What is the appropriate treatment for an elderly female patient with coronary artery disease (CAD), hypertension, and impaired glucose regulation (elevated fasting blood sugar)?

Sample Prescription for Elderly Female with CAD, Hypertension, and Impaired Fasting Glucose

This patient requires comprehensive cardiovascular risk reduction with beta-blocker, ACE inhibitor, high-intensity statin, aspirin, and metformin, targeting blood pressure <130/80 mmHg and LDL-cholesterol <55 mg/dL.

Antiplatelet Therapy

• Aspirin 81 mg once daily 1, 2
  • Essential for secondary prevention in all patients with established CAD 1
  • Reduces fatal and non-fatal coronary events by 36% 3

Beta-Blocker for Angina and Blood Pressure Control

• Metoprolol succinate (extended-release) 50 mg once daily, titrate to 100-200 mg daily 4, 1
  • First-line therapy for hypertension in patients with CAD and stable angina 4, 1
  • Cardioselective beta-blockers without intrinsic sympathomimetic activity are preferred 4
  • Reduces myocardial oxygen demand and provides symptom control 4
  • Continue for at least 6 months as Class I recommendation 2

ACE Inhibitor for Vascular Protection

• Ramipril 2.5 mg once daily, titrate to 10 mg daily over 2-4 weeks 1, 2
  • Strongly recommended in patients with diabetes, hypertension, and CAD 1
  • Provides additional vascular protection beyond blood pressure lowering 1
  • Reduces mortality in diabetic patients 2
  • Monitor renal function and potassium within 1-2 weeks of initiation 1

High-Intensity Statin Therapy

• Atorvastatin 40 mg once daily 1, 2, 3
  • Target LDL-cholesterol <55 mg/dL (<1.4 mmol/L) with ≥50% reduction from baseline 4, 1, 2
  • High-intensity statin reduces cardiovascular events in patients with hypertension and multiple risk factors 3
  • In ASCOT trial, atorvastatin 10 mg reduced coronary events by 36% in hypertensive patients 3
  • Recheck lipid panel in 4-6 weeks; add ezetimibe 10 mg daily if LDL goal not achieved 4, 1

Glucose Management

• Metformin 500 mg once daily with dinner, increase to 1000 mg twice daily over 2-4 weeks 1
  • First-line treatment for impaired fasting glucose (159 mg/dL indicates probable diabetes) 1
  • Provides cardiovascular benefits beyond glucose control 1
  • Target HbA1c <7% considering age and comorbidities 1
  • Discontinue 24 hours before any contrast procedures; restart 48 hours after if renal function stable 4

As-Needed Medication

• Nitroglycerin 0.4 mg sublingual tablets 1
  • Take one tablet under tongue at onset of chest pain 1
  • May repeat every 5 minutes up to 3 doses 1
  • Call 911 if pain persists after first dose

Blood Pressure Target and Monitoring Strategy

• Target blood pressure <130/80 mmHg 4, 1
  • Lower target justified by presence of diabetes, CAD, and multiple cardiovascular risk factors 4
  • Exercise caution if diastolic blood pressure falls below 60 mmHg 4, 5
  • In elderly patients with CAD and diabetes, excessive diastolic lowering may compromise coronary perfusion 4, 5
  • Monitor blood pressure in both sitting and standing positions to detect orthostatic hypotension 5
  • Recheck blood pressure every 2-4 weeks until target achieved 1

Critical Monitoring Parameters

• Renal function (creatinine, eGFR) and potassium at baseline, 1-2 weeks, then every 3-6 months 1
• Lipid panel at 4-6 weeks after statin initiation 1
• HbA1c every 3 months until <7%, then every 6 months 1
• Liver function tests at baseline and as clinically indicated (standard practice with statin therapy)

Essential Lifestyle Modifications

• Enroll in supervised cardiac rehabilitation program 4, 2
  • Reduces all-cause and cardiovascular mortality 4
• Mediterranean or DASH diet pattern 4, 1
  • Reduced saturated fat, increased vegetables, fruits, and fish 1
• Smoking cessation if applicable 4, 2
• Regular physical activity within patient's limitations 1
• Weight management targeting BMI <25 kg/m² 4

Special Considerations for This Elderly Female Patient

• Women with CAD should receive the same pharmacological therapy as men, with attention to weight-based and renal-adjusted dosing 4
• Elderly patients have higher rates of orthostatic and postprandial hypotension requiring careful monitoring 5
• The fasting glucose of 159 mg/dL places her at very high cardiovascular risk and warrants aggressive treatment 4, 6
• In non-diabetic patients, elevated fasting glucose is an independent predictor of severe CAD 6
• Women with elevated troponin benefit most from invasive strategies, but all women with CAD benefit from aggressive medical management 4

Follow-Up Schedule

• 2 weeks: Blood pressure check, renal function, potassium, medication tolerance 1
• 4-6 weeks: Lipid panel, HbA1c, symptom assessment 1
• 3 months: Comprehensive cardiovascular risk reassessment 2
• Consider stress testing to evaluate anti-ischemic treatment effectiveness 1