What are the typical medications used to treat a patient with coronary artery disease (CAD)?

Medications for Coronary Artery Disease

All patients with CAD require a foundational regimen of aspirin, high-intensity statin therapy, and beta-blockers (if prior MI or symptomatic), with ACE inhibitors added for those with heart failure, hypertension, diabetes, or LV dysfunction. 1

Core Medical Therapy for Event Prevention

Antiplatelet Therapy

• Aspirin 75-100 mg daily is mandatory for all CAD patients with prior MI or revascularization to prevent cardiovascular events 1, 2
• Clopidogrel 75 mg daily serves as an effective alternative if aspirin is not tolerated 1
• After PCI with stenting, dual antiplatelet therapy (aspirin 75-100 mg plus clopidogrel 75 mg daily) is required for 6 months, regardless of stent type, unless high bleeding risk warrants shorter duration (1-3 months) 1, 2

Lipid-Lowering Therapy

• High-intensity statin therapy is essential for all CAD patients, with atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily targeting LDL cholesterol <70 mg/dL 1, 3
• Atorvastatin 80 mg daily has demonstrated superior outcomes compared to lower doses in patients with clinically evident CHD 4
• If LDL goals are not achieved with maximum tolerated statin dose, add ezetimibe 1
• For very high-risk patients not at goal despite statin plus ezetimibe, add a PCSK9 inhibitor 1

ACE Inhibitors/ARBs

• ACE inhibitors are recommended for all CAD patients with heart failure, hypertension, diabetes, or LV dysfunction, reducing cardiovascular death, MI, and stroke by approximately 20% 1, 3, 5
• Target doses include ramipril 10 mg daily or perindopril 8 mg daily 3
• ARBs serve as effective alternatives if ACE inhibitors cause intolerable side effects such as cough 1, 5

Beta-Blockers

• Beta-blockers are essential for CAD patients with prior MI (Class I, Level A evidence), reducing both morbidity and mortality 1
• For symptomatic angina without prior MI, beta-blockers remain first-line therapy for symptom control and heart rate management, targeting resting heart rate of 55-60 bpm 1, 3
• Diabetes is not a contraindication; diabetic patients benefit equally or more than non-diabetic patients 3

Antianginal Therapy for Symptom Control

First-Line Agents

• Short-acting nitrates (sublingual nitroglycerin or spray) for immediate relief of angina 1, 2
• Beta-blockers and/or calcium channel blockers (CCBs) as initial treatment to control heart rate and symptoms 1, 2
• Long-acting dihydropyridine CCBs (amlodipine, long-acting nifedipine) are preferred when beta-blockers are contraindicated 1, 3

Second-Line Agents

• Long-acting nitrates or ranolazine should be added when symptoms remain inadequately controlled on beta-blockers and/or CCBs 1, 2
• Combination therapy with beta-blockers plus long-acting CCBs or long-acting nitrates is appropriate for refractory symptoms 1

Critical Contraindications

• Never use nitrates in patients with hypertrophic obstructive cardiomyopathy or those taking phosphodiesterase inhibitors 1
• Never use immediate-release or short-acting dihydropyridine CCBs in CAD, as they increase adverse cardiac events 3
• Beta-blockers are absolutely contraindicated in aortic regurgitation, as they worsen regurgitant volume and LV overload 3

Special Populations

Patients with Atrial Fibrillation

• Direct oral anticoagulant (DOAC) is preferred over warfarin in eligible patients: apixaban 5 mg twice daily, dabigatran 150 mg twice daily, edoxaban 60 mg daily, or rivaroxaban 20 mg daily 1, 2
• Long-term OAC alone (without aspirin) is recommended for chronic CAD with AF and CHA₂DS₂-VASc score ≥2 in males or ≥3 in females 1, 2
• After PCI in AF patients, use triple therapy (DOAC + aspirin + clopidogrel) for 1-6 months, then DOAC plus single antiplatelet agent 1
• Never use ticagrelor or prasugrel as part of triple antithrombotic therapy 1

Patients with Heart Failure

• Mineralocorticoid receptor antagonist (MRA) is recommended for symptomatic patients despite adequate beta-blocker and ACE inhibitor therapy 1, 5
• Diuretic therapy for patients with signs of pulmonary or systemic congestion 1, 5
• For persistent symptoms despite optimal medical therapy, consider angiotensin receptor-neprilysin inhibitor 1, 5

Gastrointestinal Protection

• Proton pump inhibitor is recommended for patients at high risk of GI bleeding receiving aspirin monotherapy, DAPT, or OAC monotherapy 1, 2

Additional Preventive Measures

• Annual influenza vaccination is recommended, especially in elderly CAD patients 1

Monitoring and Optimization

• Review patient response to medical therapies at 2-4 weeks after drug initiation 1
• Optimize beta-blocker dosing before adding additional antianginal agents 3, 5
• When initiating ACE inhibitors, monitor renal function and potassium levels, particularly in patients with pre-existing renal impairment 5
• When adding MRAs, closely monitor potassium levels, especially when combined with ACE inhibitors or ARBs 5