What is the initial treatment for Coronary Artery Disease (CAD)?

Initial Treatment for Coronary Artery Disease

All patients with CAD should immediately start aspirin 75-100 mg daily, high-intensity statin therapy targeting LDL-C <55 mg/dL, and enroll in supervised cardiac rehabilitation—these are non-negotiable foundational interventions that reduce mortality. 1, 2

Immediate Pharmacological Interventions

Antiplatelet Therapy

• Start aspirin 75-100 mg daily immediately in all patients with established CAD, defined as those with prior MI, revascularization, coronary stenoses >50% on angiography, or evidence of cardiac ischemia on diagnostic testing 1, 2
• Aspirin provides a Class I, Level A recommendation for secondary prevention and reduces cardiovascular mortality 1, 3

Lipid Management

• Initiate high-intensity statin therapy immediately with dual goals: reduce LDL-C by ≥50% from baseline AND achieve LDL-C <55 mg/dL (<1.4 mmol/L) 1, 2
• If LDL-C goals are not met after 4-6 weeks on maximally tolerated statin, add ezetimibe 1, 2
• Statins remain first-line therapy with the strongest evidence for mortality reduction 1

Anti-Ischemic Therapy for Symptom Control

• Either a beta-blocker OR calcium channel blocker is recommended as first-line antianginal therapy 1
• This represents a significant shift from older guidelines: long-term beta-blocker therapy is NOT recommended to improve outcomes in patients with CCD in the absence of MI in the past year, LVEF ≤50%, or another primary indication 1
• Short-acting nitrates should be prescribed for immediate relief of effort angina 2
• If symptoms persist on monotherapy, add the other first-line agent (beta-blocker + calcium channel blocker combination) 1

Blood Pressure Control

• Target systolic BP 120-130 mmHg in general population and 130-140 mmHg in patients >65 years 1, 3
• ACE inhibitors (or ARBs if ACE inhibitors not tolerated) are recommended in patients with heart failure with reduced LVEF (<40%), diabetes, or chronic kidney disease 2
• Exercise caution when lowering diastolic BP below 60 mmHg in diabetic patients or those >60 years, as this may compromise coronary perfusion 3

Mandatory Lifestyle Modifications

Cardiac Rehabilitation

• Enrollment in supervised exercise-based cardiac rehabilitation is mandatory, not optional—this provides significant cardiovascular benefits including decreased morbidity and mortality 1, 2, 3
• Regular physical activity should include activities to reduce sitting time and increase both aerobic and resistance exercise 1

Dietary Interventions

• Adopt a heart-healthy diet pattern (Mediterranean, DASH, or AHA diet) to reduce mortality 2, 3
• Combined dietary changes show mortality reduction with RR 0.56 (95% CI, 0.42-0.74) 4

Smoking Cessation

• Smoking cessation is non-negotiable and provides substantial mortality benefit (RR 0.64; 95% CI, 0.58-0.71) 4
• E-cigarettes are NOT recommended as first-line therapy for smoking cessation due to lack of long-term safety data 1

Physical Activity

• Increased physical activity reduces mortality (RR 0.76; 95% CI, 0.59-0.98) 4
• Moderate alcohol use may be beneficial (RR 0.80; 95% CI, 0.78-0.83), though this should be discussed carefully 4

Additional Pharmacological Considerations

Novel Agents for Select Populations

• SGLT2 inhibitors and GLP-1 receptor agonists are recommended for select groups of patients with CCD, including those without diabetes 1
• These represent important additions to the treatment armamentarium for specific patient populations 1

Gastrointestinal Protection

• Prescribe proton pump inhibitor (omeprazole 20 mg daily or pantoprazole 40 mg daily) in patients on aspirin with multiple risk factors for gastrointestinal bleeding 2

Supplements NOT Recommended

• Do NOT prescribe fish oil, omega-3 fatty acids, or vitamins—these provide no benefit in reducing cardiovascular events 1

Risk Stratification and Diagnostic Approach

Initial Testing

• In symptomatic patients with pre-test likelihood of obstructive CAD >5%, either coronary CT angiography (CCTA) or non-invasive functional imaging for myocardial ischemia is recommended as the initial diagnostic test 1, 2
• CCTA is preferred to rule out obstructive CAD in patients with low or moderate (>5%-50%) pre-test likelihood 1
• Resting echocardiography is recommended to quantify left ventricular function in all patients with suspected CAD 2

When to Consider Revascularization

• Myocardial revascularization is indicated when angina persists despite optimal antianginal drug therapy 1, 2, 3
• Perform stress imaging (stress echocardiography or myocardial perfusion imaging) to quantify ischemic burden if revascularization is being considered 2, 3
• Invasive coronary angiography with FFR assessment is recommended for patients with high-risk features or inadequate symptom response to medical treatment 1, 2

Long-Term Monitoring

• Continue all medical therapy indefinitely regardless of revascularization decision 2
• Periodic cardiovascular healthcare visits are necessary to reassess risk status, lifestyle modifications, adherence to risk factor targets, and development of comorbidities 2, 3
• Routine periodic anatomic or ischemic testing without a change in clinical or functional status is NOT recommended for risk stratification 1
• Repeat stress imaging or invasive angiography only if symptoms worsen or new high-risk features develop 2

Common Pitfalls to Avoid

• Do not routinely continue beta-blockers long-term in stable CAD patients without recent MI, reduced LVEF, or other specific indication—this represents outdated practice 1
• Do not prescribe dietary supplements or fish oil—they waste money and provide no cardiovascular benefit 1
• Do not perform routine surveillance testing in asymptomatic stable patients—this leads to unnecessary procedures without improving outcomes 1
• Do not lower diastolic BP aggressively below 60 mmHg in older or diabetic patients—this may worsen coronary perfusion 3