What is the recommended treatment plan for a patient with coronary artery disease?

Recommended Treatment Plan for Coronary Artery Disease

All patients with coronary artery disease require a combination of lifestyle modifications, antiplatelet therapy (aspirin 75-100 mg daily), statin therapy, and symptom control with beta-blockers and/or calcium channel blockers, with revascularization reserved for high-risk patients with refractory symptoms. 1, 2, 3

Immediate Pharmacological Foundation (Start All Simultaneously)

Antiplatelet Therapy:

• Aspirin 75-100 mg daily is mandatory for all CAD patients, particularly those with prior myocardial infarction or revascularization 1, 3
• Clopidogrel 75 mg daily serves as the alternative if aspirin is contraindicated or not tolerated 1, 3
• After coronary stent placement, dual antiplatelet therapy (aspirin plus clopidogrel) must continue for 6 months regardless of stent type, unless life-threatening bleeding risk necessitates shorter duration (1-3 months) 1, 3

Lipid Management:

• Statins are required for all CAD patients to reduce major vascular events and mortality 1, 2, 3
• Add ezetimibe when LDL goals are not achieved despite maximum tolerated statin dose 1, 2, 3
• For very high-risk patients failing statin plus ezetimibe combination, add a PCSK9 inhibitor 3

Symptom Control:

• Prescribe short-acting nitrates (sublingual nitroglycerin) to all patients for immediate relief of effort angina 1, 2, 3
• Beta-blockers are first-line for controlling heart rate and relieving angina symptoms 1, 2, 3
• Calcium channel blockers serve as appropriate alternatives when beta-blockers are contraindicated or poorly tolerated 2, 3

Essential Lifestyle Interventions (Non-Negotiable)

Exercise-based cardiac rehabilitation is fundamental and significantly reduces cardiovascular mortality and morbidity while improving risk factor control 2, 3

Additional lifestyle measures:

• Annual influenza vaccination, especially for elderly patients, reduces mortality risk 1, 2, 3
• Cognitive behavioral interventions help achieve and maintain healthy lifestyle changes 1, 2
• Psychological interventions address depression symptoms, which are common and impact outcomes 1, 3
• Involvement of multidisciplinary healthcare professionals (cardiologists, primary care physicians, nurses, dieticians, physiotherapists, psychologists, pharmacists) improves outcomes 1, 2

Blood Pressure Management

• ACE inhibitors or ARBs are recommended, particularly when hypertension, diabetes, heart failure, or left ventricular dysfunction coexist 3
• Beta-blockers provide dual benefit for both angina relief and blood pressure control 1, 3

Special Populations and Scenarios

Post-PCI patients:

• Peri-procedural aspirin and clopidogrel are required 1
• Continue dual antiplatelet therapy for 6 months after stenting 1, 3
• Avoid ticagrelor or prasugrel as part of triple antithrombotic therapy with aspirin and oral anticoagulation 1

Patients with atrial fibrillation:

• Long-term oral anticoagulation (NOAC preferred over VKA) is required for CHA₂DS₂-VASc score >2 in males or >3 in females 1
• When eligible for NOAC, use apixaban 5 mg twice daily, dabigatran 150 mg twice daily, edoxaban 60 mg once daily, or rivaroxaban 20 mg once daily in preference to VKA when combined with antiplatelet therapy 1

Post-CABG patients:

• Start aspirin within 6 hours after surgery to reduce saphenous vein graft closure, using dosing regimens of 100-325 mg daily for 1 year 1

Gastrointestinal Protection

• Proton pump inhibitors are required for patients receiving aspirin monotherapy, dual antiplatelet therapy, or oral anticoagulation monotherapy who have high gastrointestinal bleeding risk 1, 3

Critical Contraindications and Pitfalls

Avoid these dangerous combinations:

• Never use nitrates in patients with hypertrophic obstructive cardiomyopathy 1, 2, 3
• Never combine nitrates with phosphodiesterase inhibitors 1, 2, 3
• Do not combine ivabradine with non-dihydropyridine calcium channel blockers due to drug interactions 2

Monitoring and Follow-Up Protocol

• Review patient response to medical therapies at 2-4 weeks after drug initiation 1, 3
• Clinical follow-up at least annually to assess symptoms, functional status, adherence to lifestyle and medical interventions, and monitor for complications 3
• Patient education about the disease, risk factors, and treatment strategy is essential for long-term adherence 1, 2, 3

Revascularization Decision Algorithm

Medical therapy must be optimized before considering revascularization, except in specific high-risk scenarios 2, 3

Indications for invasive coronary angiography with FFR/iFR guidance:

• High-risk patients with severe symptoms refractory to medical treatment 3
• Non-invasive risk stratification indicates high event risk and revascularization is considered for prognosis improvement 1

CABG is recommended for:

• Left main stenosis 3
• Significant proximal left anterior descending artery stenosis 3
• Multivessel disease 3
• Disabling angina despite optimal medical therapy 3

PCI is appropriate for:

• Single vessel disease with objective evidence of ischemia 3
• Selected patients based on SYNTAX score, comorbidities, and patient preference 3

Do not perform invasive coronary angiography solely for risk stratification 1, 2