What are the management options for Coronary Artery Disease (CAD)?

Management of Coronary Artery Disease

The comprehensive management of coronary artery disease (CAD) requires a multidisciplinary approach that includes lifestyle modifications, pharmacological therapy, and revascularization when appropriate, with all interventions aimed at reducing morbidity and mortality while improving quality of life. 1, 2

Risk Factor Modification and Lifestyle Management

• Comprehensive risk profiling and multidisciplinary management are recommended, including treatment of major comorbidities such as hypertension, hyperlipidemia, diabetes, anemia, and obesity 1
• Smoking cessation is essential and significantly reduces mortality risk (relative risk 0.64) in patients with established CAD 3
• Regular physical activity should be encouraged, with exercise-based cardiac rehabilitation recommended as an effective means to achieve a healthy lifestyle and manage risk factors 1, 4
• A heart-healthy diet pattern (Mediterranean, DASH, or AHA diet) should be adopted to improve cardiovascular outcomes 2
• Annual influenza vaccination is recommended, especially for elderly patients with CAD 2
• Cognitive behavioral interventions should be implemented to help patients achieve and maintain lifestyle changes 1
• Psychological interventions are recommended to improve symptoms of depression in patients with CAD 1

Pharmacological Management

Anti-ischemic Therapy

• Short-acting nitrates are recommended for immediate relief of effort angina 1
• First-line treatment for symptom control should include beta-blockers and/or calcium channel blockers 1, 2
• In patients with hypertension and previous MI, beta-blockers and renin-angiotensin system blockers are recommended 1

Lipid Management

• Statins are recommended for all patients with CAD, with the goal of reducing LDL-C by ≥50% from baseline and/or achieving LDL-C <1.4 mmol/L (<55 mg/dL) 2, 5
• If LDL-C goals are not achieved with maximally tolerated statin dose after 4-6 weeks, combination with ezetimibe is recommended 2

Antithrombotic Therapy

• Aspirin 75-100 mg daily is recommended in patients with previous MI or revascularization 1
• In patients requiring dual antiplatelet therapy (DAPT), clopidogrel may be used in combination with aspirin, with consideration of CYP2C19 metabolizer status when appropriate 6
• For patients with atrial fibrillation requiring anticoagulation, careful balancing of bleeding and thrombotic risks is essential 1

Other Pharmacological Interventions

• 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 2
• In hypertensive patients, office BP should be controlled to target values: systolic BP 120-130 mmHg in general and 130-140 mmHg in older patients (>65 years) 1

Diagnostic Evaluation and Risk Stratification

• Non-invasive functional imaging for myocardial ischemia or coronary CT angiography (CTA) is recommended as the initial test for diagnosing CAD in symptomatic patients 1
• Risk stratification is recommended based on clinical assessment and the result of the diagnostic test initially employed to make a diagnosis of CAD 1
• In patients with suspected or newly diagnosed CAD, risk stratification using stress imaging or coronary CTA is recommended 1
• Resting echocardiography is recommended to quantify left ventricular function in all patients with suspected CAD 1

Revascularization Strategies

• Myocardial revascularization is recommended when angina persists despite treatment with antianginal drugs 1, 2
• Invasive coronary angiography (ICA) complemented by invasive physiological guidance (FFR/iwFR) is recommended for patients with high-risk features or symptoms inadequately responding to medical treatment 1
• In asymptomatic patients with high-risk features on non-invasive testing, ICA with FFR when necessary is recommended 1
• The decision between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) should consider the complexity of coronary anatomy, comorbidities, and patient preferences 2, 7
• 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 2

Long-term Follow-up and Monitoring

• A periodic visit to a cardiovascular healthcare professional is recommended to reassess potential changes in risk status, lifestyle modifications, adherence to targets of cardiovascular risk factors, and development of comorbidities 1
• Regular monitoring of symptoms, medication adherence, and risk factor control is essential 2
• Reassessment of CAD status is recommended in patients with deteriorating LV systolic function or worsening symptoms 1
• Involvement of multidisciplinary healthcare professionals (cardiologists, GPs, nurses, dieticians, physiotherapists, psychologists, and pharmacists) is recommended for comprehensive care 1, 2

Special Considerations

• In patients with diabetes, careful monitoring of blood glucose levels and aggressive risk factor modification are particularly important 2
• 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 2
• In patients with suspected vasospastic angina, an ECG during angina episodes and invasive angiography or coronary CTA are recommended 1