What are the treatment modalities for an adult patient with coronary artery disease and no significant comorbid conditions?

Treatment Modalities for Coronary Artery Disease

All adults with coronary artery disease require a combination of antiplatelet therapy, high-intensity statin therapy, lifestyle modification including cardiac rehabilitation, and selective use of additional medications based on comorbidities, with revascularization reserved for specific high-risk anatomic patterns or refractory symptoms. 1, 2

Mandatory Pharmacological Therapy for All Patients

Antiplatelet Therapy

• Aspirin 75-100 mg daily is the foundation of treatment for all patients with established coronary disease, particularly those with prior myocardial infarction or revascularization 1, 2
• Clopidogrel 75 mg daily serves as an alternative in aspirin-intolerant patients 2
• Dual antiplatelet therapy (aspirin plus clopidogrel) is required for 6 months after coronary stent implantation, though shorter durations (1-3 months) are safe when bleeding risk is high and ischemic risk is low-to-moderate 1

Lipid-Lowering Therapy

• Statins are mandatory in all patients with coronary disease to reduce major vascular events and mortality 1, 2
• Target LDL cholesterol <70 mg/dL for very high-risk patients 3, 4
• Add ezetimibe if LDL goals are not achieved with maximum tolerated statin dose 1, 2
• For very high-risk patients not reaching goals on statin plus ezetimibe, add a PCSK9 inhibitor 1, 2
• Novel agents like inclisiran and bempedoic acid may be used in select populations, though clinical outcomes data are limited 1

ACE Inhibitors or ARBs

• Recommended particularly when hypertension, diabetes, heart failure, or left ventricular dysfunction coexist 1, 2
• ACE inhibitors reduce morbidity and mortality in patients with symptomatic heart failure or asymptomatic LV dysfunction following MI 1
• ARBs serve as alternatives in patients who do not tolerate ACE inhibition 1

Symptom Management

First-Line Antianginal Therapy

• Either a beta-blocker or calcium channel blocker is recommended as first-line therapy for symptom control 1, 2
• Beta-blockers are essential for both relieving angina and reducing morbidity/mortality in heart failure 1, 2
• Long-term beta-blocker therapy is NOT recommended to improve outcomes in patients without myocardial infarction in the past year, left ventricular ejection fraction ≤50%, or another primary indication 1
• Calcium channel blockers are appropriate when beta-blockers are contraindicated or poorly tolerated 1, 2

Additional Antianginal Options

• Short-acting nitrates (sublingual nitroglycerin) provide immediate relief for effort angina and should be prescribed to all patients 2
• Long-acting nitrates can be added as second-line therapy 2
• Ranolazine serves as adjunctive therapy when beta-blockers are ineffective 5

Essential Lifestyle Modifications

Cardiac Rehabilitation and Exercise

• Exercise-based cardiac rehabilitation is fundamental and significantly reduces cardiovascular mortality and morbidity while improving risk factor control 2
• All patients should participate in habitual physical activity, including activities to reduce sitting time and increase aerobic and resistance exercise 1

Other Lifestyle Interventions

• Healthy dietary habits are recommended for all patients 1, 2
• Tobacco cessation is fundamental for reducing cardiovascular events 2, 5
• Weight management to achieve proper body weight 2, 6
• Annual influenza vaccination, especially in elderly patients, to reduce mortality risk 2

Emerging Therapies for Select Patients

Diabetes Medications with Cardiovascular Benefits

• SGLT2 inhibitors and GLP-1 receptor agonists are recommended for select groups of patients with coronary disease, including groups without diabetes 1

Supplements NOT Recommended

• Nonprescription or dietary supplements, including fish oil, omega-3 fatty acids, or vitamins, are NOT recommended given the lack of benefit in reducing cardiovascular events 1

Revascularization Strategies

Indications for Coronary Artery Bypass Grafting

• Surgical revascularization is indicated to improve survival in patients with significant left main disease (≥50% stenosis) 1
• CABG is recommended for significant proximal left anterior descending artery stenosis, multivessel disease, or disabling angina 7
• Surgical revascularization may be reasonable to improve survival in patients with stable ischemic heart disease, normal left ventricular ejection fraction, and triple-vessel CAD 1
• Radial artery as a surgical conduit is preferred versus saphenous vein to bypass the second most important target vessel after the left anterior descending artery, providing superior patency, reduced adverse cardiac events, and improved survival 1

