What are the recommended lifestyle modifications and pharmacological interventions to decrease the risk of blocked coronary arteries in an adult patient with moderate to high risk of cardiovascular disease, possibly with comorbidities such as hypertension, hyperlipidemia, or diabetes?

How to Decrease the Risk of Blocked Coronary Arteries

Complete smoking cessation, statin therapy to achieve LDL-C <70 mg/dL, blood pressure control to <130/80 mmHg, daily aspirin 75-162 mg, and at least 30-60 minutes of moderate aerobic exercise most days of the week form the cornerstone of preventing coronary artery blockages. 1, 2, 3

Smoking Cessation (Highest Priority)

• Ask about tobacco use at every single office visit and advise every tobacco user to quit at every encounter. 1, 2
• Provide counseling, develop a structured quit plan, and offer pharmacotherapy including nicotine replacement therapy and bupropion. 1, 2
• Arrange systematic follow-up to support cessation efforts. 1
• Eliminate all exposure to secondhand smoke at home, work, and public places. 1, 2

This is non-negotiable—smoking cessation provides the single greatest modifiable risk reduction for coronary disease.

Lipid Management (Aggressive LDL Lowering)

Start statin therapy immediately in all patients at moderate-to-high cardiovascular risk, regardless of baseline LDL-C level. 1, 2, 3

Statin Therapy Algorithm:

• Initiate high-dose statin therapy (atorvastatin 40-80 mg daily) to achieve LDL-C <70 mg/dL (<1.4 mmol/L) AND at least 30% reduction from baseline. 1, 2, 4
• For very high-risk patients (established cardiovascular disease, diabetes with multiple risk factors), target LDL-C <55 mg/dL with at least 50% reduction. 2, 3
• If target not achieved with maximum tolerated statin dose, add ezetimibe 10 mg daily. 2, 3
• If still not at goal on statin plus ezetimibe, add a PCSK9 inhibitor (evolocumab or alirocumab). 2, 3

Dietary Modifications:

• Reduce saturated fat to <7% of total calories. 1
• Limit cholesterol intake to <200 mg/day. 1
• Eliminate trans fats to <1% of energy intake. 2
• Increase dietary fiber to 14 g per 1,000 calories consumed. 2
• For triglycerides ≥200 mg/dL, target non-HDL-C <130 mg/dL; add fibrate therapy if triglycerides ≥500 mg/dL to prevent pancreatitis. 1

Blood Pressure Control

Target systolic blood pressure 120-129 mmHg in most adults to maximize cardiovascular risk reduction. 2

Pharmacotherapy Algorithm:

• Initiate combination therapy with two medications as a single-pill combination: ACE inhibitor or ARB PLUS either a dihydropyridine calcium channel blocker OR a thiazide/thiazide-like diuretic. 2
• For patients with diabetes or chronic kidney disease (eGFR >30 mL/min/1.73m²), target systolic BP 120-129 mmHg. 2
• If BP not controlled with two drugs, escalate to triple therapy: ACE inhibitor + calcium channel blocker + thiazide diuretic. 2
• Use ACE inhibitors or ARBs indefinitely in all patients with left ventricular ejection fraction <40%, hypertension, diabetes, or chronic kidney disease. 2, 3

Lifestyle Modifications:

• Limit sodium intake to <2,300 mg/day. 2
• Adopt a DASH or Mediterranean-style diet with 8-10 servings of fruits and vegetables daily and 2-3 servings of low-fat dairy. 2
• Maintain weight control and increase physical activity. 1

Physical Activity and Exercise

Engage in 30-60 minutes of moderate-intensity aerobic activity (brisk walking) at least 5 days per week, preferably 7 days. 1, 2

• Perform risk assessment with physical activity history and/or exercise stress test before starting an exercise program to guide prescription and identify high-risk patients. 1
• Add resistance training at least 2 days per week. 1, 2
• Increase daily lifestyle activities (walking breaks at work, gardening, household work) to move out of the least active, highest-risk category. 1
• High-risk patients (recent acute coronary syndrome, revascularization, heart failure) should participate in medically supervised cardiac rehabilitation programs. 1, 2

Weight Management

Target BMI 18.5-24.9 kg/m² and waist circumference <35 inches (89 cm) in women, <40 inches (102 cm) in men. 1, 2

• Assess BMI and waist circumference at every visit. 1, 2
• If waist circumference exceeds these thresholds, intensify therapeutic lifestyle interventions focused on weight management. 1, 2
• Initial weight loss goal should be 5-10% reduction from baseline; pursue further weight loss if indicated after achieving this milestone. 1, 2

Antiplatelet Therapy

Aspirin 75-162 mg daily (preferably 81 mg) should be taken indefinitely by all patients with established coronary artery disease unless contraindicated. 1, 3, 5

• For primary prevention in high-risk individuals (10-year CHD risk ≥10%), consider aspirin 75-160 mg daily. 2
• Clopidogrel 75 mg daily serves as an alternative for patients with aspirin intolerance or allergy. 1, 3
• After acute coronary syndrome or stent placement, dual antiplatelet therapy (aspirin plus clopidogrel, prasugrel, or ticagrelor) is required for at least 12 months. 1

Diabetes Management

Coordinate diabetes care with primary care physician/endocrinologist and target HbA1c <7% through lifestyle modifications and pharmacotherapy. 1, 2

• Metformin is the effective first-line pharmacotherapy if not contraindicated. 1
• In patients with diabetes and cardiovascular disease, add SGLT2 inhibitors or GLP-1 receptor agonists for additional cardiovascular protection. 3
• Intensify modification of all other cardiovascular risk factors (physical activity, weight management, blood pressure, lipid control). 1, 2
• For hypertensive patients with chronic kidney disease and eGFR >20 mL/min/1.73m², use SGLT2 inhibitors. 2

Alcohol Consumption

Limit alcohol to a maximum of 100 g per week; complete avoidance is preferable. 2

Critical Pitfalls to Avoid

• Never use moderate-dose statins when high-dose statins are indicated—this leaves substantial residual risk. 2, 3
• Do not delay statin initiation while attempting lifestyle modifications alone—start both simultaneously. 1, 2
• Avoid combining ACE inhibitors with ARBs—this increases adverse effects without additional benefit. 3
• Do not neglect proton pump inhibitor therapy in patients on aspirin or dual antiplatelet therapy who have high gastrointestinal bleeding risk (advanced age, prior GI bleeding, concurrent warfarin/NSAID use, H. pylori infection). 1, 3
• Never assume blood pressure control is adequate without measuring it at every visit—hypertension is often asymptomatic. 1, 2

Ongoing Monitoring

• Regular cardiovascular healthcare visits are essential to reassess risk status, evaluate adherence to lifestyle modifications and risk factor targets, and identify new comorbidities. 1, 3
• Reassess lipid profile and adjust statin therapy as early as 4 weeks after initiation. 4
• For patients with worsening symptoms despite medical therapy, expeditious referral for risk stratification with stress imaging or invasive coronary angiography is warranted. 1