What is the initial medical management for a patient with coronary artery disease (CAD), including lifestyle modifications and medications?

Initial Medical Management of Coronary Artery Disease

All patients with coronary artery disease require immediate initiation of statin therapy, aspirin 75-100 mg daily, and comprehensive lifestyle modifications including smoking cessation, with additional medications based on specific clinical features such as heart failure, diabetes, or hypertension. 1, 2

Antiplatelet Therapy

• Aspirin 75-100 mg daily is mandatory for all CAD patients and should be continued lifelong in those with prior myocardial infarction or revascularization 2
• Clopidogrel 75 mg daily serves as an effective alternative in patients with aspirin intolerance 2
• Dual antiplatelet therapy (aspirin plus clopidogrel 75 mg daily) is required for 6 months following coronary stenting, regardless of stent type 2, 3
• In acute coronary syndrome patients, clopidogrel reduces the combined risk of cardiovascular death, MI, or stroke by 20% (from 11.4% to 9.3%) when added to aspirin 3

Lipid-Lowering Therapy

• Statins must be prescribed to all CAD patients at a dose sufficient to reduce LDL-C by ≥50% from baseline and achieve LDL-C <55 mg/dL (<1.4 mmol/L) 1, 2
• If LDL-C goals are not met after 4-6 weeks on maximally tolerated statin therapy, add ezetimibe 1, 2
• For very high-risk patients not achieving goals on statin plus ezetimibe, add a PCSK9 inhibitor 1, 2
• The target for very high-risk patients is LDL-C <70 mg/dL, which is reasonable based on evidence showing additional benefit 1

Blood Pressure Management

• Target blood pressure is <140/90 mmHg for most CAD patients, with <130/80 mmHg reasonable for those at high cardiovascular risk 4
• Initiate antihypertensive therapy with beta-blockers and/or ACE inhibitors as first-line agents 1
• Add thiazide diuretics or calcium channel blockers as needed to achieve target 1
• Exercise caution with diastolic blood pressure <60 mmHg in CAD patients, as this may compromise coronary perfusion, particularly in those with left ventricular hypertrophy 5

Beta-Blockers

• Beta-blockers are mandatory in CAD patients with systolic left ventricular dysfunction or heart failure with reduced ejection fraction (<40%) 1, 4
• Beta-blockers are superior to all other drug classes after recent myocardial infarction 5
• In the absence of these specific indications, beta-blockers serve as first-line therapy for symptom control and blood pressure management 2

ACE Inhibitors or ARBs

• ACE inhibitors (or ARBs if ACE inhibitor intolerant) are required in CAD patients with heart failure with reduced LVEF (<40%), diabetes, or chronic kidney disease 1, 4
• Continue indefinitely unless contraindicated by severe renal impairment or hyperkalemia 1
• ACE inhibitors reduce all-cause and cardiovascular mortality in these high-risk subgroups 1

Antianginal Therapy for Symptom Control

• Short-acting nitrates are essential for immediate relief of angina symptoms 2
• Beta-blockers and/or calcium channel blockers serve as first-line therapy to control heart rate and symptoms 2
• Avoid nitrates in patients with hypertrophic cardiomyopathy or when using phosphodiesterase inhibitors 2
• Selection between beta-blockers and calcium channel blockers depends on heart rate, blood pressure, and presence of heart failure 2

Lifestyle Modifications

Smoking Cessation

• Ask about tobacco use at every visit and advise every tobacco user to quit 1
• Assist with counseling and develop a quit plan that includes pharmacotherapy and/or referral to smoking cessation programs 1
• Smoking cessation reduces mortality by 36% (RR 0.64) in CAD patients 6
• Advise avoidance of environmental tobacco smoke exposure at work, home, and public places 1

Physical Activity

• Prescribe 150-300 minutes per week of moderate-intensity aerobic activity or 75-150 minutes per week of vigorous-intensity activity 2, 4
• Alternatively, 30-60 minutes of moderate-intensity aerobic activity (such as brisk walking) at least 5 days per week is acceptable 1
• Add resistance training at least 2 days per week 1, 4
• Enroll patients in medically supervised cardiac rehabilitation programs, which reduce all-cause and cardiovascular mortality 1, 2
• Physical activity ≥4 times per week reduces recurrent CHD by 31% (HR 0.69) and death by 29% (HR 0.71) 7

Dietary Modifications

• Reduce saturated fat intake to <7% of total calories, trans fatty acids to <1% of total calories, and cholesterol to <200 mg/day 1
• Add plant stanols/sterols (2 g/day) and viscous fiber (10 g/day) to further lower LDL-C 1, 4
• Emphasize increased consumption of fresh fruits, vegetables, whole grains, lean proteins, fish, and low-fat dairy products 1, 4
• Adherence to Mediterranean diet (highest quartile) reduces recurrent CHD by 23% (HR 0.77) and death by 16% (HR 0.84) 7

Weight Management

• Target body mass index of 18.5-24.9 kg/m² and waist circumference <102 cm (40 inches) in men and <88 cm (35 inches) in women 1
• Assess body mass index and waist circumference at every visit 1
• Weight reduction through appropriate balance of physical activity and caloric restriction is essential 1

Additional Preventive Measures

• Annual influenza vaccination is required for all CAD patients, especially those ≥65 years of age 1, 2
• Involve multidisciplinary healthcare professionals (cardiologists, general practitioners, nurses, dieticians, physiotherapists, psychologists, pharmacists) to reduce mortality and improve quality of life 1, 2
• Provide psychological interventions to improve symptoms of depression and health-related quality of life 1

Special Populations

Diabetes Mellitus

• Screen all CAD patients for diabetes and monitor blood glucose frequently in those with known diabetes 1
• Avoid hypoglycemia 1
• Target HbA1c of 7% for most patients 4
• Metformin is the preferred initial pharmacological treatment if not contraindicated 4

Chronic Kidney Disease

• Apply the same diagnostic and therapeutic strategies as for patients with normal renal function, with dose adjustments as necessary 1
• Assess kidney function by eGFR in all patients 1
• Use low- or iso-osmolar contrast media at the lowest possible volume for invasive procedures 1

Older Patients

• Apply the same diagnostic and interventional strategies as for younger patients 1
• Adapt antithrombotic agent choice and dosage based on renal function and specific contraindications 1

Monitoring and Follow-Up

• Review patient response to medical therapies 2-4 weeks after drug initiation 2
• Conduct periodic visits (at least annually) to assess risk factor control, medication adherence, and changes in disease status 2
• Simplify medication regimens using fixed-dose combinations to increase adherence 2
• Reassess for worsening symptoms or increased risk status, which may require repeat stress imaging or invasive coronary angiography 2

Common Pitfalls

• Do not discontinue aspirin or statins without compelling contraindications, as these are cornerstone therapies with proven mortality benefit 1, 2
• Avoid combining ivabradine with non-dihydropyridine calcium channel blockers or strong CYP3A4 inhibitors 2
• Do not classify chest pain as non-cardiac without thorough evaluation including objective exclusion of myocardial ischemia 2
• Recognize that symptom severity does not always correlate with severity of obstructive CAD, particularly in women 2
• Maintaining all three ideal lifestyle factors (non-smoking, physical activity ≥4 times/week, Mediterranean diet adherence) reduces recurrent CHD by 62% (HR 0.38) and death by 59% (HR 0.41) compared to maintaining none 7