Indications for Percutaneous Coronary Intervention

• PCI is a reasonable option to improve survival in selected patients with low-to-medium anatomic complexity and left main disease equally suitable for surgical or percutaneous revascularization 1
• PCI may be considered for single vessel disease or selected patients with objective evidence of ischemia 2, 7
• Radial artery access is recommended in patients undergoing PCI to reduce bleeding and vascular complications compared with femoral approach, with additional mortality benefit in acute coronary syndromes 1
• A survival benefit with percutaneous revascularization in stable disease is uncertain 1

When Revascularization is NOT Indicated

• Routine preoperative coronary revascularization is NOT recommended in patients with non-left main CAD to reduce perioperative cardiovascular events 1
• Invasive coronary angiography is NOT recommended solely for risk stratification in asymptomatic patients 1, 3
• Coronary angiography is NOT performed to assess risk in asymptomatic patients with no evidence of ischemia on noninvasive testing 3

High-Risk Features Requiring Invasive Assessment

• Myocardial revascularization is recommended when angina persists despite treatment with antianginal drugs 1
• High-risk patients with severe symptoms refractory to medical treatment require invasive coronary angiography with FFR/iFR guidance 1, 2
• Risk stratification with ICA (with FFR when necessary) is recommended in patients with severe CAD, particularly if symptoms are refractory to medical treatment or high-risk clinical profile 1

Special Populations and Comorbidities

Heart Failure with Coronary Disease

• Diuretic therapy for symptomatic patients with signs of pulmonary or systemic congestion 1, 2
• Beta-blockers are essential components reducing both angina and mortality 1, 2
• Mineralocorticoid receptor antagonists in patients who remain symptomatic despite adequate treatment with ACE inhibitor and beta-blocker 1
• CRT is recommended for symptomatic patients in sinus rhythm with QRS duration ≥150 ms and LBBB morphology, with LVEF <35% despite optimal medical therapy 1
• Implantable cardioverter-defibrillator is recommended in patients with symptomatic heart failure and LVEF <35% to reduce sudden death and all-cause mortality 1

Atrial Fibrillation with Coronary Disease

• When oral anticoagulation is initiated in a patient with AF eligible for a NOAC, a NOAC is recommended in preference to a VKA 1
• In patients eligible for a NOAC, it is recommended that a NOAC (apixaban 5 mg b.i.d., dabigatran 150 mg b.i.d., edoxaban 60 mg o.d., or rivaroxaban 20 mg o.d.) is used in preference to a VKA in combination with antiplatelet therapy 1
• Ticagrelor or prasugrel are NOT recommended as part of triple antithrombotic therapy with aspirin and an OAC 1

Microvascular and Vasospastic Angina

• For microvascular angina: first-line beta-blocker, second-line add long-acting nitrate 2
• For vasospastic angina: first-line calcium channel blocker, second-line add long-acting nitrate 2

Hypertension Management

• Office BP should be controlled to systolic BP 120-130 mmHg in general and 130-140 mmHg in older patients (aged >65 years) 1
• In hypertensive patients with recent MI, beta-blockers and RAS blockers are recommended 1
• In patients with symptomatic angina, beta-blockers and/or calcium channel blockers are recommended 1

Gastrointestinal Protection

• Concomitant use of a proton pump inhibitor is recommended in patients receiving aspirin monotherapy, DAPT, or OAC monotherapy who are at high risk of gastrointestinal bleeding 1

Monitoring and Follow-Up

• Periodic visits to a cardiovascular healthcare professional are recommended to reassess risk status, evaluate lifestyle modifications, adherence to cardiovascular risk factor targets, and development of comorbidities 1
• Review patient response to medical therapies at 2-4 weeks after drug initiation 2
• Risk stratification is recommended for patients with new or worsening symptom levels, preferably using stress imaging or exercise stress ECG 1

Critical Pitfalls to Avoid

• Do NOT combine ACE inhibitors with ARBs—this combination is not recommended 1
• Do NOT routinely use coronary CTA as a follow-up test for patients with established CAD 1
• Do NOT perform stress testing in severe valvular heart disease to detect CAD due to low diagnostic yield and potential risks 1
• Do NOT use ticagrelor or prasugrel in triple antithrombotic therapy 1