Case Study: Initial Management of a Patient with Coronary Artery Disease

Clinical Presentation

A 62-year-old male presents with exertional chest discomfort and dyspnea for the past 3 months. He has a history of hypertension, type 2 diabetes, and a 30-pack-year smoking history. His father died of myocardial infarction at age 58. Physical examination reveals BP 148/92 mmHg, HR 88 bpm, BMI 31 kg/m². Resting 12-lead ECG shows nonspecific ST-T wave changes. Echocardiography demonstrates preserved left ventricular ejection fraction (LVEF 55%) with no regional wall motion abnormalities. Coronary CT angiography reveals 70% stenosis in the proximal left anterior descending artery and 60% stenosis in the right coronary artery.

Step 1: Immediate Pharmacological Management

Anti-Ischemic Therapy

Initiate beta-blocker therapy immediately as first-line treatment for symptom control 1, 2.
Start metoprolol tartrate 25-50 mg orally twice daily, titrating upward based on heart rate and blood pressure response 2, 3.
Prescribe sublingual nitroglycerin 0.4 mg for immediate relief of anginal episodes 2.
If symptoms persist despite beta-blocker therapy, add a calcium channel blocker (amlodipine 5-10 mg daily or diltiazem extended-release 120-240 mg daily) 1, 2.

Lipid-Lowering Therapy

Start high-intensity statin therapy immediately with a goal of reducing LDL-C by ≥50% from baseline and achieving LDL-C <55 mg/dL (<1.4 mmol/L) 1, 2.
Prescribe atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily 2.
Recheck lipid panel in 4-6 weeks; if LDL-C goal not achieved, add ezetimibe 10 mg daily 2.

Antithrombotic Therapy

Initiate aspirin 75-100 mg daily for secondary prevention 2.
Given the patient has not had prior MI or revascularization, aspirin alone is appropriate at this stage 1.

Blood Pressure Management

Start ACE inhibitor therapy given the presence of diabetes and hypertension 1, 2.
Prescribe lisinopril 10 mg daily, titrating to achieve target systolic BP 120-130 mmHg 2.
If ACE inhibitor is not tolerated (e.g., cough develops), substitute with an ARB such as losartan 50 mg daily 1, 2.

Glycemic Control

Optimize diabetes management with target HbA1c <7% 2.
Consider SGLT2 inhibitor or GLP-1 receptor agonist given cardiovascular benefits in patients with CAD and diabetes 2.

Gastroprotection

Prescribe proton pump inhibitor (omeprazole 20 mg daily or pantoprazole 40 mg daily) given aspirin use and multiple risk factors for gastrointestinal bleeding 1.

Step 2: Lifestyle Modification Program

Smoking Cessation

Implement immediate smoking cessation intervention—this is the single most impactful lifestyle change 4.
Smoking cessation reduces mortality by 36% (RR 0.64,95% CI 0.58-0.71) in CAD patients 4.
Prescribe varenicline 1 mg twice daily or bupropion SR 150 mg twice daily, combined with behavioral counseling 2.
Refer to structured smoking cessation program with nurse coordination 5.

Exercise-Based Cardiac Rehabilitation

Enroll in supervised cardiac rehabilitation program—this is mandatory, not optional 1, 2.
Physical activity increases reduce mortality by 24% (RR 0.76,95% CI 0.59-0.98) 4.
Target: 150 minutes of moderate-intensity aerobic exercise weekly, divided into 30-minute sessions 5 days per week 2.
Include resistance training 2 days per week 2.

Dietary Modification

Adopt Mediterranean-style diet pattern immediately 2.
Combined dietary changes reduce mortality by 44% (RR 0.56,95% CI 0.42-0.74) 4.
Specific targets: reduce saturated fat to <7% of total calories, eliminate trans fats, increase omega-3 fatty acids, consume 5+ servings of fruits/vegetables daily 2, 6.
Refer to registered dietitian for structured dietary counseling with weekly sessions initially 5, 6.

Weight Management

Target weight loss of ≥5% body weight over 6 months 5.
Given BMI 31 kg/m², aim for 10-15 kg weight reduction 2.
Combine caloric restriction (500-750 kcal/day deficit) with increased physical activity 5.

