What is the immediate management for an adult patient with established coronary artery disease?

Immediate Management of Established Coronary Artery Disease

All patients with established coronary artery disease require immediate initiation of aspirin 75-100 mg daily, high-intensity statin therapy, and short-acting nitrates for symptom relief, combined with aggressive lifestyle modification including exercise-based cardiac rehabilitation. 1, 2, 3, 4

Pharmacological Management for Event Prevention (Start Immediately)

Antiplatelet Therapy

• Aspirin 75-100 mg daily is mandatory as the foundation of antithrombotic therapy for all patients with established CAD 1, 2, 4
• Clopidogrel 75 mg daily serves as the alternative if aspirin is not tolerated 2, 4
• If the patient has undergone coronary stent placement, dual antiplatelet therapy (aspirin plus clopidogrel) must continue for 6 months 4

Lipid Management

• Initiate high-intensity statin therapy immediately in all patients with established CAD to reduce major vascular events and mortality 1, 2, 3, 4
• Add ezetimibe if LDL goals are not achieved with maximum tolerated statin dose 2, 3, 4
• For very high-risk patients not reaching LDL targets on statin plus ezetimibe, add a PCSK9 inhibitor 2, 4

Blood Pressure Management

• ACE inhibitors (or ARBs if ACE inhibitors not tolerated) are recommended, particularly when hypertension, diabetes, heart failure, or left ventricular dysfunction coexist 1, 2, 4
• Target office blood pressure to 120-130 mmHg systolic (130-140 mmHg in patients >65 years) 1
• Never combine ACE inhibitors with ARBs 1

Pharmacological Management for Symptom Control

First-Line Symptomatic Treatment

• Beta-blockers are first-line for controlling heart rate and relieving angina symptoms 1, 2, 3, 4
• Beta-blockers are particularly recommended in patients with recent myocardial infarction 1

Alternative Symptomatic Treatment

• Calcium channel blockers are appropriate when beta-blockers are contraindicated or poorly tolerated 1, 2, 3, 4
• In patients with symptomatic angina, beta-blockers and/or calcium channel blockers can be combined 1

Immediate Relief Medication

• Prescribe short-acting nitrates (sublingual nitroglycerin) to all patients for immediate relief of effort angina 1, 2, 3, 4
• Critical pitfall: Never use nitrates in patients with hypertrophic obstructive cardiomyopathy or in combination with phosphodiesterase inhibitors 2, 3

Essential Lifestyle Modifications (Initiate Immediately)

Cardiac Rehabilitation

• Exercise-based cardiac rehabilitation is fundamental and must be initiated as it significantly reduces cardiovascular mortality and morbidity while improving risk factor control 2, 3, 4

Preventive Measures

• Annual influenza vaccination is recommended, especially in elderly patients, to reduce mortality risk 2, 3, 4
• Smoking cessation must be addressed immediately 1

Psychological Support

• Implement psychological interventions to address depression symptoms 2, 4
• Cognitive behavioral interventions help achieve and maintain healthy lifestyle changes 2

Gastrointestinal Protection

• Proton pump inhibitors are recommended for patients on aspirin who have high gastrointestinal bleeding risk 2

Risk Stratification and Follow-Up

Initial Assessment

• Assess symptom severity, risk factors, and comorbidities to guide treatment decisions 3
• Evaluate for left ventricular ejection fraction <50%, which indicates higher risk 1
• Identify high-risk features: left main disease, multivessel disease with LV dysfunction, multivessel disease with diabetes 1

Monitoring Schedule

• Review patient response to medical therapies at 2-4 weeks after drug initiation 2, 4
• Clinical follow-up at least annually to assess symptoms, functional status, and adherence 4
• Patient education about the disease, risk factors, and treatment strategy is essential for long-term adherence 2, 3, 4

When to Consider Revascularization

High-Risk Indications for Urgent Invasive Coronary Angiography

• Severe symptoms refractory to maximal medical therapy 1, 4
• Recurrent ischemia (recurrent chest pain or dynamic ST-segment changes) 1
• Elevated troponin levels 1
• Hemodynamic instability 1
• Major arrhythmias (repetitive ventricular tachycardia, ventricular fibrillation) 1

Anatomical Indications for Revascularization

• Left main coronary artery disease 1, 4
• Multivessel disease with reduced LV function 1
• Multivessel disease with diabetes mellitus 1
• High-risk noninvasive ischemia testing (>10% of LV mass ischemic) 1

Critical Pitfall

• Medical therapy must be optimized before considering revascularization, except in high-risk patients with significant symptoms despite medical therapy 3, 4
• Do not pursue coronary angiography solely for risk stratification 1, 2
• Coronary CTA is not recommended as a routine follow-up test for patients with established CAD 1

Special Considerations

Microvascular Angina

• First-line: beta-blocker 4
• Second-line: add long-acting nitrate 4

Vasospastic Angina

• First-line: calcium channel blocker 4
• Second-line: add long-acting nitrate 4

Heart Failure with CAD

• Beta-blockers are essential for both angina relief and reducing morbidity/mortality 4
• Diuretics for symptomatic patients with signs of congestion 4