What is the management approach for a typical adult patient with Coronary Artery Disease (CAD)?

Management of Coronary Artery Disease

All patients with CAD require immediate initiation of guideline-directed medical therapy (GDMT) consisting of high-intensity statin therapy, aspirin, beta-blockers (especially if prior MI), and ACE inhibitors or ARBs (if heart failure, diabetes, or chronic kidney disease), combined with aggressive lifestyle modification including supervised cardiac rehabilitation. 1, 2

Pharmacological Management: The Foundation

Antiplatelet Therapy

• Start aspirin 75-100 mg daily immediately in all patients with previous MI or revascularization to reduce recurrent ischemic events 2, 3
• Continue indefinitely unless contraindicated 2

Lipid-Lowering Therapy

• Initiate high-intensity statin therapy immediately with the goal of reducing LDL-C by ≥50% from baseline AND achieving LDL-C <55 mg/dL (<1.4 mmol/L) 2, 4, 3
• If LDL-C goals are not achieved after 4-6 weeks with maximally tolerated statin dose, add ezetimibe 2, 4
• Atorvastatin is FDA-approved to reduce MI, stroke, revascularization procedures, and angina in adults with multiple CHD risk factors 5

Anti-Ischemic Therapy

• Beta-blockers are first-line therapy for all patients with previous MI and for symptom control in angina 2, 4, 3
• Use cardioselective (β1) agents without intrinsic sympathomimetic activity 1
• Short-acting nitrates should be prescribed for immediate relief of angina symptoms 2, 4
• Calcium channel blockers can be added to or substituted for beta-blockers if symptoms persist or beta-blockers are contraindicated 1, 2

Renin-Angiotensin System Blockade

• ACE inhibitors (or ARBs if ACE inhibitors not tolerated) are mandatory in patients with heart failure with reduced LVEF (<40%), diabetes, or chronic kidney disease 2, 4, 3
• In hypertensive patients with previous MI, combine beta-blockers with renin-angiotensin system blockers 1, 3
• Never combine ACE inhibitors with ARBs 1

Blood Pressure Management

• Target systolic BP 120-130 mmHg in general population with CAD 1, 2
• Target systolic BP 130-140 mmHg in older patients (>65 years) 1, 2, 3
• Caution when lowering diastolic BP below 60 mmHg in patients with diabetes or age >60 years, as this may worsen myocardial ischemia 1

Gastroprotection

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

Lifestyle Modification: Mandatory, Not Optional

Cardiac Rehabilitation

• Enrollment in supervised exercise-based cardiac rehabilitation is mandatory for all patients with CAD 2, 4, 3
• This is not optional—it reduces mortality and improves outcomes 4, 3
• Exercise-based rehabilitation is an effective means to achieve healthy lifestyle and manage risk factors 2

Dietary Interventions

• Implement a heart-healthy diet pattern (Mediterranean, DASH, or AHA diet) 2, 4, 3
• Combined dietary changes reduce mortality (RR 0.56) 6
• Limit sodium to 2 gm/day (6 gm sodium chloride) for hypertension control 7

Smoking Cessation

• Complete cessation of smoking reduces mortality by 36% (RR 0.64) in CAD patients 6
• This is one of the most powerful interventions available 7, 6

Physical Activity

• Increased physical activity reduces mortality by 24% (RR 0.76) in CAD patients 6
• Regular exercise should be encouraged beyond formal cardiac rehabilitation 2

Behavioral Support

• Implement cognitive behavioral interventions to help patients achieve and maintain lifestyle changes 2, 4
• Psychological interventions should be provided to improve symptoms of depression 2, 4

Vaccination

• Annual influenza vaccination is recommended, especially for elderly patients 2, 4

Risk Stratification and Diagnostic Evaluation

Initial Assessment

• Perform resting echocardiography to quantify left ventricular function in all patients 2
• Obtain careful assessment of symptoms, functional limitations, and quality of life at each visit 1
• Use validated patient-reported health status measures (e.g., 7-item Seattle Angina Questionnaire) to reliably quantify symptom burden 1

