What is the primary care physician (PCP) treatment for an adult patient with coronary artery disease (CAD) and no significant comorbidities or allergies?

Primary Care Treatment of Coronary Artery Disease

All adult patients with CAD require a foundational regimen of aspirin, beta-blocker, high-intensity statin, and ACE inhibitor to prevent myocardial infarction and death, combined with lifestyle modifications and symptom management as needed. 1

Core Pharmacotherapy to Prevent MI and Death

Antiplatelet Therapy

• Aspirin 75-325 mg daily is mandatory for all patients with CAD unless absolutely contraindicated 1, 2
• Dosages of 75-150 mg daily and 160-325 mg daily show similar reductions in vascular events, but doses below 75 mg are less effective 1
• Clopidogrel 75 mg daily is reserved exclusively for patients who cannot tolerate aspirin 1, 2
• Never use dipyridamole as it can enhance exercise-induced myocardial ischemia in stable angina 1, 2

Beta-Blockers

• Beta-blockers should be strongly considered as initial therapy for all patients with chronic stable angina 1, 2
• They reduce cardiac events and mortality, particularly in post-MI patients (Level A evidence) and those without prior MI (Level B evidence) 1
• Diabetes is NOT a contraindication—diabetic patients benefit as much or more than non-diabetics 1, 2
• Preferred agents: metoprolol 50-100 mg twice daily or atenolol 50-100 mg daily 2
• Beta-blockers are underused in practice despite strong evidence 1

Lipid-Lowering Therapy

• High-intensity statin therapy is essential with atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily 2
• Target LDL cholesterol <70 mg/dL in all patients with established CAD 1, 3, 2
• Statins reduce adverse ischemic events even with mild-to-moderate LDL elevations 1
• Add ezetimibe if LDL goals are not achieved with maximum tolerated statin dose 2
• Monitor lipid profile at 4-6 weeks after initiating therapy 2

ACE Inhibitors

• ACE inhibitors reduce cardiovascular death, MI, and stroke in patients with vascular disease (Level A evidence) 1
• Ramipril 10 mg daily or perindopril 8 mg daily are evidence-based choices 1, 2
• The benefit extends beyond blood pressure reduction and represents a vasculoprotective effect 1
• Particularly beneficial in patients with diabetes and CAD 1, 2
• Evidence for angiotensin-receptor blockers in chronic stable angina is insufficient 1

Symptom Management (Antianginal Therapy)

Immediate Relief

• Sublingual nitroglycerin 0.4 mg for acute angina episodes (Level B evidence) 1, 2
• Instruct patients to take up to 3 doses at 5-minute intervals 2

Long-Term Symptom Control

• Optimize beta-blocker dose before adding additional antianginal agents 2
• If beta-blockers are contraindicated or cause unacceptable side effects, use long-acting calcium antagonists or long-acting nitrates (Level B evidence) 1
• If beta-blockers alone are unsuccessful, add long-acting calcium antagonists or long-acting nitrates in combination (Level B evidence) 1
• Long-acting calcium antagonists are often preferable to long-acting nitrates for maintenance therapy due to sustained 24-hour effects 1
• Never use immediate-release or short-acting dihydropyridine calcium antagonists—they increase adverse cardiac events 1, 2
• Nitrates have not been shown to reduce mortality 1

Essential Lifestyle Modifications

Physicians must always recommend lifestyle modifications alongside pharmacologic therapy 1

• Smoking cessation 1
• Appropriate diet (low-fat dietary pattern) 1
• Regular physical exercise 1
• Weight management 3
• Cardiovascular risk factor control 3

Blood Pressure Management

• Target blood pressure <130/80 mmHg in patients with diabetes and CAD 2
• Beta-blockers serve dual purposes for both angina and hypertension control 2
• Monitor blood pressure every 2-4 weeks until target is reached 2

Monitoring and Follow-Up

• Evaluate angina symptoms at each visit and adjust anti-ischemic medication as needed 2
• Assess adherence to treatment at each visit—this is crucial for therapeutic success 2
• Monitor renal function and electrolytes periodically with ACE inhibitor therapy 2
• Consider stress testing to evaluate severity of CAD and effectiveness of anti-ischemic treatment 2
• Coronary angiography should be undertaken if symptoms are not satisfactorily controlled by medical means, with a view to revascularization 2

Treatment Algorithm Priority

The treatment hierarchy prioritizes therapies that prevent death over those that merely reduce symptoms 1. When two therapeutic strategies are equally effective in alleviating symptoms, recommend the therapy with an advantage in preventing death 1.

First Priority: Prevent MI and Death

1. Aspirin (or clopidogrel if aspirin contraindicated)
2. Beta-blocker
3. High-intensity statin (target LDL <70 mg/dL)
4. ACE inhibitor

Second Priority: Reduce Symptoms

1. Sublingual nitroglycerin for acute episodes
2. Optimize beta-blocker dose
3. Add long-acting calcium antagonist or long-acting nitrate if needed

Critical Pitfalls to Avoid

• Do not withhold beta-blockers in diabetic patients—diabetes is not a contraindication and these patients benefit significantly 1, 2
• Do not use dipyridamole as an antiplatelet agent 1, 2
• Do not use immediate-release or short-acting dihydropyridine calcium antagonists 1, 2
• Ensure proton pump inhibitor therapy if the patient is at high risk of gastrointestinal bleeding with aspirin 2
• Do not perform coronary angiography solely for risk stratification in asymptomatic patients with no evidence of ischemia on noninvasive testing 3

Special Considerations for Asymptomatic Patients with Known CAD

Even if asymptomatic, patients with documented CAD require:

• Aspirin (Level A evidence if prior MI, Level B without prior MI) 1
• Beta-blocker if prior MI (Level B evidence) 1
• Statin therapy (Level A evidence) 1, 3
• ACE inhibitor if diabetes, systolic dysfunction, or both (Level A evidence) 1, 3