What is the optimal management strategy for patients with suspected or known coronary artery disease?

Optimal Management of Suspected or Known Coronary Artery Disease

For patients with suspected or known coronary artery disease, the optimal management strategy should include aspirin, β-blockers, statins, and ACE inhibitors to prevent myocardial infarction and death, along with symptom-targeted therapy using nitrates, calcium channel blockers, or both when necessary. 1

Pharmacotherapy for Prevention of Mortality and Morbidity

First-Line Agents (Evidence Level A)

• Aspirin - Should be prescribed for all patients with CAD, particularly those with previous MI, at daily doses of at least 75mg to reduce cardiovascular events 1
• β-Blockers - Recommended for all patients with previous MI (Level A) and those without previous MI (Level B) to reduce mortality and morbidity 1
• Statins (LDL-lowering therapy) - Should be prescribed even with mild-to-moderate LDL elevations as they significantly reduce adverse ischemic events in established CAD 1
• ACE inhibitors - Recommended for all patients with CAD, particularly beneficial in those with diabetes, as they reduce cardiovascular death, MI, and stroke 1

Alternative Agents

• Clopidogrel - Should be used only when aspirin is absolutely contraindicated (Level B) 1
• Angiotensin-receptor blockers - Currently insufficient evidence for use in chronic stable angina 1

Symptom Management for Chronic Stable Angina

Immediate Relief

• Sublingual nitroglycerin or nitroglycerin spray - First-line for immediate relief of angina symptoms (Level B) 1

Maintenance Therapy

• β-Blockers - First-line maintenance therapy for symptom control due to their effects on heart rate, contractility, and potential mortality benefits 1
• Long-acting calcium channel blockers - When β-blockers are contraindicated or when used in combination with β-blockers for inadequate symptom control (Level B) 1
• Long-acting nitrates - Alternative when β-blockers are contraindicated or as add-on therapy when β-blockers alone are unsuccessful (Level B) 1

Important Considerations for Anti-anginal Therapy

• Long-acting calcium antagonists are often preferable to long-acting nitrates for maintenance therapy due to their sustained 24-hour effects 1
• Immediate-release or short-acting dihydropyridine calcium antagonists should be avoided as they increase adverse cardiac events 1
• The combination of nitrates with heart rate-increasing calcium channel blockers (like nifedipine) should be avoided 2

Management of Asymptomatic Patients with Evidence of CAD

• Aspirin - Recommended for all patients with previous MI (Level A) and may be beneficial for those without previous MI (Level B) 1
• β-Blockers - Recommended for patients with previous MI (Level B) 1
• Statins - Recommended for all patients with documented CAD or type 2 diabetes (Level A) 1
• ACE inhibitors - Recommended for patients with CAD who also have diabetes, systolic dysfunction, or both (Level A) 1

Therapies to Avoid

• Dipyridamole - Not recommended as it can enhance exercise-induced myocardial ischemia (Level B) 1
• Chelation therapy - Not recommended due to lack of evidence (Level B) 1
• Short-acting dihydropyridine calcium antagonists - Should be avoided due to increased risk of adverse cardiac events 1

Special Considerations

• Recent evidence suggests no anti-anginal drug is clearly superior to another for symptom relief, with equivalence demonstrated between β-blockers, calcium antagonists, and newer agents like ivabradine 3
• For patients with refractory angina who are not candidates for revascularization, alternative therapies like spinal cord stimulation or enhanced external counterpulsation may be considered 1, 4
• Diabetes is not a contraindication to β-blocker use; diabetic patients may benefit as much as or more than non-diabetic patients 1
• ACE inhibitors provide particular benefit for secondary prevention in patients with diabetes and CAD 1

Comprehensive Approach

The optimal management strategy should integrate pharmacological therapy with appropriate lifestyle modifications and consideration of revascularization when indicated. The evidence suggests that optimal medical therapy alone may be equivalent to percutaneous coronary intervention with medical therapy in preventing myocardial infarction and death in patients with stable angina 4.