What is the initial treatment for Coronary Artery Disease (CAD)?

Initial Treatment for Coronary Artery Disease

All patients with CAD should immediately begin lifestyle modifications (heart-healthy diet, regular exercise, smoking cessation) combined with statin therapy targeting LDL-C reduction ≥50% from baseline and/or achieving LDL-C <55 mg/dL, plus aspirin 75-100 mg daily for those with previous MI or revascularization. 1, 2

Immediate Universal Interventions

Lifestyle Modifications (Foundation for All Patients)

• Heart-healthy dietary pattern is mandatory for all CAD patients, with evidence showing combined dietary changes reduce mortality (RR 0.56; 95% CI 0.42-0.74) 3, 1
• Regular physical activity must be prescribed, with exercise-based cardiac rehabilitation providing significant cardiovascular benefits including decreased morbidity and mortality 1, 2
  • Patients should engage in activities to reduce sitting time and increase both aerobic and resistance exercise 1
  • Increased physical activity reduces mortality (RR 0.76; 95% CI 0.59-0.98) 3
• Smoking cessation is critical, with cessation reducing mortality by 36% (RR 0.64; 95% CI 0.58-0.71) 3, 1
  • E-cigarettes are NOT recommended as first-line therapy due to lack of long-term safety data 1
• Weight management and stress reduction should be implemented immediately 1, 2

Lipid Management (First-Line Pharmacotherapy)

• Statins are mandatory for all CAD patients regardless of baseline LDL-C 1, 2, 4
  • Target: LDL-C reduction ≥50% from baseline AND/OR LDL-C <1.4 mmol/L (<55 mg/dL) 1, 2
  • Therapeutic response occurs within 2 weeks, maximum response by 4 weeks 4
• Add ezetimibe if LDL-C goals not achieved with maximally tolerated statin after 4-6 weeks 1, 2
• Do NOT use fish oil, omega-3 fatty acids, or vitamin supplements—no benefit in reducing cardiovascular events 1

Antiplatelet Therapy

• Aspirin 75-100 mg daily is recommended for patients with previous MI or revascularization 1, 2
• Clopidogrel 75 mg daily is an alternative if aspirin is contraindicated 1, 5
• For stable CAD >1 year post-event: single antiplatelet therapy is preferred over dual therapy 1

Antianginal Therapy (Symptom Control)

First-Line Agents

• Beta-blockers OR calcium channel blockers as first-line antianginal therapy 1, 2
  • Critical update: Long-term beta-blocker therapy is NOT recommended to improve outcomes in stable CAD patients without MI in the past year, LVEF ≤50%, or another primary indication 1
  • Either agent is equally acceptable as initial therapy 1
• Short-acting nitrates for immediate relief of effort angina 2

Second-Line Agents (When First-Line Inadequate)

• Long-acting nitrates, ranolazine, nicorandil, ivabradine, or trimetazidine can be added 1, 5
• Use stepwise approach: add second-line agents when beta blockers or calcium channel blockers are ineffective or contraindicated 5

Additional Pharmacotherapy Based on Comorbidities

ACE Inhibitors/ARBs

• Recommended for patients with: 2
  • Heart failure with LVEF <40%
  • Diabetes mellitus
  • Chronic kidney disease
  • Hypertension (especially with previous MI) 2

Blood Pressure Control

• Target office BP: 2
  • Systolic BP 120-130 mmHg (general population)
  • Systolic BP 130-140 mmHg (patients >65 years)

Novel Agents for Select Patients

• SGLT2 inhibitors and GLP-1 receptor agonists are recommended for select CAD patients, including those without diabetes 1

Risk Factor Management

Comprehensive Risk Profiling

• Aggressive management of hypertension, hyperlipidemia, diabetes, anemia, and obesity 2
• Annual influenza vaccination, especially for elderly patients 2
• Cognitive behavioral interventions to achieve and maintain lifestyle changes 2
• Psychological interventions for depression symptoms 2

Common Pitfalls to Avoid

• Do NOT continue beta-blockers indefinitely in stable CAD patients >1 year post-MI without reduced LVEF or other indication—this represents outdated practice 1
• Do NOT use dual antiplatelet therapy routinely in stable CAD >1 year post-event—increases bleeding risk without benefit 1
• Do NOT perform routine periodic testing (anatomic or ischemic) without clinical status change—not recommended for risk stratification 1
• Do NOT prescribe dietary supplements (fish oil, vitamins)—no cardiovascular benefit demonstrated 1

When to Consider Revascularization

• Revascularization should be considered when: 1, 2
  • Angina persists despite optimal medical therapy
  • High-risk features on non-invasive testing (≥10% LV ischemia on SPECT/PET, ≥3 segments with stress-induced dysfunction)
  • Left main disease ≥50% stenosis, three-vessel disease ≥70% stenosis, or proximal LAD disease ≥70% stenosis
• Invasive coronary angiography with FFR/iFR availability is recommended for high-risk patients 1