What are the treatment modalities for coronary disease?

Treatment Modalities for Coronary Disease

Coronary disease treatment requires both pharmacological therapy to prevent events and mortality, plus symptom management with antianginal medications, supported by intensive lifestyle modification and selective revascularization for high-risk anatomy or refractory symptoms. 1

Pharmacological Management for Event Prevention (Mandatory for All Patients)

Antiplatelet Therapy

• Aspirin 75-100 mg daily is the foundation for all patients with established coronary disease, particularly those with prior myocardial infarction or revascularization 1, 2, 3
• Clopidogrel 75 mg daily serves as an alternative in aspirin-intolerant patients 2, 4
• After coronary stent implantation, dual antiplatelet therapy (aspirin plus clopidogrel) is required for 6 months 4
• Add proton pump inhibitors for patients on aspirin with high gastrointestinal bleeding risk 2, 3

Lipid-Lowering Therapy (Prognostic Benefit)

• Statins are mandatory in all patients with coronary disease to reduce major vascular events and mortality 1, 2, 3, 5
• Add ezetimibe if LDL goals are not achieved with maximum tolerated statin dose 1, 2, 4
• For very high-risk patients not reaching goals on statin plus ezetimibe, add a PCSK9 inhibitor 2, 4

ACE Inhibitors or ARBs

• Recommended particularly when hypertension, diabetes, heart failure, or left ventricular dysfunction coexist 1, 2, 4
• ACE inhibitors reduce morbidity and mortality after myocardial infarction in patients with symptomatic heart failure or asymptomatic LV dysfunction 1, 5

Pharmacological Management for Symptom Relief

First-Line Antianginal Therapy

• Beta-blockers are first-line for controlling heart rate and relieving angina symptoms 1, 2, 3, 6
• Beta-blockers also reduce morbidity and mortality in patients with heart failure 1, 4
• Metoprolol has demonstrated effectiveness in reducing angina attacks and increasing exercise tolerance at oral dosages of 100-400 mg daily 7

Alternative or Additional Antianginal Agents

• Calcium channel blockers are appropriate when beta-blockers are contraindicated or poorly tolerated 1, 2, 3, 6
• Short-acting nitrates (sublingual nitroglycerin) provide immediate relief for effort angina and should be prescribed to all patients 1, 2, 3, 4
• Long-acting nitrates can be added as second-line therapy 1, 6

Critical Contraindications to Avoid

• Never use nitrates in hypertrophic obstructive cardiomyopathy or with phosphodiesterase inhibitors 2, 3, 4
• Avoid combining ivabradine with non-dihydropyridine calcium channel blockers 3

Lifestyle Modifications (Essential Component)

Exercise and Cardiac Rehabilitation

• Exercise-based cardiac rehabilitation is fundamental and significantly reduces cardiovascular mortality and morbidity while improving risk factor control 1, 2, 3, 4, 8
• Even moderate levels of physical activity provide substantial benefit 9, 5

Smoking Cessation

• Smoking cessation is universally recommended and reduces risk of coronary and vascular disease 1, 10, 6, 9, 5
• Physicians can have major positive impact merely by asking patients whether they smoke and advising smokers to quit 9
• Nicotine replacement therapy should be prescribed when appropriate 9

Dietary Intervention

• Low-fat diet with reduced saturated fat, sugar, and cholesterol intake 10, 8
• Dietary intervention should be tailored to individual patients, their food preferences and ethnic backgrounds 9

Vaccination

• Annual influenza vaccination is recommended, especially in elderly patients, to reduce mortality risk 1, 2, 3, 4
• Vaccination against pneumococcal disease and COVID-19 1

Psychosocial Support

• Psychological interventions are recommended to address depression symptoms 1, 2, 4
• Cognitive behavioral interventions help achieve and maintain healthy lifestyle changes 2

Revascularization Strategies

Indications for Invasive Coronary Angiography

• High-risk patients with severe symptoms refractory to medical treatment require invasive coronary angiography with FFR/iFR guidance 1, 4
• Patients with mild or no symptoms but high-risk features on non-invasive testing should undergo ICA with FFR when revascularization is considered for prognostic improvement 1
• Patients with new or worsening symptoms, deteriorating LV systolic function, or significant left main/multivessel disease 1

Revascularization Method Selection

• Coronary artery bypass grafting (CABG) is recommended for left main stenosis, significant proximal left anterior descending artery stenosis, multivessel disease, or disabling angina 1, 5
• Percutaneous coronary intervention (PCI) is appropriate for single vessel disease or selected patients with objective evidence of ischemia 1, 5
• In double-vessel or some triple-vessel disease, either PCI or CABG may be appropriate 1

Important Limitation

• Medical therapy must be optimized before considering revascularization, except in high-risk patients with significant symptoms despite medical therapy 3
• Major trials (COURAGE, BARI 2D, ISCHEMIA) showed no improvement in clinical endpoints with routine revascularization plus guideline-directed medical therapy versus initial medical therapy alone 1
• Coronary angiography is not recommended solely for risk stratification 1, 2

Special Populations

Coronary Microvascular Dysfunction and Vasospastic Angina

• For microvascular angina: First-line beta-blocker (e.g., carvedilol 6.25 mg BID uptitrated), second-line add long-acting nitrate 1
• For vasospastic angina: First-line calcium channel blocker (e.g., verapamil 40 mg BID uptitrated), second-line add long-acting nitrate 1
• Consider aspirin and statin if atherosclerosis or endothelial impairment present 1

Heart Failure with Coronary Disease

• Diuretics for symptomatic patients with signs of congestion 1, 4
• Beta-blockers are essential for both angina relief and reducing morbidity/mortality in heart failure 1, 4
• Mineralocorticoid receptor antagonists (MRA) for patients remaining symptomatic despite ACE inhibitor and beta-blocker 1
• Implantable cardioverter-defibrillator for symptomatic heart failure with LVEF <35% 1
• Cardiac resynchronization therapy (CRT) for specific indications based on QRS duration and morphology 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
• Review patient response to medical therapies at 2-4 weeks after drug initiation 2, 4
• Patient education about the disease, risk factors, and treatment strategy is essential for long-term adherence 2, 3, 4
• Telehealth visits may supplement annual in-person evaluation when clinically appropriate 1

Team-Based Approach

• Involvement of cardiologists, primary care physicians, nurses, dieticians, physiotherapists, psychologists, and pharmacists improves outcomes 1, 3, 4