What is the optimal medical management for an adult patient with chronic coronary syndrome, hypertension, diabetes, hyperlipidemia, and a history of smoking?

Medical Management for Chronic Coronary Syndrome

All patients with chronic coronary syndrome require comprehensive medical therapy targeting multiple pathways: antiplatelet agents, statins with aggressive LDL-lowering, ACE inhibitors (or ARBs), beta-blockers if post-MI, blood pressure control, diabetes management with SGLT2 inhibitors or GLP-1 agonists, and intensive lifestyle modification including smoking cessation. 1

Core Pharmacological Therapy

Antiplatelet Therapy

• Aspirin 75-100 mg daily is the foundation for all patients with chronic coronary syndrome unless contraindicated 1, 2
• Clopidogrel 75 mg daily serves as an alternative in patients with aspirin intolerance 1
• Following coronary stenting, dual antiplatelet therapy (aspirin plus clopidogrel) is required for 6 months, though shorter duration (1-3 months) may be indicated if life-threatening bleeding risk exists 1
• Add a proton pump inhibitor when prescribing aspirin monotherapy, dual antiplatelet therapy, or oral anticoagulation in patients at high gastrointestinal bleeding risk 1

Lipid-Lowering Therapy

• Statins are mandatory in all patients with chronic coronary syndrome 1, 3, 4
• Target LDL-cholesterol <70 mg/dL for very high-risk patients; consider <55 mg/dL based on 2024 ESC guidelines 1, 4
• If maximum tolerated statin dose fails to achieve goals, add ezetimibe 1
• For patients at very high risk not reaching goals on statin plus ezetimibe, add a PCSK9 inhibitor 1
• Atorvastatin specifically reduces risk of MI, stroke, revascularization procedures, and angina in adults with multiple CHD risk factors 3

Renin-Angiotensin System Blockade

• ACE inhibitors (or ARBs if ACE inhibitors not tolerated) are recommended in the presence of hypertension, diabetes, heart failure, or post-MI 1, 5
• ACE inhibitors reduce mortality in hemodynamically stable patients within 24 hours of acute MI 5
• In hypertensive patients with recent MI, combine beta-blockers with RAS blockers 1
• Target office blood pressure: systolic 120-130 mmHg (general population) or 130-140 mmHg (patients >65 years) 1
• Never combine ACE inhibitors with ARBs due to lack of benefit and increased harm 1

Beta-Blockers

• Beta-blockers are essential in patients with prior MI to reduce morbidity and mortality 1, 2, 4
• Also recommended for symptomatic angina control and in hypertensive patients with recent MI 1, 4
• Beta-blockers serve dual purposes: symptom relief and prognostic benefit in post-MI patients 1, 4

Diabetes-Specific Therapy

• SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) are recommended in patients with diabetes and cardiovascular disease 1
• GLP-1 receptor agonists (liraglutide or semaglutide) are recommended in patients with diabetes and cardiovascular disease 1
• Target HbA1c, blood pressure, and LDL-cholesterol to recommended goals 1
• ACE inhibitors specifically recommended for event prevention in chronic coronary syndrome patients with diabetes 1

Antianginal Symptom Management

First-Line Options

• Beta-blockers and/or calcium channel blockers for symptomatic angina 1, 4
• Sublingual nitroglycerin for acute symptom relief (symptoms should resolve within 1-5 minutes) 1
• Long-acting nitrates can be added for additional symptom control 4

Combination Therapy

• Any combination of beta-blockers, calcium channel blockers, and nitrates may be used for refractory symptoms 4
• If angina persists despite optimal antianginal therapy, myocardial revascularization is recommended 1

Risk Factor Modification

Smoking Cessation

• Quantitative assessment of tobacco use is mandatory at every visit 1
• Smoking decreases age at CHD event by nearly one decade across all risk factor combinations 6
• Smoking is the most frequent risk factor in men with coronary disease (68% prevalence) 7

Hypertension Management

• Office BP control to systolic 120-130 mmHg (general) or 130-140 mmHg (>65 years) 1
• Start with beta-blockers and RAS blockers in post-MI patients 1
• Calcium channel blockers or ARBs are acceptable alternatives if beta-blockers or ACE inhibitors not tolerated 1, 4

Hyperlipidemia Control

• Aggressive LDL-lowering with statins as first-line 1, 3
• Sequential addition of ezetimibe, then PCSK9 inhibitors if goals not met 1
• Two-thirds of ACS patients have low HDL-cholesterol levels, though specific HDL-raising therapy recommendations are not established 7

Team-Based Care and Patient Education

Multidisciplinary Approach

• A team-based approach is mandatory to improve health outcomes, facilitate ASCVD risk factor modification, and improve health service utilization 1
• Team-based care reduces emergency department visits, unplanned hospitalizations, and readmission costs 1
• Communication through telehealth, patient education sessions, and specialty clinics are appropriate delivery methods 1

Ongoing Education

• Patients require ongoing individualized education on symptom management, lifestyle changes, and medication adherence 1
• Educational interventions improve patient knowledge and facilitate behavior change 1
• Use validated patient-reported measures (e.g., 7-item Seattle Angina Questionnaire) to quantify symptom burden and guide treatment decisions 1

Follow-Up and Monitoring

Periodic Assessment

• Regular cardiovascular healthcare visits to reassess risk status, lifestyle modifications, adherence to risk factor targets, and development of comorbidities 1
• Periodic resting ECG in asymptomatic diabetic patients for detection of conduction abnormalities, atrial fibrillation, and silent MI 1
• Risk stratification with stress imaging or exercise ECG for patients with new or worsening symptoms 1

High-Risk Features Requiring Invasive Evaluation

• Severe symptoms refractory to medical treatment 1
• High-risk clinical profile despite medical therapy 1
• New or worsening anginal symptoms despite optimal medical therapy 2
• High-risk features on noninvasive stress testing 2

Critical Pitfalls to Avoid

• Do not use ticagrelor or prasugrel as part of triple antithrombotic therapy with aspirin and oral anticoagulation 1
• Do not combine ACE inhibitors with ARBs 1
• Do not neglect proton pump inhibitor in patients on antiplatelet or anticoagulant therapy at high GI bleeding risk 1
• Do not underestimate conventional risk factors: 80-90% of CHD patients have at least one conventional risk factor (smoking, hypertension, diabetes, hyperlipidemia), and 95.7% of ACS patients with significant CAD have at least one 6, 7
• Do not delay smoking cessation counseling: smoking is present in 68% of patients with coronary disease and reduces age at CHD event by approximately 10 years 6, 7