What is the target therapy for Coronary Artery Disease (CAD)?

Target Therapy for Coronary Artery Disease

All patients with CAD require guideline-directed medical therapy (GDMT) as the foundation of treatment, combining aggressive risk factor modification with evidence-based pharmacotherapy to reduce mortality and improve quality of life. 1

Core Pharmacological Interventions

Lipid Management (First Priority)

• 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, 3
• If target not achieved after 4-6 weeks on maximally tolerated statin, add ezetimibe 1, 2
• For patients still not at goal, consider PCSK9 inhibitors (evolocumab or alirocumab), which reduce cardiovascular events though with minimal mortality benefit 1
• Additional options include inclisiran and bempedoic acid, though clinical outcomes data remain limited for these newer agents 1

Antiplatelet Therapy

• Start aspirin 75-100 mg daily immediately in all patients with previous MI or revascularization 3
• Dual antiplatelet therapy (DAPT) duration can be shortened in many circumstances, particularly when bleeding risk is high and ischemic risk is low-to-moderate 1

Beta-Blockers (Nuanced Approach)

• Beta-blockers are mandatory for patients with MI within the past year or left ventricular ejection fraction ≤50% 1, 2
• Continue for at least 6 months post-MI 3
• Long-term beta-blocker therapy is NOT recommended to improve outcomes in patients with CCD in the absence of recent MI, reduced LVEF, or another primary indication 1
• Either calcium channel blocker or beta-blocker is appropriate as first-line antianginal therapy for symptom control 1, 2

ACE Inhibitors/ARBs

• Recommended in patients with heart failure with reduced LVEF (<40%), diabetes, or chronic kidney disease 2
• Particularly beneficial for mortality reduction in diabetic patients 3

Additional Pharmacotherapy

• Sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists are now recommended for select groups of patients with CCD, including those without diabetes 1
• Short-acting nitrates for immediate angina relief 2

Blood Pressure Management

• Target systolic BP 120-130 mmHg in the general population 3
• Target systolic BP 130-140 mmHg in patients >65 years 3
• Exercise caution when lowering diastolic BP below 60 mmHg in diabetic patients or those >60 years, as this may compromise coronary perfusion 3
• Lower BP slowly in patients with elevated diastolic BP and evidence of myocardial ischemia 3

Lifestyle Interventions (Non-Negotiable)

Dietary Modifications

• Implement heart-healthy diet pattern: Mediterranean, DASH, or AHA diet 2, 3
• These dietary patterns reduce all-cause and cardiovascular mortality 1, 2

Exercise and Cardiac Rehabilitation

• Enroll all eligible patients in supervised exercise-based cardiac rehabilitation programs 3
• Multidisciplinary exercise-based cardiac rehabilitation reduces all-cause and cardiovascular mortality and morbidity while improving quality of life 1, 2
• Patients should participate in habitual physical activity, including activities to reduce sitting time and increase aerobic and resistance exercise 1

Smoking Cessation

• Smoking cessation is mandatory 3, 4
• While e-cigarettes increase likelihood of successful cessation compared with nicotine replacement therapy, they are NOT recommended as first-line therapy due to lack of long-term safety data and risks of sustained use 1

Additional Lifestyle Measures

• Cognitive behavioral interventions to help achieve healthy lifestyle 1, 2
• Weight management for patients with BMI >27 kg/m² 5
• Stress reduction 4

Revascularization Strategy

The role of routine revascularization in stable CAD remains controversial, with major trials (COURAGE, BARI 2D, ISCHEMIA) showing no improvement in clinical endpoints when added to GDMT 1

When to Consider Revascularization

• Myocardial revascularization is indicated when angina persists despite optimal antianginal drug therapy 2, 3
• Progressive or refractory symptoms despite medical management 1
• High-risk patients with left ventricular systolic dysfunction, diabetes mellitus, and those with severe 3-vessel or left main disease should be considered for CABG 2

Important Caveats

• In secondary analysis of ISCHEMIA trial, ischemia severity on noninvasive testing was associated with all-cause death, but no treatment interaction was observed when stratified by mild, moderate, or severe ischemia 1
• 21-42% of patients initially randomized to GDMT alone eventually underwent revascularization in major trials 1

Monitoring and Follow-Up

• Clinical follow-up at least annually to assess symptoms, functional status, adherence to lifestyle and medical interventions, and monitor for complications 1
• Validated CCD-specific patient-reported health status measures may be reasonable to assess symptoms, functional status, and QOL 1
• Routine periodic anatomic or ischemic testing without a change in clinical or functional status is NOT recommended for risk stratification or to guide therapeutic decision-making 1

Special Populations

Diabetic Patients

• Apply aggressive risk factor modification with careful blood glucose monitoring 3
• Target HbA1c <7% 1
• ACE inhibitors specifically recommended to reduce mortality 3
• Most patients require >1 antihypertensive agent 1

Older Patients (>65 years)

• Apply same diagnostic and interventional strategies as younger patients 2
• Adjust medication dosages to renal function and specific contraindications 2
• Use higher BP target (systolic 130-140 mmHg) 3
• Recent data show invasive strategy superior to conservative strategy in patients ≥80 years with NSTE-ACS 1

What NOT to Do

• Do NOT use nonprescription or dietary supplements, including fish oil, omega-3 fatty acids, or vitamins - they lack benefit in reducing cardiovascular events 1
• Do NOT continue long-term beta-blockers in stable CCD patients without recent MI, reduced LVEF, or other indication 1
• Do NOT perform routine periodic testing in stable patients without clinical change 1

Multidisciplinary Team Approach

• Involvement of cardiologists, general practitioners, nurses, dieticians, physiotherapists, psychologists, and pharmacists improves outcomes 1, 2
• Psychological interventions improve symptoms of depression and health-related quality of life 1, 2
• Annual influenza vaccination, especially in older individuals 1, 2