What is the best approach to manage coronary artery disease in a patient over 45 with risk factors such as hypertension, hyperlipidemia, or diabetes mellitus?

Management of Coronary Artery Disease in Patients Over 45 with Risk Factors

For patients over 45 with coronary artery disease and risk factors including hypertension, hyperlipidemia, or diabetes, implement aggressive medical therapy targeting blood pressure to 120-130 mmHg systolic, LDL-cholesterol below 55 mg/dL with high-intensity statins plus ezetimibe if needed, aspirin 75-100 mg daily, ACE inhibitors (especially in diabetics), and SGLT2 inhibitors or GLP-1 agonists in diabetic patients, while reserving revascularization for refractory angina or high-risk anatomy. 1, 2

Risk Factor Control: The Foundation

Blood Pressure Management

• Target systolic blood pressure of 120-130 mmHg in general population, or 130-140 mmHg if over 65 years old. 1
• Start with beta-blockers if prior myocardial infarction (Class I recommendation), as they reduce morbidity and mortality. 1, 2
• Add ACE inhibitors or ARBs for additional cardiovascular protection, particularly in patients with hypertension, diabetes, heart failure, or post-MI. 1, 2
• Calcium channel blockers are acceptable alternatives if beta-blockers are not tolerated, and can be combined with beta-blockers for symptomatic angina. 1
• Avoid combining ACE inhibitors with ARBs as this combination is not recommended. 1, 2

Lipid Management: Aggressive LDL Lowering

• High-intensity statins are mandatory in all patients with coronary artery disease, targeting LDL-cholesterol reduction of ≥50% from baseline and achievement of LDL-C <55 mg/dL. 3, 2
• Add ezetimibe if maximum tolerated statin dose fails to achieve goals. 3, 2
• Consider PCSK9 inhibitors for very high-risk patients not reaching goals on statin plus ezetimibe. 2
• The ASCOT trial demonstrated that atorvastatin 10 mg daily reduced coronary events by 36% in hypertensive patients with risk factors (p=0.0005), with consistent benefit regardless of baseline LDL levels. 4

Diabetes Management

• Control HbA1c, blood pressure, and LDL-cholesterol to target values in diabetic patients with coronary artery disease (Class I recommendation). 1
• SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) are recommended in patients with diabetes and cardiovascular disease. 1, 3, 2
• GLP-1 receptor agonists (liraglutide or semaglutide) are recommended in diabetic patients with cardiovascular disease. 3, 2
• ACE inhibitors are specifically recommended in diabetic patients for event prevention (Class I recommendation). 1, 3
• Perform periodic resting ECG in asymptomatic diabetic patients to detect conduction abnormalities, atrial fibrillation, and silent myocardial infarction. 1, 2

Antiplatelet Therapy

• Aspirin 75-100 mg daily is the foundation for all patients with coronary artery disease unless contraindicated. 3, 2
• Clopidogrel 75 mg daily serves as an alternative in patients with aspirin intolerance. 3, 2
• Add a proton pump inhibitor when prescribing aspirin monotherapy, dual antiplatelet therapy, or oral anticoagulation in patients at high gastrointestinal bleeding risk. 2

Symptom Management

For Angina

• Beta-blockers and/or calcium channel blockers are recommended for symptomatic angina (Class I recommendation). 1
• Sublingual nitroglycerin for acute symptom relief, with symptoms resolving within 1-5 minutes. 2
• If angina persists despite optimal antianginal therapy, myocardial revascularization is recommended. 2

Risk Stratification and Follow-Up

Asymptomatic Patients

• Use the SCORE system for risk estimation in asymptomatic adults over 40 without evidence of cardiovascular disease, diabetes, chronic kidney disease, or familial hypercholesterolemia. 1, 3
• Do not perform coronary CTA or functional imaging in low-risk non-diabetic asymptomatic adults (Class III recommendation). 1, 3
• Do not use coronary CTA as a routine follow-up test for patients with established coronary artery disease (Class III recommendation). 3, 5

Symptomatic Patients

• Perform risk stratification using stress imaging preferably, or exercise ECG as an alternative for patients with new or worsening symptoms (Class I recommendation). 1, 3
• Refer patients with significant symptom worsening for urgent evaluation. 1, 3
• Invasive coronary angiography with FFR/iwFR is recommended for risk stratification in patients with severe coronary artery disease, particularly if symptoms are refractory to medical treatment or if they have a high-risk clinical profile. 1, 3

Lifestyle Modifications

• Quantitative assessment of tobacco use is mandatory at every visit, with aggressive cessation counseling. 2
• Regular exercise and weight loss are critical components of management. 6, 7
• A prospective study of 2,390 patients demonstrated that 12 weeks of intensive lifestyle intervention helped many patients achieve goal risk factor levels without medications. 7

Critical Pitfalls to Avoid

• Do not lower diastolic blood pressure below 60 mmHg in diabetic patients or those over 60 years, as this may worsen myocardial ischemia. 1
• Do not use ticagrelor or prasugrel as part of triple antithrombotic therapy with aspirin and oral anticoagulation. 2
• Do not neglect proton pump inhibitor in patients on antiplatelet or anticoagulant therapy at high gastrointestinal bleeding risk. 2
• Do not perform invasive coronary angiography solely for risk stratification without clinical indication (Class III recommendation). 1, 3
• Do not use carotid ultrasound intima-media thickness for cardiovascular risk assessment (Class III recommendation). 1, 3

Team-Based Approach

• A team-based approach is mandatory to improve health outcomes, facilitate risk factor modification, and improve health service utilization. 2
• Provide ongoing individualized patient education on symptom management, lifestyle changes, and medication adherence. 2
• Regular cardiovascular healthcare visits are recommended to reassess risk status, lifestyle modifications, adherence to risk factor targets, and development of comorbidities. 2