Non-Invasive Testing

• Stress imaging (stress echocardiography or myocardial perfusion imaging) is recommended to quantify ischemic burden and guide revascularization decisions 2
• Coronary CTA is an alternative for diagnosis but not recommended for routine follow-up 1

Invasive Assessment

• Invasive coronary angiography (ICA) with FFR/iwFR is recommended for patients with high-risk features or symptoms inadequately responding to medical treatment 2
• ICA is not recommended solely for risk stratification in asymptomatic patients 1

Revascularization Strategy

Indications for Revascularization

• Myocardial revascularization is recommended when angina persists despite optimal antianginal drug therapy 1, 2, 4, 3
• Consider revascularization for high-risk patients with obstructive CAD to prevent spontaneous MI and cardiac death, not just for symptom relief 4, 3

Choosing Between PCI and CABG

• High-risk patients with left ventricular systolic dysfunction, diabetes mellitus, and those with severe 3-vessel or left main disease should be considered for CABG 2, 3
• PCI is appropriate for symptomatic patients with less extensive disease (e.g., two-vessel disease with FFR ≤0.80) 2
• The burden of ischemic symptoms before intervention is the strongest predictor of symptomatic improvement after revascularization 1

Important Caveat

• Revascularization does not eliminate the need for GDMT—continue all medical therapy indefinitely regardless of revascularization decision 2
• In trials like COURAGE and ISCHEMIA, 21-42% of patients initially randomized to medical therapy eventually underwent revascularization, and there was no interaction between treatment strategy and severity of ischemia 1

Long-Term Follow-Up and Monitoring

Frequency and Content of Visits

• Clinical follow-up at least annually is recommended to assess symptoms, functional status, medication adherence, and complications 1
• Annual in-person evaluation may be supplemented with telehealth visits when appropriate 1

What to Monitor

• Assess for new or worsened symptoms, change in functional status, or decline in quality of life 1
• Verify adherence to lifestyle interventions: physical activity, nutrition, weight management, stress reduction, smoking cessation, immunization status 1
• Monitor cardiovascular risk factors: blood pressure, glycemic control, lipid levels 1
• Screen for complications of disease or adverse effects of therapy 1

When to Reassess

• Reassess CAD status in patients with deteriorating LV systolic function that cannot be attributed to reversible causes 1
• Expeditiously refer patients with significant worsening of symptoms for evaluation 1
• Repeat stress imaging or invasive angiography only if symptoms worsen or new high-risk features develop 2

Team-Based Approach

• Involve multidisciplinary healthcare professionals (cardiologists, GPs, nurses, dieticians, physiotherapists, psychologists, pharmacists) for comprehensive care 2, 4
• Remote, algorithmically driven disease management programs may provide useful adjunctive strategy to achieve GDMT optimization 1

Special Populations

Diabetes Mellitus

• Apply aggressive risk factor modification with careful monitoring of blood glucose levels 3
• ACE inhibitors are particularly important in this population 3
• Strict glucose control is essential to minimize microvascular disease 1, 7

Older Patients (>65 Years)

• Apply the same diagnostic and interventional strategies as for younger patients 4
• Adapt medication dosages to renal function and specific contraindications 4, 3
• Use higher BP target (systolic 130-140 mmHg) in this age group 1, 2, 3

Hypertension

• In hypertensive patients with recent MI, beta-blockers and RAS blockers are both recommended 1
• In patients with symptomatic angina, beta-blockers and/or calcium channel blockers are recommended 1

Vasospastic Angina

• Obtain ECG during angina episodes if possible 1
• Invasive angiography or coronary CTA is recommended in patients with characteristic episodic resting angina and ST-segment changes that resolve with nitrates and/or calcium antagonists 1

Common Pitfalls to Avoid

• Do not underestimate symptom burden—clinicians frequently inaccurately estimate ischemic symptoms, leading to under- or overtreatment 1
• Do not stop GDMT after revascularization—medical therapy must continue indefinitely 2
• Do not use coronary CTA for routine follow-up in patients with established CAD 1
• Do not perform ICA solely for risk stratification in asymptomatic patients 1
• Do not combine ACE inhibitors with ARBs 1
• Avoid excessive lowering of diastolic BP (<60 mmHg) in older patients or those with diabetes, as this may worsen ischemia 1