What is the primary management approach for a patient with Coronary Artery Disease (CAD)?

Primary Management Approach for Coronary Artery Disease (CAD)

The primary management of coronary artery disease requires a comprehensive approach focused on lifestyle modifications, guideline-directed medical therapy, and selective revascularization to reduce mortality, morbidity, and improve quality of life.

Risk Factor Modification and Lifestyle Management

• Improvement of lifestyle factors alongside appropriate pharmacological management is recommended to reduce all-cause and cardiovascular mortality and morbidity, and improve health-related quality of life 1
• Cognitive behavioral interventions should be implemented to help patients achieve a healthy lifestyle 1
• Multidisciplinary exercise-based cardiac rehabilitation is essential for patients with CAD to achieve a healthy lifestyle and manage risk factors 1, 2
• Annual influenza vaccination is recommended for patients with CAD, especially in older individuals 1
• Smoking cessation with appropriate support is critical for all patients with CAD 2
• Regular physical activity (moderate-to-vigorous) should be encouraged 2
• Heart-healthy diet (Mediterranean, DASH, or AHA diet) is recommended 2
• Weight management targeting appropriate BMI is recommended 2

Pharmacological Management

Antiplatelet Therapy

• Aspirin (75-162 mg daily) is recommended indefinitely for all patients with established CAD 2, 3
• For patients with recent acute coronary syndrome or stent placement, dual antiplatelet therapy with aspirin plus P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) is recommended for at least 12 months with drug-eluting stents 2, 3
• For patients with aspirin allergy, clopidogrel 75 mg daily is recommended as monotherapy 3

Lipid-Lowering Therapy

• Statins are recommended in all patients with CAD, with the aim to reduce LDL-C by ≥50% from baseline and/or achieve LDL-C <1.4 mmol/L (<55 mg/dL) 1
• If LDL-C goals are not achieved after 4-6 weeks with maximally tolerated statin dose, combination with ezetimibe is recommended 1
• If LDL-C goals are still not achieved despite maximally tolerated statin therapy and ezetimibe, addition of a PCSK9 inhibitor should be considered 1

Anti-Ischemic Therapy

• Beta-blockers are recommended as first-line therapy for patients with previous MI and for symptom control in angina 2
• Beta-blockers are particularly recommended in patients with systolic LV dysfunction or heart failure with reduced LVEF (<40%) 1
• Calcium channel blockers (particularly dihydropyridines like amlodipine) are recommended as alternatives when beta-blockers are contraindicated or for additional symptom control 4
• Short-acting nitrates are recommended for immediate relief of angina symptoms 1

Renin-Angiotensin-Aldosterone System Inhibitors

• ACE inhibitors (or ARBs if ACE inhibitors are not tolerated) are recommended in patients with heart failure with reduced LVEF (<40%), diabetes, or chronic kidney disease 1, 2
• Target blood pressure should be 120-130 mmHg systolic for most patients and 130-140 mmHg for older patients (>65 years) 1, 2

Revascularization Strategies

• Myocardial revascularization is recommended when angina persists despite treatment with antianginal drugs 1
• Revascularization should be considered for patients with obstructive CAD who are at high risk of adverse events, not only for symptom relief but also to prevent spontaneous MI and cardiac death 1
• The decision between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) should consider:
  • Severity and complexity of coronary disease (SYNTAX score) 5
  • Comorbidities 5
  • Patient preferences 5
• High-risk patients with left ventricular systolic dysfunction, diabetes mellitus, and those with severe 3-vessel or left main disease should be considered for CABG 1

Long-term Follow-up and Monitoring

• Regular follow-up visits to monitor symptoms, medication adherence, and risk factor control are recommended 2
• Involvement of multidisciplinary healthcare professionals (cardiologists, general practitioners, nurses, dieticians, physiotherapists, psychologists, pharmacists) is recommended to improve outcomes 1, 2
• Regular monitoring of lipid levels, blood pressure, and glycemic control is essential 2
• Psychological interventions should be implemented to improve symptoms of depression in patients with CAD 1

Special Considerations

• In patients with diabetes, screening for CAD is recommended, and blood glucose levels should be monitored frequently 1
• For older persons with CAD, the same diagnostic and interventional strategies should be applied as for younger patients, with medication dosages adapted to renal function and specific contraindications 1
• In patients with chronic kidney disease, the same diagnostic and therapeutic strategies should be applied (with dose adjustments as necessary) as for patients with normal renal function 1

Common Pitfalls to Avoid

• Avoid reducing diastolic blood pressure below 60 mmHg in patients over 60 years or with diabetes 2
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with heart failure 4
• When combining beta-blockers with calcium channel blockers, dihydropyridine agents like amlodipine are preferred to avoid excessive bradycardia 4
• Avoid dipyridamole as it can enhance exercise-induced myocardial ischemia 2