Treatment of Coronary Artery Disease Symptoms
The treatment of coronary artery disease (CAD) symptoms requires comprehensive risk profiling and multidisciplinary management, including aggressive risk factor modification, antianginal medications, and myocardial revascularization when symptoms persist despite optimal medical therapy. 1
First-Line Medical Therapy
Antianginal Medications
- Beta-blockers and/or calcium channel blockers (CCBs) are first-line treatments for symptomatic angina 1, 2
- Short-acting nitrates (nitroglycerin) for acute symptom relief:
- Onset of action: 1-3 minutes after sublingual administration
- Maximum effect: 5 minutes post-dose
- Effects persist for at least 25 minutes 3
- Instruct patients to take at the onset of angina or prophylactically before activities that might trigger symptoms
Risk Factor Modification
Hypertension management:
Lipid management:
- High-intensity statin therapy (e.g., atorvastatin 40-80 mg daily) 2, 4
- Add ezetimibe if LDL-C goals not achieved after 4-6 weeks
- Consider PCSK9 inhibitors for patients not reaching targets with maximum tolerated statin plus ezetimibe 2
- Monitor for side effects: myalgia (0.7%), liver enzyme elevations (dose-dependent, 0.2-2.3%) 4
Other essential measures:
- Smoking cessation
- Diabetes management
- Weight management
- Regular physical activity
- Diet emphasizing vegetables, fruits, legumes, nuts, whole grains, and lean protein 2
Revascularization Therapy
Indications for Revascularization
- Persistent angina despite optimal medical therapy (Class I, Level A) 1
- High-risk features identified on non-invasive testing 1
- Severe CAD (especially left main or proximal LAD disease) 2
Revascularization Options
Percutaneous Coronary Intervention (PCI):
- Preferred for focal, less complex disease
- Suitable for patients at high surgical risk
- Lower initial procedural risk compared to CABG
Coronary Artery Bypass Grafting (CABG):
- Preferred for complex multivessel disease, especially with diabetes
- Offers survival advantage in specific patient subsets compared to medical therapy alone 5
- Consider for patients with left main disease or three-vessel disease with impaired LV function
Diagnostic Evaluation and Risk Stratification
Initial Assessment
- Risk stratification for patients with new or worsening symptoms using:
Invasive Assessment
- Invasive coronary angiography (ICA) with fractional flow reserve (FFR) or instantaneous wave-free ratio (iwFR) when necessary for:
- Severe CAD with symptoms refractory to medical treatment
- High-risk clinical profile
- Consideration for revascularization 1
Follow-up and Monitoring
Regular clinical follow-up every 3-6 months initially to assess:
- Medication adherence and tolerance
- Blood pressure control
- Lipid levels
- New or changing symptoms 2
Periodic cardiovascular assessment to evaluate:
Special Considerations
Vasospastic Angina
- Calcium channel blockers are first-line therapy
- Long-acting nitrates as adjunctive therapy
- Diagnostic approach: ECG during angina episodes and invasive angiography or coronary CTA 1
Microvascular Angina
- Beta-blockers as first-line therapy
- Calcium channel blockers as alternative or add-on therapy
- Consider ACE inhibitors for their microvascular effects
Common Pitfalls to Avoid
- Overreliance on symptoms alone without objective testing 2
- Delaying statin therapy in high-risk patients 2
- Neglecting lifestyle modifications as a cornerstone of therapy 2
- Inappropriate use of coronary calcium scoring as a routine follow-up test in established CAD (Class III recommendation) 1
- Performing invasive coronary angiography solely for risk stratification without clinical indications (Class III recommendation) 1