What is the management plan for a patient with cardiovascular disease (CVD)?

Management of Cardiovascular Disease

For patients with established cardiovascular disease, initiate comprehensive risk reduction immediately with dual antiplatelet therapy (aspirin 75-100 mg daily plus clopidogrel 75 mg for up to 6 months post-PCI, then aspirin or clopidogrel monotherapy lifelong), high-intensity statin therapy, blood pressure control targeting <130/80 mmHg, and structured lifestyle interventions including 150-300 minutes weekly of moderate-intensity aerobic exercise. 1, 2, 3

Antithrombotic Management

For patients with prior myocardial infarction or PCI:

• Aspirin 75-100 mg daily is the cornerstone of lifelong therapy after completing initial dual antiplatelet therapy (DAPT) 1
• Clopidogrel 75 mg daily represents an equally effective and safe alternative to aspirin monotherapy 1
• Following PCI with stenting, DAPT (aspirin 75-100 mg plus clopidogrel 75 mg) should continue for up to 6 months as the default strategy in patients without oral anticoagulation indication 1
• In high bleeding risk patients not at high ischemic risk, discontinue DAPT at 1-3 months post-PCI and continue single antiplatelet therapy 1

For patients post-CABG:

• Aspirin 75-100 mg daily is mandatory lifelong 1

For patients with obstructive CAD but no prior MI or revascularization:

• Aspirin 75-100 mg daily is recommended lifelong 1

Lipid Management

Statin therapy is essential for all CVD patients:

• The ASCOT trial demonstrated that atorvastatin 10 mg daily reduced coronary events by 36% (1.9% vs 3%, p=0.0005) and revascularization procedures by 42% in hypertensive patients with cardiovascular risk factors 4
• In diabetic patients without prior CVD (CARDS trial), atorvastatin 10 mg daily reduced major cardiovascular events by 37% (HR 0.63, p=0.001) and stroke by 48% 4
• The TNT study showed that high-dose atorvastatin 80 mg daily further reduced cardiovascular events by 22% compared to 10 mg daily in patients with established CHD 4
• Target LDL-C <100 mg/dL, with consideration for more intensive therapy (LDL-C <70 mg/dL) in very high-risk patients 5, 3

Blood Pressure Control

Aggressive blood pressure management is critical:

• Target BP <130/80 mmHg for all CVD patients, particularly those with diabetes or chronic kidney disease 2, 5
• For confirmed hypertension ≥140/90 mmHg, initiate combination therapy immediately with two drugs rather than monotherapy 2, 5
• Preferred first-line combinations include a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic 2, 5
• Use single-pill combinations to improve adherence 2, 5
• For patients with diabetes, ACE inhibitors or ARBs provide additional renal protection 2

Antianginal Therapy

Tailor antianginal medications to patient characteristics, comorbidities, and underlying pathophysiology:

• Short-acting nitrates are essential for immediate angina relief 1
• Beta-blockers and/or calcium channel blockers represent initial treatment for most CCS patients to control heart rate and symptoms 1
• Ivabradine should be considered as add-on therapy in patients with LVEF <40% and inadequate symptom control 1
• Critical pitfall: Ivabradine is not recommended in patients with LVEF >40% and no clinical heart failure 1
• Critical pitfall: Do not combine ivabradine with non-dihydropyridine calcium channel blockers or strong CYP3A4 inhibitors 1
• Critical pitfall: Avoid nitrates in patients with hypertrophic cardiomyopathy or those taking phosphodiesterase inhibitors 1

Lifestyle Interventions

Structured multidisciplinary behavioral programs are mandatory, not optional:

Dietary modifications:

• Adopt Mediterranean or DASH diet emphasizing fruits, vegetables, fish, nuts, unsaturated fatty acids, and low-fat dairy products 1, 3
• Restrict sodium to <2 g/day (equivalent to <5 g salt daily) 2, 3
• Limit total fat to <30% of energy intake, with saturated fat <10% and dietary cholesterol <300 mg/day 1, 3
• Limit free sugar to <10% of energy intake and avoid sugar-sweetened beverages 2

Physical activity requirements:

• Aerobic exercise of 150-300 minutes per week of moderate intensity OR 75-150 minutes per week of vigorous intensity 1, 3
• Add resistance training at least twice weekly 3
• Reduce sedentary time throughout the day 1
• Home-based cardiac rehabilitation and mobile health interventions should be considered to improve long-term adherence 1

Weight management:

• Target BMI 20-25 kg/m² 1
• Target waist circumference <94 cm (men) or <80 cm (women) 1
• Even 5-10% weight loss significantly reduces cardiovascular risk 5

Tobacco and alcohol:

• Complete tobacco cessation is non-negotiable; refer to cessation programs 1, 3
• Limit alcohol to <100 g/week pure alcohol, preferably avoid completely 2

Risk Stratification and Monitoring

Initial risk stratification based on clinical assessment:

• Age, ECG findings, anginal threshold, presence of diabetes, chronic kidney disease, and LVEF guide initial risk assessment 1

High-risk features requiring invasive coronary angiography with functional assessment capability:

• Duke Treadmill Score <-10 on exercise ECG 1
• Area of ischemia ≥10% of LV myocardium on stress SPECT or PET 1
• ≥3 of 16 segments with stress-induced hypokinesia or akinesia on stress echocardiography 1
• ≥2 of 16 segments with stress perfusion defects or ≥3 dobutamine-induced dysfunctional segments on stress CMR 1
• Left main disease ≥50% stenosis, three-vessel disease ≥70% stenosis, two-vessel disease ≥70% stenosis including proximal LAD, or proximal LAD disease ≥70% with FFR-CT ≤0.8 on CCTA 1

Ongoing monitoring:

• Implement home blood pressure monitoring to improve control and patient engagement 2, 5
• Monitor for medication adherence at every visit, as this is the most common cause of treatment failure 1, 5
• For patients on ACE inhibitors, ARBs, or diuretics, monitor serum creatinine/eGFR and potassium levels 2
• Measure blood pressure at every routine visit 2
• Reassess cardiovascular risk factors every 1-3 months until targets achieved 5

Special Considerations Across CVD Manifestations

The prevention strategy is identical regardless of which arterial territory becomes symptomatic (coronary, cerebrovascular, or peripheral):

• All atherosclerotic manifestations share the same risk factors and require identical lifestyle interventions and risk factor management for blood pressure, lipids, and hyperglycemia 1
• Patients with cerebrovascular disease or peripheral arterial disease should have risk factors managed assuming they have coronary heart disease to broadly reduce CVD event risk 1
• Specific drug therapies may differ by clinical presentation (e.g., preference for beta-blockers or ACE inhibitors for blood pressure control in CHD patients) 1

Critical Pitfalls to Avoid

• Never delay pharmacological therapy while attempting lifestyle modifications alone in patients with established CVD or confirmed hypertension ≥140/90 mmHg 2, 5
• Do not start with monotherapy when initiating antihypertensive therapy in CVD patients with BP ≥140/90 mmHg; combination therapy is more effective 2, 5
• Avoid beta-blockers as first-line antihypertensive therapy in obese patients with metabolic features due to adverse effects on glucose metabolism 5
• Do not use ivabradine in patients with LVEF >40% without heart failure or in combination with non-dihydropyridine calcium channel blockers 1
• Recognize that low adherence rates (potentially as low as 50% for long-term interventions) require systematic approaches including cost reduction, depression treatment, health literacy assessment, and use of adherence aids 1