From the Guidelines
Guideline-directed medical therapy (GDMT) for coronary artery disease (CAD) should prioritize a comprehensive medication regimen, including antiplatelet therapy, statins, beta-blockers, ACE inhibitors or ARBs, and lifestyle modifications, to reduce cardiovascular events and mortality, as recommended by the most recent guidelines 1. The cornerstone medications for GDMT in CAD include:
- Antiplatelet therapy with aspirin 81mg daily for all patients with CAD, with consideration of dual antiplatelet therapy (adding clopidogrel 75mg daily, ticagrelor 90mg twice daily, or prasugrel 10mg daily) for those with recent acute coronary syndrome or stent placement 1
- Statins, with high-intensity therapy (atorvastatin 40-80mg or rosuvastatin 20-40mg daily) recommended for most patients to achieve LDL reduction of >50% 1
- Beta-blockers (metoprolol succinate 25-200mg daily, carvedilol 3.125-25mg twice daily, or bisoprolol 2.5-10mg daily) for patients with prior myocardial infarction or heart failure
- ACE inhibitors (lisinopril 5-40mg daily, ramipril 2.5-10mg daily) or ARBs (losartan 25-100mg daily, valsartan 40-320mg daily) for patients with left ventricular dysfunction, diabetes, or hypertension For patients with persistent angina despite other therapies, nitrates (isosorbide mononitrate 30-60mg daily or nitroglycerin 0.4mg sublingual as needed) and calcium channel blockers (amlodipine 5-10mg daily) may be added. Revascularization should be considered in patients with high risk of adverse events, significant ischemia, or symptoms that persist despite GDMT, as recommended by the 2024 ESC guidelines 1. Key considerations in the management of CAD include:
- Lifestyle and risk factor modification to improve prognosis
- Revascularization to improve prognosis in patients with obstructive CAD who are at high risk of adverse events
- Antianginal medical treatment to reduce symptoms
- GDMT should be tailored to individual patient needs and risk factors, with regular monitoring and adjustment as needed to optimize outcomes.
From the FDA Drug Label
In controlled clinical trials, metoprolol, administered orally two or four times daily, has been shown to be an effective antianginal agent, reducing the number of angina attacks and increasing exercise tolerance. The oral dosage used in these studies ranged from 100 to 400 mg daily A controlled, comparative, clinical trial showed that metoprolol was indistinguishable from propranolol in the treatment of angina pectoris. In a large (1,395 patients randomized), double-blind, placebo-controlled clinical study, metoprolol was shown to reduce 3-month mortality by 36% in patients with suspected or definite myocardial infarction The Gruppo Italiano per lo Studio della Sopravvienza nell’Infarto Miocardico (GISSI-3) study was a multicenter, controlled, randomized, unblinded clinical trial conducted in 19,394 patients with acute myocardial infarction (MI) admitted to a coronary care unit Patients receiving lisinopril (n=9,646), alone or with nitrates, had an 11% lower risk of death (p = 0.04) compared to patients who did not receive lisinopril (n=9,672) (6.4% vs. 7. 2%, respectively) at six weeks
The guideline-directed medical therapy (GDMT) management for Coronary Artery Disease (CAD) includes:
- Beta blockers: metoprolol has been shown to be an effective antianginal agent and to reduce 3-month mortality by 36% in patients with suspected or definite myocardial infarction 2
- ACE inhibitors: lisinopril has been shown to reduce the risk of death by 11% in patients with acute myocardial infarction 3 Key points:
- Metoprolol and lisinopril are both effective in the management of CAD
- The dosage of metoprolol used in clinical trials ranged from 100 to 400 mg daily
- Lisinopril has been shown to reduce mortality in patients with acute myocardial infarction
From the Research
Guideline-Directed Medical Therapy (GDMT) for Coronary Artery Disease (CAD)
The management of CAD involves a combination of lifestyle modifications, medical treatments, and revascularization strategies. According to 4, the treatment objective for chronic stable coronary artery disease (SCAD) is a combination of both symptomatic and prognostic improvement.
Medical Treatment
- Initial medical treatment is safe and beneficial for most patients, and includes:
- Nitrates
- Beta-blockers
- Calcium channel blockers
- Antiplatelet agents
- ACEI/ARB
- Statins
- The American College of Cardiology (ACC) and American Heart Association (AHA) recommend the use of five classes of medications after acute coronary syndrome (ACS), including aspirin, P2Y12 inhibitors, β-blockers, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), and statins 5.
Revascularization Strategies
- Patients with moderate-to-severe symptoms and complex lesions should be considered for revascularization 4.
- The management of revascularization should take individual characteristics, preference, and compliance into consideration 4.
- Dual antiplatelet therapy (DAPT) combining aspirin with a P2Y12 receptor inhibitor is indicated for patients with CAD presenting with acute coronary syndrome or undergoing coronary stenting 6.
Adherence to GDMT
- Adherence to GDMT is suboptimal, with only 57% of patients discharged on five guideline-directed medical treatment 5.
- The rate of GDMT utilization did not change with the change in patient's age, gender or nationality 7.
- GDMT is associated with reduced mortality in patients with CAD and heart failure with reduced ejection fraction (HFrEF) independent of revascularization with CABG 8.