What are the management options for Cardiovascular Disease (CVD)?

Management of Cardiovascular Disease (CVD)

The comprehensive management of cardiovascular disease requires a multidisciplinary approach focusing on lifestyle modifications, pharmacological interventions, and risk factor control to reduce morbidity and mortality and improve quality of life.

Risk Assessment and Stratification

• Initial stratification of CVD risk should be based on basic clinical assessment including age, ECG findings, anginal threshold, presence of diabetes, chronic kidney disease (CKD), and left ventricular ejection fraction (LVEF) 1
• High-risk individuals can be identified using various test results including:
  • Exercise ECG with Duke Treadmill Score < −10
  • Stress imaging showing significant ischemia
  • Coronary CT angiography (CCTA) showing significant disease 1
• In individuals at high risk of adverse events, invasive coronary angiography with functional assessment is recommended to improve outcomes through appropriate revascularization 1

Lifestyle Interventions

• Multidisciplinary exercise-based cardiac rehabilitation is recommended to achieve healthy lifestyle, manage risk factors, reduce mortality and morbidity, and improve quality of life 1
• Aerobic physical activity of at least 150–300 minutes per week of moderate intensity or 75–150 minutes per week of vigorous intensity is recommended, along with reduction in sedentary time 1
• Dietary recommendations include:
  • Varied diet with adjusted energy intake to maintain ideal body weight
  • Increased consumption of fruits, vegetables, whole grains, low-fat dairy, fish, and lean meat
  • Oily fish and omega-3 fatty acids have protective properties
  • Total fat intake should not exceed 30% of energy intake 1
• The DASH diet has shown the most effectiveness on multiple CVD risk factors 1
• Annual influenza vaccination is recommended for patients with coronary artery disease to improve morbidity 1
• Smoking cessation is essential for CVD risk reduction 1

Pharmacological Management

Antithrombotic Therapy

• For chronic coronary syndrome (CCS) patients with prior myocardial infarction (MI) or percutaneous coronary intervention (PCI), aspirin 75–100 mg daily is recommended lifelong after an initial period of dual antiplatelet therapy (DAPT) 1
• Clopidogrel 75 mg daily is a safe and effective alternative to aspirin monotherapy 1
• After coronary artery bypass grafting (CABG), aspirin 75–100 mg daily is recommended lifelong 1
• In patients without prior MI or revascularization but with evidence of significant obstructive coronary artery disease (CAD), aspirin 75–100 mg daily is recommended lifelong 1

Lipid-Lowering Therapy

• Statins are recommended in all non-ST-elevation acute coronary syndrome (NSTE-ACS) patients 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 goals remain unmet despite statin and ezetimibe therapy, addition of a PCSK9 inhibitor is recommended 1
• Atorvastatin is indicated to reduce the risk of MI, stroke, revascularization procedures, and angina in adults with multiple risk factors for coronary heart disease 2

Antihypertensive Therapy

• ACE inhibitors (or ARBs if intolerant) are recommended in patients with heart failure with reduced LVEF (<40%), diabetes, or CKD to reduce all-cause and cardiovascular mortality 1
• Beta-blockers are recommended in patients with systolic LV dysfunction or heart failure with reduced LVEF (<40%) 1
• Mineralocorticoid receptor antagonists (MRAs) are recommended in patients with heart failure with reduced LVEF (<40%) to reduce mortality and morbidity 1

Antianginal Therapy

• Short-acting nitrates are recommended for immediate relief of angina 1
• Initial treatment with beta-blockers and/or calcium channel blockers to control heart rate and symptoms is recommended for most patients with CCS 1
• Selection of antianginal drugs should be tailored to patient characteristics, comorbidities, concomitant medications, and underlying pathophysiology of angina 1

Management of Comorbidities

Diabetes Management

• All patients with NSTE-ACS should be screened for diabetes, and blood glucose levels should be monitored frequently in patients with known diabetes or admission hyperglycemia 1
• Avoidance of hypoglycemia is recommended 1

Chronic Kidney Disease Considerations

• The same diagnostic and therapeutic strategies should be applied in patients with CKD as for patients with normal renal function, with appropriate dose adjustments 1
• Use of low- or iso-osmolar contrast media (at lowest possible volume) is recommended in invasive strategies 1
• Kidney function should be assessed by estimated glomerular filtration rate (eGFR) in all patients 1

Special Populations

Elderly Patients

• The same diagnostic and interventional strategies should be applied in older patients as for younger patients 1
• Antithrombotic agent choice and dosage should be adapted to renal function and specific contraindications in elderly patients 1

Patients with Inflammatory Joint Disorders

• In patients with rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis, CVD risk management should follow national guidelines 1
• For prolonged treatment, glucocorticoid dosage should be kept to a minimum due to potential increased CVD risk 1

Common Pitfalls to Avoid

• Therapeutic inertia is a major cause of poor blood pressure control 3
• Inadequate dosing or inappropriate drug combinations can lead to treatment failure 3
• Failing to address medication adherence is a common cause of uncontrolled hypertension 3
• Routine use of intra-aortic balloon pump in patients with cardiogenic shock and no mechanical complications due to ACS is not recommended 1
• Ivabradine is not recommended as add-on therapy in patients with CCS, LVEF >40%, and no clinical heart failure 1
• Combination of ivabradine with non-dihydropyridine calcium channel blockers or other strong CYP3A4 inhibitors is not recommended 1

Monitoring and Follow-up

• Proton pump inhibitors are recommended in patients receiving aspirin monotherapy, DAPT, or other antithrombotic regimens who are at high risk of gastrointestinal bleeding 1
• Regular monitoring of lipid levels, blood pressure, and other risk factors is essential for optimal management 1
• Psychological interventions are recommended to improve symptoms of depression in patients with CAD to improve health-related quality of life 1