What is the recommended guideline-directed medical therapy and lifestyle management for a patient with coronary heart disease?

Guideline-Directed Medical Therapy for Coronary Heart Disease

All patients with established coronary heart disease must immediately receive aspirin 75-100 mg daily, high-intensity statin therapy, short-acting sublingual nitrates, and enrollment in exercise-based cardiac rehabilitation to reduce cardiovascular events and mortality. 1, 2

Antiplatelet Therapy for Event Prevention

• Aspirin 75-100 mg daily is mandatory for all patients with prior myocardial infarction or revascularization 1, 2, 3
• Clopidogrel 75 mg daily serves as the alternative in patients with documented aspirin intolerance 1
• After coronary stent placement, dual antiplatelet therapy (aspirin plus clopidogrel) is required for 6 months, though shorter durations (1-3 months) are safe when bleeding risk is high and ischemic risk is low-to-moderate 1, 2
• Concomitant proton pump inhibitor therapy is recommended in patients receiving antiplatelet therapy who have high gastrointestinal bleeding risk 1

Lipid-Lowering Therapy

• High-intensity statin therapy must be initiated immediately in every patient with coronary disease, targeting LDL-C <70 mg/dL 1, 2, 4
• Add ezetimibe when maximum tolerated statin dose fails to achieve LDL goals 1, 2
• For very high-risk patients not reaching goals on statin plus ezetimibe, add a PCSK9 inhibitor (evolocumab, alirocumab) or inclisiran 1, 2
• Bempedoic acid may be used as adjunctive therapy, though long-term clinical outcomes data remain limited 1
• Fish oil, omega-3 fatty acids, and vitamin supplements are not recommended as they provide no benefit in reducing cardiovascular events 1

Blood Pressure Management

• ACE inhibitors (or ARBs if ACE-inhibitor intolerant) are recommended particularly when hypertension, diabetes, heart failure, or left ventricular ejection fraction ≤50% coexist 1, 2, 4
• Target office systolic blood pressure 120-130 mmHg (130-140 mmHg in patients >65 years) 2
• Never combine ACE inhibitors with ARBs due to increased harm without additional benefit 2

Antianginal Therapy for Symptom Control

First-Line Therapy

• Either beta-blockers or calcium channel blockers are recommended as first-line antianginal therapy 1, 2
• Beta-blockers are particularly indicated in patients with recent myocardial infarction (within past year), left ventricular ejection fraction ≤50%, or heart failure 1, 2, 4
• Long-term beta-blocker therapy is NOT recommended to improve outcomes in chronic coronary disease patients without recent MI, reduced ejection fraction, or another primary indication 1

Immediate Symptom Relief

• Short-acting sublingual nitrates must be prescribed to all patients for immediate relief of effort angina 1, 2, 5
• Nitrates are contraindicated in patients with hypertrophic obstructive cardiomyopathy or those taking phosphodiesterase-5 inhibitors 1, 5

Second-Line and Adjunctive Therapy

• Long-acting nitrates, ranolazine, or additional calcium channel blockers may be added when first-line therapy is insufficient 1, 6

Diabetes and Heart Failure Management

• In patients with type 2 diabetes, use either an SGLT2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit to reduce major adverse cardiovascular events 1
• In patients with heart failure and LVEF ≤40%, SGLT2 inhibitors are recommended to reduce cardiovascular death and heart failure hospitalization, regardless of diabetes status 1
• In patients with heart failure and LVEF >40%, SGLT2 inhibitors can be beneficial in decreasing heart failure hospitalizations and improving quality of life 1
• Diuretics are recommended for symptomatic patients with signs of pulmonary or systemic congestion 1, 4, 5
• Mineralocorticoid receptor antagonists are recommended in patients who remain symptomatic despite adequate ACE inhibitor and beta-blocker therapy 1

Lifestyle Modifications

• Exercise-based cardiac rehabilitation is fundamental and must be emphasized at every patient contact, as it significantly reduces cardiovascular mortality and morbidity 1, 2, 5
• Habitual physical activity substantially reduces long-term cardiovascular event risk, and patients should be reminded that the small risk of events during exertion is far outweighed by the protective benefits of regular exercise 1
• Smoking cessation interventions must be implemented immediately in all patients who smoke 2, 4
• E-cigarettes are NOT recommended as first-line therapy for smoking cessation due to lack of long-term safety data and risks of sustained use 1
• Annual influenza vaccination is recommended, especially in elderly patients 1, 2, 5
• Psychological interventions are recommended to improve symptoms of depression, which commonly coexist with coronary disease 1, 2, 5

Revascularization Considerations

• Invasive coronary angiography with FFR/iFR guidance is recommended for high-risk patients with severe symptoms refractory to optimal medical therapy 1, 2, 5
• Myocardial revascularization is indicated when angina persists despite optimal antianginal drug therapy 1, 4
• Routine periodic anatomic or ischemic testing without clinical change is NOT recommended for risk stratification or to guide therapeutic decisions 1
• Coronary CT angiography is NOT recommended as a routine follow-up test in patients with established coronary disease 1, 2
• Invasive coronary angiography should NOT be performed solely for risk stratification 1, 2

Monitoring and Follow-Up

• Review patient response to medical therapies within 2-4 weeks after drug initiation 1, 4, 5
• Periodic cardiovascular healthcare visits are recommended to reassess risk status, evaluate lifestyle modification adherence, monitor cardiovascular risk factor targets, and identify new comorbidities 1, 4
• Patient education about the disease, risk factors, and treatment strategy is essential for long-term adherence and outcomes 1, 2, 5
• Multidisciplinary team-based care involving cardiologists, primary care physicians, nurses, dieticians, physiotherapists, psychologists, and pharmacists optimizes outcomes 1, 5

Common Pitfalls to Avoid

• Do not continue beta-blockers indefinitely in stable chronic coronary disease patients beyond one year post-MI if ejection fraction is preserved and no other indication exists 1
• Do not use ticagrelor or prasugrel as part of triple antithrombotic therapy with aspirin and oral anticoagulation due to excessive bleeding risk 1
• Do not prescribe niacin or fibrates as adjunctive lipid therapy in most patients, as studies show no improvement in cardiovascular outcomes 1, 6
• Do not overlook social determinants of health and associated costs when making treatment decisions, as these factors significantly impact adherence and outcomes 1