What is the best management approach for a patient with cardiovascular disease?

Management of Cardiovascular Disease

For patients with established cardiovascular disease, initiate comprehensive risk reduction with aspirin 75-100 mg daily, high-intensity statin therapy targeting >50% LDL-C reduction, ACE inhibitor or ARB, and structured cardiac rehabilitation, while addressing all modifiable risk factors through both pharmacological and lifestyle interventions. 1

Immediate Assessment and Risk Stratification

Clinical Evaluation

• Measure vital signs including blood pressure in both arms to detect subclavian stenosis or aortic coarctation 2
• Perform pulse palpation at rest to determine heart rate and detect arrhythmias, particularly atrial fibrillation 2
• Conduct cardiac auscultation to identify heart murmurs, extra heart sounds, and arrhythmias 2
• Examine for signs of heart failure: pulmonary rales, peripheral edema, jugular venous distention (JVD reflects right atrial pressure with 81% sensitivity and 80% specificity for elevated pulmonary capillary wedge pressure ≥18 mmHg), and hepatomegaly 2, 3
• Assess peripheral pulses for absence, reduction, or asymmetry; examine for cold extremities or ischemic skin lesions 2
• Auscultate for carotid, abdominal, and femoral bruits 2

Diagnostic Testing

• Obtain 12-lead ECG for all patients with suspected or confirmed CVD 2
• Order basic laboratory tests: complete blood count, fasting plasma glucose, lipid profile, renal function, liver function, and thyroid function 2
• Perform chest X-ray to assess for cardiomegaly or pulmonary congestion 2
• Measure natriuretic peptides (BNP or NT-proBNP) when heart failure diagnosis is uncertain 1, 2
• Obtain echocardiography as the cornerstone diagnostic test for structural heart disease, valvular abnormalities, or heart failure 2

Antithrombotic Therapy

Aspirin Monotherapy

• Prescribe aspirin 75-100 mg daily lifelong for patients with prior myocardial infarction or revascularization 1
• Use aspirin 75-100 mg daily lifelong for patients without prior MI or revascularization but with evidence of significant obstructive coronary artery disease 1
• After coronary artery bypass grafting (CABG), prescribe aspirin 75-100 mg daily lifelong 1

Alternative Antiplatelet Therapy

• Consider clopidogrel 75 mg daily as a safe and effective alternative to aspirin monotherapy in patients with prior MI or PCI 1, 4
• In acute coronary syndrome without ST-elevation, clopidogrel (300 mg loading dose followed by 75 mg daily) plus aspirin reduces cardiovascular death, MI, or stroke by 20% compared to aspirin alone 4

Dual Antiplatelet Therapy

• Continue dual antiplatelet therapy for the appropriate duration post-PCI or acute coronary syndrome before transitioning to monotherapy 1

Enhanced Antithrombotic Strategies

• In patients with stable coronary disease and high ischemic risk, consider adding rivaroxaban 2.5 mg twice daily to aspirin for reduction of cardiovascular ischemic events, particularly in those with diabetes or peripheral artery disease 1

Lipid Management

Statin Therapy

• Initiate high-intensity statin therapy to achieve LDL-C goal and >50% reduction from baseline 1, 2
• In patients with known atherosclerotic CVD or established kidney disease and type 2 diabetes, statins reduce cardiovascular events 1
• Continue statin therapy even during pregnancy in women with CVD after discussing risks and benefits 1

Combination Lipid-Lowering Therapy

• Add ezetimibe if target LDL-C levels are not achieved with maximally tolerated statins 2
• Add PCSK9 inhibitors for patients still not at goal after statin plus ezetimibe therapy 2

Blood Pressure Management

• Use ACE inhibitor or ARB therapy in patients with known atherosclerotic CVD, particularly coronary artery disease, to reduce cardiovascular events 1
• Follow a stepped approach based on cardiovascular risk and comorbidities for hypertension management 2
• Target blood pressure control is essential as hypertension represents one of the most significant modifiable risk factors 5, 6

Heart Failure Management

Pharmacological Therapy

• In patients with type 2 diabetes and established heart failure with reduced ejection fraction (HFrEF), prescribe an SGLT2 inhibitor with proven benefit to reduce risk of worsening heart failure and cardiovascular death 1
• In patients with type 2 diabetes and established atherosclerotic CVD or kidney disease, prescribe an SGLT2 inhibitor with proven cardiovascular outcomes benefit to reduce major adverse cardiovascular events 1
• Prescribe a beta-blocker with proven cardiovascular outcomes benefit for patients with HFrEF, unless contraindicated 1
• Continue metformin for glucose lowering in patients with type 2 diabetes and stable heart failure if eGFR remains >30 mL/min/1.73 m², but avoid in unstable or hospitalized patients 1
• Use ACE inhibitors or ARBs to reduce progression from asymptomatic to symptomatic heart failure 2

Post-Myocardial Infarction

• Continue beta-blockers for 3 years after myocardial infarction 1

Antianginal Therapy

• Use short-acting nitrates for immediate relief of angina symptoms 2
• Prescribe beta-blockers and/or calcium channel blockers for long-term angina control 2
• Consider ivabradine as add-on antianginal therapy in patients with left ventricular systolic dysfunction (LVEF <40%) and inadequate symptom control, or as part of initial treatment in properly selected patients 1
• Do not use ivabradine as add-on therapy in patients with chronic coronary syndrome, LVEF >40%, and no clinical heart failure 1
• Avoid combining ivabradine with non-dihydropyridine calcium channel blockers or other strong CYP3A4 inhibitors 1

