What is the treatment for coronary artery disease?

Treatment of Coronary Artery Disease

The comprehensive treatment of coronary artery disease requires a combination of lifestyle modifications, pharmacological therapy for symptom relief and event prevention, and consideration of revascularization in appropriate patients. 1

Lifestyle Modifications

• Nonpharmacologic therapies, including healthy dietary habits and regular physical activity, are recommended for all patients with coronary artery disease (CAD) 1
• Smoking cessation significantly reduces mortality (relative risk 0.64) in patients with established CAD 2
• Regular physical activity reduces mortality (relative risk 0.76) and should include both aerobic and resistance exercise 1, 2
• Dietary modifications should focus on:
  • Substituting unsaturated fats for saturated and trans fats
  • Increasing consumption of omega-3 fatty acids
  • Consuming a diet high in fruits, vegetables, nuts, and whole grains 3, 4
• Cardiac rehabilitation provides significant cardiovascular benefits, including decreased morbidity and mortality, and should be recommended for eligible patients 1, 5
• Annual influenza vaccination is recommended for CAD patients, especially in the elderly 1, 6

Pharmacological Therapy for Event Prevention

• Antiplatelet therapy:

  • Aspirin 75-100 mg daily is recommended in patients with previous myocardial infarction or revascularization 1
  • Clopidogrel 75 mg daily is recommended as an alternative in patients with aspirin intolerance 1

• Lipid-lowering therapy:

  • Statins are recommended for all CAD patients 1
  • If LDL goals are not achieved with maximum tolerated statin dose, combination with ezetimibe is recommended 1
  • For very high-risk patients not achieving goals on statin and ezetimibe, PCSK9 inhibitors should be considered 1

• Other preventive medications:

  • ACE inhibitors (or ARBs) are recommended in the presence of other conditions such as heart failure, hypertension, or diabetes 1
  • Sodium glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists are recommended for select groups of patients with CAD, including those without diabetes 1

Pharmacological Therapy for Symptom Relief

• Short-acting nitrates are recommended for immediate relief of effort angina 1, 6
• First-line treatment for chronic angina:
  • Either a calcium channel blocker or beta-blocker is recommended as first-line antianginal therapy 1
  • Long-term beta-blocker therapy is not recommended to improve outcomes in patients with CAD in the absence of myocardial infarction in the past year, left ventricular ejection fraction ≤50%, or another primary indication for beta-blocker therapy 1

Antithrombotic Therapy in Special Populations

• For patients with CAD and atrial fibrillation:

  • Long-term oral anticoagulation therapy is recommended in patients with AF and elevated CHA₂DS₂-VASc score 1
  • When oral anticoagulation is initiated, a NOAC is recommended in preference to a VKA 1

• For post-PCI patients:

  • Dual antiplatelet therapy duration may be shortened (1-3 months) when bleeding risk is high 1
  • Concomitant use of a proton pump inhibitor is recommended in patients at high risk of gastrointestinal bleeding 1

Revascularization

• Myocardial revascularization is recommended when angina persists despite treatment with antianginal drugs 1
• The decision for revascularization should consider symptom severity, extent of ischemia, and coronary anatomy 7

Common Pitfalls and Caveats

• Routine periodic anatomic or ischemic testing without a change in clinical or functional status is not recommended 1
• The use of nonprescription or dietary supplements, including fish oil and omega-3 fatty acids or vitamins, is not recommended given the lack of benefit in reducing cardiovascular events 1
• Nitrates should not be used in patients with hypertrophic obstructive cardiomyopathy or in combination with phosphodiesterase inhibitors 1, 6
• Although e-cigarettes increase the likelihood of successful smoking cessation compared with nicotine replacement therapy, they are not recommended as first-line therapy due to lack of long-term safety data 1

Treatment Algorithm

1. Start with lifestyle modifications for all patients (smoking cessation, diet, exercise) 1, 2
2. Initiate preventive pharmacotherapy (aspirin, statin) 1
3. Add symptom-relief medications (beta-blockers or calcium channel blockers) 1
4. Consider revascularization if symptoms persist despite optimal medical therapy 1
5. Implement secondary prevention measures and regular follow-up 1