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

Treatment of Coronary Artery Disease

All patients with CAD require immediate initiation of aspirin 75-100 mg daily, high-intensity statin therapy targeting LDL-C <55 mg/dL, and beta-blocker therapy, combined with aggressive lifestyle modification including mandatory enrollment in cardiac rehabilitation. 1, 2, 3

Immediate Pharmacological Management

Antiplatelet Therapy

• Start aspirin 75-100 mg daily immediately in all patients with previous myocardial infarction or revascularization 1, 2, 3
• This is non-negotiable for secondary prevention and reduces recurrent ischemic events 3

Lipid-Lowering Therapy

• Initiate high-intensity statin therapy immediately (e.g., atorvastatin 40-80 mg daily) with the goal of reducing LDL-C by ≥50% from baseline AND achieving LDL-C <55 mg/dL (<1.4 mmol/L) 1, 2, 3
• Add ezetimibe if LDL-C goals are not achieved after 4-6 weeks of maximally tolerated statin dose 1, 2
• High-intensity atorvastatin (80 mg) reduces major cardiovascular events by 22% compared to moderate-intensity therapy 4

Anti-Ischemic Therapy

• Beta-blockers are first-line for all patients with previous MI and for symptom control in angina (e.g., carvedilol 6.25 mg BID uptitrated) 1, 2, 3
• Beta-blockers reduce mortality and improve symptoms through negative chronotropic and inotropic effects 1
• Use for at least 6 months post-MI as Class I recommendation 1
• If beta-blockers are contraindicated or not tolerated, substitute with calcium channel blockers (diltiazem or verapamil), but avoid if bradycardia or left ventricular dysfunction is present 1, 2

Renin-Angiotensin System Blockade

• Start ACE inhibitor (or ARB if ACE inhibitor not tolerated) in patients with heart failure (LVEF <40%), diabetes, chronic kidney disease, or hypertension 1, 2, 3
• Combine beta-blockers with ACE inhibitors/ARBs in hypertensive patients with previous MI 1, 2, 3

Symptomatic Relief

• Prescribe sublingual nitroglycerin as needed for immediate relief of effort angina 1, 2
• Short-acting nitrates are recommended for acute symptom management 2

Blood Pressure Management

Target systolic BP 120-130 mmHg in general population and 130-140 mmHg in patients >65 years 2, 3

• Lower BP slowly in patients with elevated diastolic BP and evidence of myocardial ischemia 1
• Exercise caution when lowering diastolic BP below 60 mmHg in diabetic patients or those >60 years, as this may compromise coronary perfusion 1
• In older patients with wide pulse pressures, monitor carefully for symptoms of myocardial ischemia when lowering systolic BP causes very low diastolic values 1

Mandatory Lifestyle Modifications

Cardiac Rehabilitation

• Enroll all patients in supervised exercise-based cardiac rehabilitation programs—this is mandatory, not optional 2, 3
• Cardiac rehabilitation improves outcomes and reduces mortality 3

Dietary Interventions

• Implement heart-healthy diet pattern (Mediterranean, DASH, or AHA diet) to reduce mortality 2, 3
• Dietary modifications reduce systolic BP by 3-7 mmHg depending on sodium intake 1

Risk Factor Control

• Smoking cessation is non-negotiable 1, 2
• Weight loss and regular physical activity are essential components 1, 2
• Annual influenza vaccination, especially for elderly patients 2
• Implement cognitive behavioral interventions to support lifestyle adherence 2, 3

Revascularization Strategy

Myocardial revascularization is indicated when angina persists despite optimal antianginal drug therapy 1, 2, 3

Diagnostic Evaluation

• Perform stress imaging (stress echocardiography or myocardial perfusion imaging) to quantify ischemic burden 2
• Invasive coronary angiography with FFR assessment is recommended for patients with high-risk features or inadequate symptom response to medical treatment 1, 2

Revascularization Decision-Making

• High-risk patients with left ventricular systolic dysfunction, diabetes mellitus, severe 3-vessel disease, or left main disease should be considered for CABG 1, 2
• PCI is appropriate for symptomatic patients with FFR ≤0.80 2
• Revascularization decisions should be made by an interdisciplinary "heart team" 5

Special Populations

Diabetic Patients

• Apply aggressive risk factor modification with careful blood glucose monitoring 3
• ACE inhibitors are specifically recommended to reduce mortality 3
• Exercise particular caution with beta-blockers in brittle diabetics with hypoglycemic events, as they may mask hypoglycemia symptoms 1

Older Patients (>65 years)

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

Vasospastic Angina

• Calcium channel blockers are first-line (e.g., verapamil 40 mg BID uptitrated) 1
• Add long-acting nitrate as second-line (e.g., isosorbide mononitrate 10 mg BID) 1
• Beta-blockers should be avoided in pure vasospastic angina 1

Long-Term Monitoring

• Continue all medical therapy indefinitely regardless of revascularization 2
• Periodic cardiovascular healthcare visits to reassess risk status, lifestyle modifications, adherence to risk factor targets, and development of comorbidities 1, 2
• Repeat stress imaging or invasive angiography only if symptoms worsen or new high-risk features develop 2
• Multidisciplinary involvement (cardiologists, GPs, nurses, dieticians, physiotherapists, psychologists, pharmacists) improves outcomes 2

Common Pitfalls to Avoid

• Do not withhold beta-blockers in patients with mild bronchospastic disease or peripheral arterial disease—these are not absolute contraindications 1
• Do not stop antiplatelet therapy and statins unless there is a specific contraindication 1
• Do not use beta-blockers as monotherapy in vasospastic angina—calcium channel blockers are superior 1
• Do not lower diastolic BP too aggressively (<60 mmHg) in high-risk patients, as this may compromise coronary perfusion 1