What is the initial management for a patient with coronary artery disease (CAD) and angina pectoris?

Initial Management of Coronary Artery Disease with Angina Pectoris

All patients with coronary artery disease and angina pectoris should immediately receive aspirin 75-100 mg daily, high-intensity statin therapy targeting LDL-C <55 mg/dL, and beta-blocker therapy as first-line treatment, along with sublingual nitroglycerin for acute symptom relief. 1, 2, 3

Immediate Pharmacological Interventions

Anti-Ischemic Therapy

• Prescribe sublingual nitroglycerin or nitroglycerin spray for immediate relief of angina attacks 1, 2

  • Instruct patients to sit when first using sublingual nitrate to prevent hypotension 1
  • Warn about potential side effects, particularly headache 1
  • Advise patients to seek medical attention if angina persists >10-20 minutes after resting and/or is not relieved by sublingual nitrate 1
  • Encourage prophylactic nitrate use before predictable exertion-induced angina 1

• Initiate beta-blocker therapy immediately as first-line for symptom control 1, 2, 3

  • Beta-blockers are the drugs of first choice for hypertension in patients with CAD causing angina 1
  • Use cardioselective (β1) agents without intrinsic sympathomimetic activity 1
  • Beta-blockers reduce mortality in patients with previous MI and provide symptom relief 1, 3

• If beta-blockers are contraindicated or not tolerated, substitute with long-acting calcium channel blockers or long-acting nitrates 1

  • Long-acting calcium channel blockers (such as amlodipine 5-10 mg daily) are effective for chronic stable angina 4
  • Amlodipine increases exercise time by 12.8% (63 seconds) at 10 mg dose and reduces angina attack rate 4
  • Avoid immediate-release or short-acting dihydropyridine calcium antagonists as they increase adverse cardiac events 1

Secondary Prevention Medications

• Start aspirin 75-100 mg daily immediately (or clopidogrel if aspirin is absolutely contraindicated) 1, 2, 3

• Initiate high-intensity statin therapy immediately with goal of reducing LDL-C by ≥50% from baseline and achieving LDL-C <55 mg/dL (<1.4 mmol/L) 1, 2, 3

  • If LDL-C goals are not achieved with maximally tolerated statin dose after 4-6 weeks, add ezetimibe 2

• Start ACE inhibitor therapy 1, 2, 3

  • Mandatory in patients with co-existing ventricular dysfunction (LVEF <40%), hypertension, diabetes, or chronic kidney disease 1, 2, 3
  • Should be considered in patients with other high-risk features 1
  • Use ARB if ACE inhibitor is not tolerated 2

• Prescribe proton pump inhibitor (omeprazole 20 mg daily or pantoprazole 40 mg daily) given aspirin use and risk factors for gastrointestinal bleeding 2

Lifestyle Modifications (Mandatory, Not Optional)

Cardiovascular Risk Factor Management

• Strongly discourage cigarette smoking 1

• Prescribe Mediterranean diet pattern with vegetables, fruit, fish, and poultry as mainstays 1, 2, 3

  • Intensity of dietary change should be guided by lipid abnormalities 1

• Implement weight reduction diet for overweight patients 1

• Limit alcohol to moderate consumption 1

• Enroll in supervised exercise-based cardiac rehabilitation program—this is mandatory 2, 3

  • Encourage physical activity within patient's limitations to increase exercise tolerance and reduce symptoms 1
  • Regular exercise has favorable effects on weight, blood lipids, blood pressure, glucose tolerance, and insulin sensitivity 1
  • Exercise-based cardiac rehabilitation reduces mortality and improves outcomes 3

• Implement cognitive behavioral interventions to support lifestyle adherence 2

Blood Pressure Management

• Target office BP <130/80 mmHg in patients with diabetes, chronic kidney disease, or high cardiovascular risk 1, 2
• Target systolic BP 130-140 mmHg in older patients (>65 years) 2, 3
• In patients with elevated diastolic BP and evidence of myocardial ischemia, lower BP slowly and avoid diastolic BP <60 mmHg, especially in patients with diabetes or age >60 years 1

Diabetes and Comorbidity Management

• Manage diabetes with strict glycemic control and aggressive risk factor modification 1, 3
• Correct anemia or hyperthyroidism if present 1

Diagnostic Evaluation and Risk Stratification

Initial Assessment

• Obtain comprehensive history focusing on chest pain characteristics, risk factors, and medication history 1, 5
• Perform 12-lead resting ECG in all patients 1, 5
• Order basic blood tests including complete blood count, creatinine with renal function estimation, lipid profile (including LDL-C), fasting glucose, HbA1c, and thyroid function if clinically indicated 1, 5
• Perform resting transthoracic echocardiography to exclude alternative causes of angina, identify regional wall motion abnormalities, measure LVEF for risk stratification, and evaluate diastolic function 1, 2

Non-Invasive Testing

• Perform non-invasive functional imaging for myocardial ischemia (stress echocardiography or myocardial perfusion scintigraphy) or coronary CT angiography as initial test 1, 2
  • Exercise ECG should be interpreted with attention to hemodynamic response, workload achieved, clinical features, symptoms, and ST-segment response 1
  • Alternative investigations are needed when exercise ECG is not possible or interpretable 1
  • Stress imaging quantifies ischemic burden and demonstrates extent and localization of myocardial ischemia 1, 2

Medication Optimization Strategy

• Optimize dosing of one anti-anginal drug before adding another 1
• Switch drug combinations before attempting a three-drug regimen 1
• Tailor anti-anginal drug treatment to individual patient needs and monitor individually 1

When to Consider Revascularization

• Perform coronary arteriography when symptoms are not satisfactorily controlled by medical therapy, with a view to revascularization 1, 2, 3
• Consider invasive coronary angiography with FFR assessment in patients with high-risk features or symptoms inadequately responding to medical treatment 2
• PCI is indicated for patients with angina not satisfactorily controlled by medical treatment when anatomically suitable lesions are present 1
• CABG should be considered for high-risk patients with LV systolic dysfunction, diabetes, severe 3-vessel disease, or left main stenosis 1, 2

Common Pitfalls to Avoid

• Do not use unopposed COX-2 inhibition without effective simultaneous platelet COX-1 inhibition (aspirin) 1
• Avoid ibuprofen in patients on aspirin, as it prevents effective platelet inhibition 1
• Do not use coronary calcium scoring to identify individuals with obstructive CAD 1
• Do not use ambulatory ECG monitoring as routine examination in suspected chronic coronary syndrome 1
• Do not assume chest pain is always cardiac—women and men may present with different symptom patterns, and many patients with coronary disease present with atypical symptoms 1, 5

Long-Term Follow-Up

• Continue all medical therapy indefinitely regardless of revascularization decision 2
• Schedule periodic visits to reassess risk status, lifestyle modifications, adherence to cardiovascular risk factor targets, and development of comorbidities 2
• Repeat stress imaging or invasive angiography only if symptoms worsen or new high-risk features develop 2
• Involve multidisciplinary healthcare professionals (cardiologists, GPs, nurses, dieticians, physiotherapists, psychologists, and pharmacists) for comprehensive care 2