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

Medical Management of Coronary Artery Disease

All patients with CAD require immediate initiation of comprehensive pharmacological therapy combined with aggressive lifestyle modification and risk factor control, as this approach reduces mortality, prevents recurrent events, and improves quality of life. 1

Immediate Pharmacological Interventions

Antiplatelet Therapy

• Start aspirin 75-100 mg daily immediately for all patients with previous MI or revascularization 1, 2
• This is non-negotiable for secondary prevention and reduces recurrent ischemic events 1

Lipid-Lowering Therapy

• Initiate high-intensity statin therapy immediately with the goal of reducing LDL-C by ≥50% from baseline AND achieving LDL-C <55 mg/dL (<1.4 mmol/L) 1, 2
• If LDL-C goals are not achieved after 4-6 weeks on maximally tolerated statin dose, add ezetimibe 1, 2
• This dual target approach (both percentage reduction and absolute value) is critical—meeting only one target is insufficient 1

Anti-Ischemic Therapy for Symptom Control

• Beta-blockers are first-line therapy for all patients with previous MI and for symptom control in angina 1, 2
• In patients with hypertension and previous MI, combine beta-blockers with renin-angiotensin system (RAS) blockers 3, 1
• Calcium channel blockers (CCBs) can be used as first-line therapy either alone or in combination with beta-blockers for symptomatic angina 3, 1
• Short-acting nitrates should be prescribed for immediate relief of effort angina 1, 2

ACE Inhibitors or ARBs

• Start ACE inhibitors (or ARBs if ACE inhibitors are not tolerated) in patients with heart failure with reduced LVEF (<40%), diabetes, or chronic kidney disease 1, 2
• In hypertensive patients with recent MI, RAS blockers are mandatory 3, 1
• Critical caveat: The combination of ACE inhibitors and ARBs is contraindicated 3

Blood Pressure Control

• Target office BP to systolic 120-130 mmHg in general population 3, 1
• In older patients (>65 years), target systolic BP 130-140 mmHg 3, 1
• Use beta-blockers and/or CCBs in patients with symptomatic angina to achieve dual benefit of BP control and symptom relief 3

Gastrointestinal Protection

• Prescribe proton pump inhibitor (omeprazole 20 mg daily or pantoprazole 40 mg daily) in patients on aspirin or combination antithrombotic therapy who are at high risk of gastrointestinal bleeding 3, 1

Comprehensive Lifestyle Modification

Cardiac Rehabilitation (Mandatory, Not Optional)

• Enroll all patients in supervised exercise-based cardiac rehabilitation programs—this is a Class I recommendation and is mandatory for improving outcomes 3, 1, 2
• Cardiac rehabilitation is an effective means to achieve healthy lifestyle, manage risk factors, and reduce mortality 3, 2

Dietary Interventions

• Implement a heart-healthy diet pattern such as Mediterranean, DASH, or AHA diet 2
• Combined dietary changes have shown significant mortality reduction (RR 0.56) in CAD patients 4

Physical Activity

• Encourage regular physical activity beyond formal cardiac rehabilitation 2
• Increased physical activity reduces mortality (RR 0.76) in CAD patients 4

Smoking Cessation

• Smoking cessation is the single most effective lifestyle intervention, reducing mortality by 36% (RR 0.64) 4
• This effect size is comparable to many pharmacological interventions 4

Alcohol Consumption

• Moderate alcohol use is associated with reduced mortality (RR 0.80) in CAD patients 4

Psychological Support

• Implement cognitive behavioral interventions to help patients achieve and maintain lifestyle changes 3, 1, 2
• Provide psychological interventions to improve symptoms of depression, which are common in CAD patients 3, 1, 2

Annual Influenza Vaccination

• Administer annual influenza vaccination, especially in elderly patients 3, 1, 2

Risk Stratification and Revascularization Decision-Making

When to Consider Revascularization

• Myocardial revascularization is recommended when angina persists despite optimal antianginal drug therapy 3, 1, 2
• Consider revascularization for high-risk patients with obstructive CAD to prevent spontaneous MI and cardiac death, not just for symptom relief 2

Risk Stratification Approach

• Perform stress imaging (stress echocardiography or myocardial perfusion imaging) to quantify ischemic burden in symptomatic patients 1
• In patients with severe symptoms refractory to medical therapy or high-risk clinical profile, proceed to invasive coronary angiography (ICA) with fractional flow reserve (FFR) assessment 3, 1
• Critical point: ICA is not recommended solely for risk stratification in asymptomatic patients 3

Revascularization Strategy Selection

• High-risk patients with LV systolic dysfunction, diabetes mellitus, and those with severe 3-vessel or left main disease should be considered for CABG rather than PCI 1, 2
• In symptomatic patients with two-vessel disease including proximal LAD stenosis, perform FFR assessment and proceed with PCI if FFR ≤0.80 1

Multidisciplinary Team Approach

• Involve cardiologists, general practitioners, nurses, dieticians, physiotherapists, psychologists, and pharmacists in comprehensive care 3, 1, 2
• This multidisciplinary approach improves outcomes and adherence to treatment 3, 2

Long-Term Monitoring and Follow-Up

Periodic Reassessment

• Schedule periodic visits to cardiovascular healthcare professionals to reassess risk status, lifestyle modifications, adherence to risk factor targets, and development of comorbidities 3, 1, 2
• Monitor symptoms, medication adherence, and risk factor control regularly 1, 2

When to Repeat Testing

• Reassess CAD status in patients with deteriorating LV systolic function that cannot be attributed to reversible causes 3
• Perform risk stratification using stress imaging in patients with new or worsening symptom levels 3
• Important caveat: Coronary CTA is not recommended as a routine follow-up test for patients with established CAD 3
• Repeat stress imaging or invasive angiography only if symptoms worsen or new high-risk features develop 1

Duration of Medical Therapy

• Continue all medical therapy indefinitely regardless of revascularization decision 1
• Knowledge gap: The optimal duration of beta-blocker therapy following MI in the absence of LV systolic dysfunction remains uncertain 3

Special Populations

Patients with Diabetes

• Apply aggressive risk factor modification with careful monitoring of blood glucose levels 2
• ACE inhibitors are particularly important in this population 1, 2

Older Patients (>65 years)

• Apply the same diagnostic and interventional strategies as for younger patients 2
• Adapt medication dosages to renal function and specific contraindications 2
• Use the higher BP target (systolic 130-140 mmHg) 3, 1

Patients with Atrial Fibrillation

• Carefully balance bleeding and thrombotic risks when anticoagulation is required 1
• Consider gastrointestinal protection given increased bleeding risk 3, 1

Common Pitfalls to Avoid

• Do not combine ACE inhibitors with ARBs—this combination is contraindicated and increases adverse events without additional benefit 3
• Do not perform ICA solely for risk stratification in stable asymptomatic patients—this exposes patients to unnecessary procedural risks 3
• Do not use coronary CTA for routine follow-up in patients with established CAD—it provides no additional prognostic information and may lead to unnecessary interventions 3
• Do not neglect cardiac rehabilitation enrollment—this is a Class I recommendation with strong evidence for mortality reduction, yet it remains underutilized 3, 1
• Do not target only LDL-C percentage reduction OR absolute value—both targets must be achieved for optimal benefit 1, 2