended 2

Dosing Considerations

• Aspirin: 75-100 mg daily is optimal for long-term use 2
• Clopidogrel: 75 mg daily following appropriate loading (e.g., 600 mg) 2
• Statins: High-intensity (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) preferred 1

Common Pitfalls to Avoid

1. Underuse of beta-blockers - Despite clear benefits, they are often underutilized 2
2. Inadequate statin intensity - Many patients receive lower doses than recommended
3. Premature discontinuation of DAPT - Can lead to stent thrombosis and adverse events
4. Overlooking ACE inhibitors in patients without hypertension - Benefits extend beyond blood pressure control 2
5. Inappropriate dose reduction of aspirin - Doses <75 mg daily have less benefit 2

Monitoring and Follow-up

• Timely review of patient's response to medical therapies (2-4 weeks after drug initiation) 2
• Annual control of lipids, glucose metabolism, and creatinine 1
• Monitor for side effects, especially myalgia and liver enzyme elevations with statins 1

These evidence-based medications significantly reduce morbidity and mortality in CAD patients when used appropriately and in combination with lifestyle modifications.