What is the best treatment approach for a patient with coronary vascular disease (CVD) and 3 blocked coronary arteries?

Treatment of 3-Vessel Coronary Artery Disease

For a patient with 3-vessel coronary artery disease, revascularization with CABG is the preferred strategy over PCI to improve long-term survival and reduce cardiovascular mortality, combined with aggressive guideline-directed medical therapy including high-intensity statin, beta-blocker, ACE inhibitor/ARB, and antiplatelet therapy. 1

Revascularization Strategy

CABG is superior to PCI for 3-vessel disease because it provides more complete revascularization and better long-term outcomes. 1 In patients with LVEF >35% and functionally significant three-vessel disease, myocardial revascularization is recommended in addition to medical therapy to improve long-term survival, reduce cardiovascular mortality, and decrease the risk of spontaneous myocardial infarction. 1

Heart Team Approach

• A multidisciplinary Heart Team discussion is mandatory for complex cases like 3-vessel disease, including interventional cardiology, cardiac surgery, and non-interventional cardiology representatives. 1
• The decision must be patient-centered, considering patient preferences, health literacy, and social support, with balanced communication in language the patient understands. 1
• Calculate the SYNTAX score to assess anatomical complexity of disease when evaluating multivessel CAD. 1
• Calculate the STS score to estimate in-hospital morbidity and 30-day mortality after CABG. 1

Special Consideration for Reduced LVEF

If LVEF ≤35%, CABG is specifically recommended over medical therapy alone to improve long-term survival. 1 However, careful evaluation by the Heart Team is required, assessing coronary anatomy, correlation between CAD and LV dysfunction, comorbidities, life expectancy, and individual risk-to-benefit ratio. 1

Mandatory Medical Therapy (All Patients)

High-Intensity Statin Therapy

• Start atorvastatin 40-80 mg or rosuvastatin 20-40 mg immediately, targeting ≥50% reduction in LDL-C. 1
• Statins are recommended for all patients with chronic coronary disease regardless of baseline cholesterol levels. 1
• If goals are not achieved with maximum tolerated statin dose, add ezetimibe. 1
• For very high-risk patients not at goal despite statin plus ezetimibe, add a PCSK9 inhibitor. 1
• Monitor response with fasting lipid panels periodically to assess adherence and therapeutic response. 1

Beta-Blocker Therapy

• Beta-blockers are essential components of treatment, effective for both angina relief and reducing morbidity and mortality. 1, 2
• Use cardioselective agents (metoprolol succinate, carvedilol, or bisoprolol) without intrinsic sympathomimetic activity. 1
• Beta-blockers are particularly effective in patients with ongoing angina, reducing angina, improving exercise tolerance, and reducing risk of CV events. 1

ACE Inhibitor or ARB

• ACE inhibitors (or ARBs if ACE inhibitor intolerant) are recommended as first-line therapy for compelling indications including hypertension (BP ≥130/80 mmHg), diabetes, or heart failure. 1
• Ramipril therapy reduced risk of MI or stroke by 22% in high-risk CAD patients. 1
• ACE inhibitor therapy produced a 20% reduction in risk of CV death, MI, or cardiac arrest compared with placebo. 1

Antiplatelet Therapy

• Aspirin 75-100 mg daily is recommended in all patients with previous MI or revascularization. 1
• Clopidogrel 75 mg daily is the alternative if aspirin intolerance exists. 1
• Following coronary stenting, continue clopidogrel 75 mg daily (after appropriate loading) in addition to aspirin for 6 months, unless shorter duration (1-3 months) is indicated due to life-threatening bleeding risk. 1

Blood Pressure Management

• Target BP <130/80 mmHg in patients with diabetes, chronic kidney disease, or high cardiovascular risk (10-year Framingham risk ≥10%). 1
• When beta-blockers, ACE inhibitors, and ARBs do not sufficiently control BP, add thiazide diuretics, calcium channel blockers, or mineralocorticoid receptor antagonists. 1
• Critical pitfall: In older patients with wide pulse pressures, lowering systolic BP may cause very low diastolic BP (<60 mmHg), which requires caution especially in patients with diabetes or age >60 years. 1

Proton Pump Inhibitor

• Add a PPI for gastrointestinal protection in patients receiving aspirin monotherapy, dual antiplatelet therapy, or oral anticoagulation who are at high risk of GI bleeding. 1

Symptom Management (If Angina Present)

First-Line Anti-Anginal Therapy

• Short-acting nitrates for immediate relief of effort angina. 1
• Beta-blockers and/or calcium channel blockers as first-line treatment to control heart rate and symptoms. 1
• Avoid nitrates in patients with hypertrophic obstructive cardiomyopathy or those taking phosphodiesterase inhibitors. 1

Second-Line Options for Refractory Symptoms

• Consider ranolazine or trimetazidine if symptoms persist despite first-line therapy. 3
• These agents do not cause hypotension and are particularly useful in patients with borderline blood pressure. 4

Essential Lifestyle Modifications

Mandatory Interventions

• Smoking cessation is non-negotiable and must be addressed with counseling and pharmacotherapy. 1, 2, 4
• Enroll in cardiac rehabilitation with supervised exercise, which is fundamental to treatment. 2, 4
• Implement heart-healthy diet with attention to sodium intake, moderation of alcohol, and weight management. 1, 2
• Regular physical activity as an effective means to achieve healthy lifestyle and control risk factors. 1, 2

Additional Risk Factor Management

• Aggressive glycemic control if diabetic (HbA1c target individualized but generally <7%). 1
• Consider GLP-1 receptor agonists with proven CV benefit in patients with type 2 diabetes to reduce CV events. 1
• Annual influenza vaccination, especially in elderly patients. 1
• Psychological interventions to improve symptoms of depression. 1

Follow-Up and Monitoring

• Review patient response to medical therapies within 2-4 weeks after drug initiation. 1
• Educate patients about the disease, risk factors, and treatment strategy. 1
• Reassess symptoms, blood pressure, heart rate, renal function, and potassium levels 1-2 weeks after initiating or adjusting medications. 5
• A multidisciplinary team approach involving cardiologists, primary care physicians, nurses, dieticians, physiotherapists, psychologists, and pharmacists is recommended. 1, 2

Critical Clinical Pitfall

Do not rely on PCI alone for 3-vessel disease when CABG is surgically feasible, as CABG provides superior long-term survival and more complete revascularization in this anatomically complex disease. 1 The decision between CABG and PCI must involve Heart Team discussion when both hold similar levels of recommendation, but for typical 3-vessel disease, CABG is the evidence-based choice. 1