What is the treatment for atherosclerotic coronary artery disease?

Treatment of Atherosclerotic Coronary Artery Disease

All patients with atherosclerotic coronary artery disease require comprehensive medical therapy combining antiplatelet agents, high-intensity statins, and lifestyle modifications, with revascularization reserved for those with refractory symptoms or high-risk anatomy despite optimal medical management. 1

Antiplatelet Therapy

Aspirin 75-162 mg daily is the cornerstone of treatment and must be started immediately in all patients unless contraindicated. 1, 2

• For aspirin-intolerant patients, clopidogrel 75 mg daily serves as the alternative. 1, 2
• After acute coronary syndrome or stent placement, dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) is mandatory for at least 12 months. 1
• Specific P2Y12 inhibitor options include clopidogrel 75 mg daily, prasugrel 10 mg daily, or ticagrelor 90 mg twice daily. 1
• For patients with prior myocardial infarction at high ischemic risk and low bleeding risk, consider extending dual antiplatelet therapy beyond 12 months. 1
• Proton pump inhibitors are mandatory in patients on antiplatelet therapy who have high gastrointestinal bleeding risk (history of GI bleeding, peptic ulcer disease, age >65, or concurrent anticoagulation). 1, 3

Lipid Management

High-intensity statin therapy is non-negotiable for all patients with coronary artery disease, targeting LDL-C <100 mg/dL with at least 30% reduction from baseline. 1, 2

• For very high-risk patients (recent acute coronary syndrome, recurrent events, or extensive disease), target LDL-C <70 mg/dL. 1
• When maximum tolerated statin dose fails to achieve target, add ezetimibe. 1, 2
• For very high-risk patients not reaching goals on statin plus ezetimibe, add a PCSK9 inhibitor. 1, 2
• Atorvastatin 80 mg daily reduces major cardiovascular events by 22% compared to atorvastatin 10 mg daily in patients with established coronary disease. 4
• If triglycerides are 200-499 mg/dL despite statin therapy, consider adding fibrate or niacin. 1
• If triglycerides exceed 500 mg/dL, initiate fibrate therapy immediately to prevent acute pancreatitis. 1

Blood Pressure Control

Beta-blockers and ACE inhibitors are first-line agents for blood pressure management in coronary artery disease. 1

• Target blood pressure <140/90 mm Hg in all patients. 1
• Beta-blockers are particularly essential in patients with left ventricular dysfunction or heart failure with reduced ejection fraction. 1
• ACE inhibitors (or ARBs if ACE inhibitors are not tolerated) are mandatory in patients with heart failure, diabetes, hypertension, or high-risk features. 1, 2
• If beta-blockers or ACE inhibitors are contraindicated, calcium channel blockers or ARBs are acceptable alternatives. 5

Anti-Anginal Therapy

Beta-blockers and/or calcium channel blockers are first-line agents for symptom control, with short-acting nitrates reserved for acute symptom relief. 1, 2, 3

• Short-acting nitrates provide immediate relief for effort angina but should not be used as monotherapy. 2, 3
• Long-acting nitrates require a 10-14 hour nitrate-free interval daily to prevent tolerance. 1
• Never prescribe nitrates in patients with hypertrophic obstructive cardiomyopathy or those taking phosphodiesterase inhibitors (sildenafil, tadalafil, vardenafil). 2, 3
• Adjust anti-anginal drug selection based on heart rate, blood pressure, and left ventricular function. 1

Lifestyle Modifications

Exercise-based cardiac rehabilitation is mandatory and reduces cardiovascular mortality independent of pharmacotherapy. 1, 2, 3

• Prescribe at least 30-60 minutes of moderate-intensity aerobic activity daily or at minimum 3-4 times weekly. 1
• Target body mass index between 18.5-24.9 kg/m². 1
• If waist circumference exceeds 35 inches (89 cm) in women or 40 inches (102 cm) in men, intensify weight management interventions. 1
• Initial weight loss goal should be 5-10% reduction from baseline. 1
• Dietary modifications must include: saturated fat <7% of total calories, trans fatty acids <1% of total calories, and cholesterol <200 mg/day. 1
• Smoking cessation is non-negotiable—provide pharmacotherapy (varenicline, bupropion, or nicotine replacement) and referral to cessation programs at every visit. 1
• Avoid all environmental tobacco smoke exposure. 1

Diabetes Management

Coordinate diabetes care with primary care or endocrinology, targeting individualized HbA1c goals while avoiding hypoglycemia. 1

• Metformin is the preferred first-line agent if not contraindicated. 1
• A target HbA1c of ≤7% is reasonable for most patients. 1
• Less stringent HbA1c goals are appropriate for patients with severe hypoglycemia history, limited life expectancy, advanced complications, or extensive comorbidities. 1

Revascularization Strategy

Invasive coronary angiography with physiological guidance (FFR/iwFR) is indicated for symptomatic patients with inadequate response to medical therapy or asymptomatic patients at high risk by non-invasive testing. 1, 2

• Medical therapy alone is safe and appropriate for most stable patients without high-risk features. 1, 6
• CABG should be considered over PCI in patients with multivessel disease, acceptable surgical risk, and life expectancy >1 year. 7
• The mortality benefit of revascularization diminishes in patients with severe chronic kidney disease (eGFR <15 mL/min/1.73m²) or on dialysis. 7

Additional Preventive Measures

Annual influenza vaccination is mandatory, particularly in elderly patients, to reduce mortality risk. 2, 3

• Implement psychological interventions for patients with depression symptoms. 1, 2
• Engage multidisciplinary teams including cardiologists, primary care physicians, nurses, dietitians, exercise physiologists, and psychologists. 2
• Cognitive behavioral interventions improve adherence to lifestyle modifications. 1, 3

Monitoring and Follow-Up

Review patient response to medical therapies 2-4 weeks after initiating or adjusting medications. 2, 3

• Reassess symptoms, medication adherence, and achievement of risk factor targets at every visit. 1
• Patient education about the disease, risk factors, and treatment strategy is essential for long-term adherence. 2, 3
• For asymptomatic patients with long-standing disease, consider repeat functional testing or stress imaging every 3-5 years. 1
• Repeat invasive evaluation is warranted only with worsening symptoms or increased risk status. 1

Critical Pitfalls to Avoid

• Never withhold aspirin without a clear contraindication—the mortality benefit is unequivocal. 1
• Do not prescribe statins at inadequate doses; use high-intensity therapy to achieve target LDL-C reductions. 1
• Avoid combining nitrates with phosphodiesterase inhibitors due to life-threatening hypotension risk. 2, 3
• Do not pursue routine revascularization in stable, asymptomatic patients without high-risk features on non-invasive testing. 1
• Never discontinue beta-blockers abruptly in patients post-myocardial infarction—this increases mortality risk. 1