Chronic Coronary Syndrome Management with Dosage
For patients with chronic coronary syndrome, initiate aspirin 75-100 mg daily lifelong as the cornerstone of antithrombotic therapy, combined with beta-blockers and/or calcium channel blockers for symptom control, plus high-intensity statin therapy (atorvastatin 80 mg daily) for cardiovascular risk reduction. 1
Antithrombotic Therapy
Patients with Prior MI or Remote PCI
- Aspirin 75-100 mg daily is recommended lifelong after an initial period of dual antiplatelet therapy (DAPT) 1, 2
- Clopidogrel 75 mg daily is a safe and effective alternative to aspirin monotherapy if aspirin is not tolerated 1, 2
Patients Without Prior MI or Revascularization
- Aspirin 75-100 mg daily is recommended lifelong in patients with evidence of significant obstructive coronary artery disease 1
Post-PCI Antithrombotic Strategy
- DAPT with aspirin 75-100 mg plus clopidogrel 75 mg daily for up to 6 months is the default strategy after PCI-stenting, regardless of stent type 1, 2
- Clopidogrel loading: 600 mg or >5 days of maintenance therapy before PCI 1
- In high bleeding risk patients (but not high ischemic risk), discontinue DAPT after 1-3 months and continue single antiplatelet therapy 1, 2
Post-CABG
- Aspirin 75-100 mg daily is recommended lifelong, initiated postoperatively as soon as bleeding concerns resolve 1, 2
Antianginal Therapy
First-Line Antianginal Medications
- Beta-blockers and/or calcium channel blockers (CCBs) are recommended as initial treatment for most patients to control heart rate and symptoms 1
- Short-acting nitrates are recommended for immediate relief of angina 1
Second-Line Antianginal Medications
- Long-acting nitrates or ranolazine should be considered as add-on therapy when symptoms are inadequately controlled on beta-blockers and/or CCBs 1
- Nicorandil or trimetazidine may be considered as add-on therapy in patients with inadequate symptom control 1
Important Contraindications
- Ivabradine is NOT recommended as add-on therapy in patients with LVEF >40% and no clinical heart failure 1
- Do not combine ivabradine with non-dihydropyridine CCBs or strong CYP3A4 inhibitors 1
- Nitrates are contraindicated in hypertrophic cardiomyopathy or with phosphodiesterase inhibitors 1
Lipid-Lowering Therapy
Statin Therapy
- High-intensity statin therapy is essential for all patients with chronic coronary syndrome 3, 4
- Atorvastatin 80 mg daily demonstrated superior outcomes compared to lower doses in reducing non-fatal MI and stroke 5
- Target LDL-C <100 mg/dL, with consideration of <70 mg/dL for very high-risk patients 4
- Therapeutic response occurs within 2 weeks, with maximum response at 4 weeks 5
Additional Lipid-Lowering Agents
- Ezetimibe or PCSK9 inhibitors should be considered if target LDL-C is not achieved with statin monotherapy 6
ACE Inhibitors/ARBs
- ACE inhibitors are recommended for all patients with chronic coronary syndrome, especially those with heart failure, hypertension, diabetes, or LV dysfunction 6, 4
- ARBs are effective alternatives if ACE inhibitors are not tolerated (e.g., due to cough) 6
- ACE inhibitors reduce cardiovascular death, MI, and cardiac arrest by approximately 20% 6
- Monitor renal function and potassium levels when initiating therapy, especially in patients with pre-existing renal impairment 6
Special Populations: Patients Requiring Oral Anticoagulation
Long-Term Management
- Direct oral anticoagulant (DOAC) is preferred over vitamin K antagonist (VKA) in eligible patients 1, 2
- OAC alone (without aspirin) is recommended lifelong for patients with chronic coronary syndrome and atrial fibrillation 1
Post-PCI with OAC Indication
- Initial triple therapy: low-dose aspirin once daily plus OAC plus clopidogrel 1, 2
- Early cessation of aspirin (≤1 week) after uncomplicated PCI 1
- Continue OAC plus clopidogrel for up to 6 months (not at high ischemic risk) or up to 12 months (high ischemic risk) 1
- Then continue OAC alone 1
- Ticagrelor or prasugrel are NOT recommended as part of triple antithrombotic therapy 1
Critical caveat: A 2025 trial demonstrated that adding aspirin to oral anticoagulation in patients with chronic coronary syndrome at high atherothrombotic risk significantly increased cardiovascular events (adjusted HR 1.53), all-cause mortality (adjusted HR 1.72), and major bleeding (adjusted HR 3.35) compared to OAC alone 7. This reinforces the guideline recommendation against routine aspirin use in patients already receiving OAC for chronic coronary syndrome.
Gastrointestinal Protection
- Proton pump inhibitor is recommended in patients at increased risk of gastrointestinal bleeding during antithrombotic therapy 1, 2