How should coronary artery disease be managed, including risk‑factor modification, medication therapy, and revascularization?

Management of Coronary Artery Disease

All patients with coronary artery disease require immediate initiation of aspirin 75-100 mg daily, high-intensity statin therapy targeting LDL <55 mg/dL, an ACE inhibitor (especially with hypertension, diabetes, heart failure, or LV dysfunction), beta-blocker for symptom control and mortality reduction, sublingual nitroglycerin for acute angina relief, and comprehensive lifestyle modification including exercise-based cardiac rehabilitation. 1, 2, 3

Immediate Pharmacological Therapy for Event Prevention

Antiplatelet Therapy

• Aspirin 75-100 mg daily is mandatory as the foundation for all patients with established coronary disease, particularly those with prior myocardial infarction or revascularization 1, 3
• Clopidogrel 75 mg daily serves as the alternative in aspirin-intolerant patients 1, 3
• Dual antiplatelet therapy (aspirin plus clopidogrel) is required for 6 months after coronary stent implantation, though shorter duration may be indicated if life-threatening bleeding risk exists 3
• Add a proton pump inhibitor when prescribing antiplatelet therapy in patients at high gastrointestinal bleeding risk 2, 3

Lipid-Lowering Therapy

• High-intensity statin therapy must be initiated immediately in every CAD patient with a target LDL-cholesterol <55 mg/dL for very high-risk patients 1, 2, 3
• Add ezetimibe if maximum tolerated statin dose fails to achieve LDL goals 1, 2, 3
• Add a PCSK9 inhibitor (evolocumab or alirocumab) if LDL goals remain unmet on statin plus ezetimibe 1, 2, 3
• Reassess lipid profile 4-12 weeks after initiating statin therapy to evaluate response 2

Blood Pressure Management

• ACE inhibitor is mandatory, particularly when hypertension, diabetes, heart failure, or left ventricular dysfunction coexist 1, 2, 3
• ARB serves as alternative if ACE inhibitor is not tolerated 1, 3
• Target office systolic blood pressure 120-130 mmHg (130-140 mmHg in patients >65 years) 1
• Never combine ACE inhibitors with ARBs as this increases harm 2, 3

Additional Prognostic Medications

• SGLT2 inhibitors and GLP-1 receptor agonists are recommended in patients with diabetes and cardiovascular disease 3

Pharmacological Therapy for Symptom Relief

First-Line Antianginal Agents

• Beta-blockers are first-line for heart rate control and angina relief, particularly essential after recent myocardial infarction for both symptom control and mortality reduction 1, 2, 3
• Calcium channel blockers are appropriate when beta-blockers are contraindicated or poorly tolerated; they may be combined with beta-blockers 1, 3
• Short-acting nitrates (sublingual nitroglycerin) should be prescribed to all CAD patients for immediate relief of effort angina, with symptoms resolving within 1-5 minutes 1, 3

Special Populations

• For microvascular angina: first-line beta-blocker, second-line add long-acting nitrate 1
• For vasospastic angina: first-line calcium channel blocker, second-line add long-acting nitrate 1

Comprehensive Lifestyle Modifications

Exercise and Rehabilitation

• Exercise-based cardiac rehabilitation is fundamental and significantly reduces cardiovascular mortality and morbidity while improving risk factor control 1
• Aerobic physical activity 150-300 minutes per week of moderate intensity should be recommended 2

Dietary Interventions

• Mediterranean, DASH, or AHA diet with saturated fat <7% of total calories should be recommended 2

Tobacco Cessation

• Smoking-cessation interventions must be implemented immediately in all CAD patients 1
• Quantitative assessment of tobacco use is mandatory at every visit 2, 3

Additional Interventions

• Weight management targeting obesity reduction is recommended 2
• Annual influenza vaccination is recommended, especially in elderly patients, to reduce mortality risk 1
• Psychological interventions are recommended to address depression symptoms 1

Risk Stratification and Indications for Revascularization

High-Risk Features Requiring Aggressive Management

• Left ventricular ejection fraction <50% identifies a higher-risk subgroup 1
• High-risk anatomical features include left main disease, multivessel disease with reduced LV function, multivessel disease with diabetes mellitus, and high-risk non-invasive ischemia testing (>10% of LV mass ischemic) 1

When to Perform Invasive Coronary Angiography

• Severe angina refractory to maximal medical therapy warrants urgent invasive coronary angiography with FFR/iwFR guidance 4, 1, 2
• Risk stratification using stress imaging is recommended for patients with new or worsening symptoms 4, 2
• Recurrent ischemia (recurrent chest pain or dynamic ST-segment changes), elevated troponin levels, hemodynamic instability, or major arrhythmias are additional urgent indications 1
• Coronary angiography should not be performed solely for risk stratification; medical therapy must be optimized before considering revascularization, except in high-risk patients with persistent symptoms 4, 1

Revascularization Decision-Making

• Myocardial revascularization is recommended when angina persists despite optimal antianginal drug therapy 4, 1, 2, 3
• Coronary artery bypass grafting (CABG) is recommended for left main stenosis, significant proximal left anterior descending artery stenosis, multivessel disease, or disabling angina 1
• Percutaneous coronary intervention (PCI) is appropriate for single vessel disease or selected patients with objective evidence of ischemia 1

Monitoring and Follow-Up Strategy

Regular Assessment Schedule

• Regular cardiovascular healthcare visits every 3-6 months initially to reassess risk status, lifestyle modifications, adherence to risk factor targets, and development of new comorbidities 2, 3
• Clinical follow-up at least annually thereafter to assess symptoms, functional status, adherence to lifestyle and medical interventions, and monitor for complications 1
• Review patient response to medical therapies at 2-4 weeks after drug initiation 1

Surveillance Testing

• Periodic resting ECG is recommended in asymptomatic diabetic patients for detection of conduction abnormalities, atrial fibrillation, and silent MI 3
• Repeat stress imaging or ICA with functional testing is recommended in the presence of worsening symptoms and/or increased risk status 2
• Coronary CTA is not recommended as a routine follow-up test for patients with established CAD 4, 1, 2

Patient Education

• Patient education about the disease, risk factors, and treatment strategy is essential for long-term adherence 1
• Patients require ongoing individualized education on symptom management, lifestyle changes, and medication adherence 3

Critical Pitfalls to Avoid

• Do not combine ACE inhibitor with ARB as this increases harm 1, 2, 3
• Do not use ticagrelor or prasugrel as part of triple antithrombotic therapy with aspirin and oral anticoagulation 2, 3
• Do not neglect proton pump inhibitor in patients on antiplatelet therapy at high GI bleeding risk 2, 3
• Do not use coronary CTA as a routine follow-up test for patients with established CAD 4, 1, 2
• Do not perform ICA solely for risk stratification without clinical indication 4, 1, 2