Alcohol Consumption

Moderate alcohol use (1-2 drinks daily) is associated with 20% mortality reduction (RR 0.80,95% CI 0.78-0.83) 4.
If patient does not drink, do not recommend starting; if drinking heavily, counsel reduction to moderate levels 4.

Psychosocial Interventions

Screen for depression and anxiety using validated tools (PHQ-9, GAD-7) 2.
Implement cognitive behavioral interventions to support lifestyle adherence 1, 2.
Include spouse/partner in lifestyle modification program—partner participation increases success rate from 34% to 46% 5.

Step 3: Risk Stratification and Revascularization Decision

Functional Assessment

Perform stress imaging (stress echocardiography or myocardial perfusion imaging) to quantify ischemic burden 1.
Given two-vessel disease including proximal LAD stenosis, invasive coronary angiography with fractional flow reserve (FFR) assessment is recommended 1.

Revascularization Strategy

For symptomatic two-vessel disease involving proximal LAD with FFR ≤0.80, percutaneous coronary intervention (PCI) is recommended to improve symptoms 1.
If symptoms persist despite optimal medical therapy after 4-6 weeks, proceed with revascularization 1, 2.
Coronary artery bypass grafting (CABG) may be considered for two-vessel disease involving proximal LAD, particularly given diabetes 1.
Continue all medical therapy indefinitely regardless of revascularization decision 1, 2.

Step 4: Long-Term Monitoring and Follow-Up

Scheduled Reassessments

Schedule cardiovascular follow-up at 2 weeks, 6 weeks, 3 months, then every 6 months 2.
At each visit, assess: symptom status, medication adherence, achievement of risk factor targets (BP, LDL-C, HbA1c, weight), and development of new comorbidities 1, 2.

Laboratory Monitoring

Lipid panel at 4-6 weeks, then every 6-12 months once at goal 2.
HbA1c every 3 months until stable, then every 6 months 2.
Renal function and electrolytes at 2 weeks after ACE inhibitor initiation, then annually 2.
Liver function tests at baseline and 12 weeks after statin initiation 2.

Repeat Functional Testing

Repeat stress imaging or invasive angiography only if symptoms worsen or new high-risk features develop 1.
In asymptomatic patients with long-standing CAD, consider functional testing every 3-5 years 1.

Multidisciplinary Team Involvement

Coordinate care with cardiologist, primary care physician, cardiac rehabilitation nurse, dietitian, exercise physiologist, and clinical psychologist 2, 6.
Nurse-coordinated referral to community-based lifestyle programs significantly improves outcomes 5.

Annual Preventive Measures

Administer annual influenza vaccination 2.
Consider pneumococcal vaccination per age-appropriate guidelines 2.

Critical Pitfalls to Avoid

Do not delay statin therapy while waiting for baseline lipid levels—start immediately and adjust based on subsequent testing 2.
Do not assume chest pain characteristics alone determine CAD severity—only 10-25% of CCS patients present with classic angina 1.
Do not perform revascularization without functional assessment (FFR/iwFR) unless stenosis is >90% 1.
Do not discontinue beta-blocker therapy prematurely—continue indefinitely in patients with prior MI or reduced LVEF 1, 2.
Do not underestimate the mortality benefit of lifestyle modification—combined lifestyle changes rival pharmacological interventions in reducing cardiovascular events 4.
Do not manage CAD in isolation—aggressive treatment of hypertension, diabetes, and hyperlipidemia is equally important as antianginal therapy 1, 2.

Expected Outcomes at 3 Months

With adherence to this comprehensive management strategy:

Anginal symptoms should be reduced by ≥50% or eliminated entirely 1, 2.
LDL-C should be <55 mg/dL 2.
Blood pressure should be 120-130/70-80 mmHg 2.
Weight reduction of ≥5% should be achieved 5.
Smoking cessation should be maintained 5, 4.
Exercise capacity should improve by ≥10% on 6-minute walk test 5.
Overall cardiovascular mortality risk should be reduced by approximately 40-50% compared to no intervention 4.

What is the initial management for a patient with coronary artery disease (CAD)?

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