Lifestyle Modifications and Cardiac Rehabilitation

Exercise Prescription

• Prescribe aerobic physical activity of at least 150-300 minutes per week of moderate intensity or 75-150 minutes per week of vigorous intensity, with reduction in sedentary time 1, 2
• Refer all eligible patients to comprehensive cardiovascular rehabilitation programs either before hospital discharge or during the first outpatient visit 1
• Begin aerobic exercise training 1-2 weeks after discharge in patients treated with PCI or CABG 1
• Consider mild-to-moderate resistance training starting 2-4 weeks after aerobic training 1
• Target heart rate range of 60-75% of maximum age-predicted heart rate for unsupervised exercise, or 70-85% for supervised training 1

Dietary Modifications

• Recommend varied foods with energy intake adjusted to maintain ideal body weight 1
• Encourage consumption of fruits, vegetables, whole grain cereals and bread, low-fat dairy products, fish, and lean meat 1
• Emphasize oily fish and omega-3 fatty acids for their protective properties 1
• Limit total fat intake to no more than 30% of energy intake, with saturated fats not exceeding one-third of total fat intake 1
• Restrict cholesterol intake to less than 300 mg/day 1
• Replace saturated fat with complex carbohydrates, monounsaturated fats, and polyunsaturated fats from vegetables and marine sources 1

Smoking Cessation

• Provide smoking cessation counseling with consideration of e-cigarettes as a potential aid 2
• Emphasize that tobacco use is a critical modifiable risk factor 5, 6

Patient Education

• Educate patients about appropriate cholesterol management, blood pressure control, smoking cessation, and lifestyle management 1
• Counsel patients who have undergone PCI or CABG that revascularization does not eliminate the need for lifestyle changes 1
• Use multidisciplinary behavioral approaches to help patients achieve healthy lifestyles in addition to pharmacological management 1

Special Populations

Diabetes Management

• Screen for peripheral arterial disease with ankle-brachial index in patients aged ≥65 years or with diabetes for >10 years 2
• Do not perform routine screening for coronary artery disease in asymptomatic patients with diabetes, as it does not improve outcomes when atherosclerotic CVD risk factors are treated 1
• Investigate for coronary artery disease in the presence of atypical cardiac symptoms (unexplained dyspnea, chest discomfort), signs or symptoms of associated vascular disease (carotid bruits, TIA, stroke, claudication, peripheral arterial disease), or ECG abnormalities (Q waves) 1

Pregnant Women with CVD

• Risk-stratify and counsel women with CVD who are contemplating pregnancy or who are pregnant regarding risks of adverse maternal, obstetric, and fetal outcomes 1
• Provide care from a multidisciplinary cardio-obstetric team beginning before conception and continuing throughout pregnancy, delivery, and postpartum 1

Cancer Patients

• Utilize a multidisciplinary team including cardiology and oncology expertise to improve long-term CVD outcomes in patients with CVD and cancer 1
• Resume CVD medications as soon as possible if stopped for cancer treatment 1

Older Adults with Multimorbidity

• Adopt a patient-centered care approach rather than disease-specific guidelines, as multiple disease-specific guidelines may lead to contradictory recommendations 1
• Coordinate care through a multidisciplinary team including cardiologists, other specialists, nurses, pharmacists, social workers, family, and caregivers 1
• Prioritize goals of preserving quality of life, maintaining functional capacity and independence, controlling symptoms, and reducing treatment burden and hospitalizations 1

Vaccination

• Administer pneumococcal vaccine to patients 65 years of age and older and high-risk patients with CVD 1
• Provide influenza vaccine annually 1

Advanced Diagnostic Testing for Risk Stratification

Non-Invasive Testing

• Consider stress testing for patients with suspected coronary artery disease 2
• Use coronary CT angiography for patients with intermediate pretest probability of coronary artery disease 2
• Identify high-risk patients using stress imaging: area of ischemia ≥10% of LV myocardium on SPECT or PET, ≥3 of 16 segments with stress-induced hypokinesia or akinesia on stress echo, or ≥2 of 16 segments with stress perfusion defects on stress CMR 1
• Identify high-risk anatomy on CCTA: left main disease with ≥50% stenosis, three-vessel disease with ≥70% stenosis, two-vessel disease with ≥70% stenosis including proximal LAD, or one-vessel disease of proximal LAD with ≥70% stenosis and FFR-CT ≤0.8 1

Invasive Testing

• Perform invasive coronary angiography with availability of invasive functional assessments to confirm or exclude obstructive CAD or ANOCA/INOCA in patients with uncertain diagnosis on non-invasive testing 1, 2

Common Pitfalls to Avoid

• Do not confuse jugular venous distention with carotid pulsations—jugular venous pulsations are obliterated by light pressure at the base of the neck, while carotid pulsations persist 3
• Never administer diuretics to patients with right ventricular infarction presenting with JVD and hypotension, as they require volume loading instead 3
• In patients with suspected cardiac tamponade, do not delay transfer for extensive diagnostic workup—rapid transport to a surgical facility is mandatory 3
• Do not assume revascularization eliminates the need for aggressive risk factor modification and lifestyle changes 1
• Avoid applying multiple disease-specific guidelines simultaneously in patients with multimorbidity without integration, as this may lead to contradictory or harmful recommendations 1