What is the recommended management for coronary artery disease, including lifestyle modifications, pharmacologic therapy, and indications for 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-cholesterol <55 mg/dL (1.4 mmol/L) with ≥50% reduction from baseline, and comprehensive lifestyle modification including exercise-based cardiac rehabilitation, with revascularization reserved for those with refractory symptoms despite optimal medical therapy or high-risk anatomical features. 1, 2

Immediate Pharmacological Therapy

Antiplatelet Therapy

• Aspirin 75-100 mg daily is mandatory for all patients with established CAD unless contraindicated 1, 2, 3
• Clopidogrel 75 mg daily serves as the alternative in aspirin-intolerant patients 2, 3
• Following coronary stenting, dual antiplatelet therapy (aspirin plus clopidogrel) is required for 6 months, though shorter duration may be considered if life-threatening bleeding risk exists 3
• Add a proton pump inhibitor when prescribing antiplatelet therapy in patients at high gastrointestinal bleeding risk 4, 3

Lipid-Lowering Therapy

• Initiate high-intensity statin therapy immediately with a target LDL-cholesterol <1.4 mmol/L (55 mg/dL) and achieve ≥50% reduction from baseline 1, 2, 4
• If maximum tolerated statin dose fails to achieve goals, add ezetimibe 1, 2, 4
• For patients not achieving goals on maximum tolerated statin plus ezetimibe, add bempedoic acid 1
• For very high-risk patients not reaching goals on statin plus ezetimibe, add a PCSK9 inhibitor (evolocumab or alirocumab) 2, 4

Blood Pressure Management

• Prescribe an ACE inhibitor (or ARB if ACE inhibitor intolerant) for all CAD patients, particularly when hypertension, diabetes, heart failure, or left ventricular dysfunction 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 as this increases harm 2, 4, 3

Glucose-Lowering Therapy in Diabetic Patients

• SGLT2 inhibitors with proven cardiovascular benefit are mandatory in patients with type 2 diabetes and CAD to reduce cardiovascular events, independent of baseline or target HbA1c 1, 3
• GLP-1 receptor agonist semaglutide should be considered in CAD patients without diabetes but with overweight or obesity (BMI >27 kg/m²) to reduce cardiovascular mortality, MI, or stroke 1

Anti-Inflammatory Therapy

• Low-dose colchicine 0.5 mg daily should be considered in CAD patients with atherosclerotic disease to reduce myocardial infarction, stroke, and need for revascularization 1

Antianginal Therapy for Symptom Control

First-Line Agents

• Beta-blockers are first-line for controlling heart rate and relieving angina symptoms, particularly in patients with prior myocardial infarction 2, 3
• Calcium channel blockers are appropriate when beta-blockers are contraindicated or poorly tolerated, and may be combined with beta-blockers 2, 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 2, 3

Combination Therapy

• If angina persists despite optimal single-agent antianginal therapy, add a second antianginal drug from a different class 1
• If angina persists despite optimal antianginal therapy, myocardial revascularization is recommended 3

Lifestyle Modifications

Exercise and Cardiac Rehabilitation

• Exercise-based cardiac rehabilitation is fundamental and significantly reduces cardiovascular mortality and morbidity while improving risk factor control 2
• Prescribe aerobic physical activity 150-300 minutes per week of moderate intensity 4

Tobacco Cessation

• Mandatory tobacco cessation with quantitative assessment at every visit 2, 4

Dietary Interventions

• Recommend a Mediterranean, DASH, or AHA diet with saturated fat <7% of total calories 4

Weight Management

• Target obesity reduction through comprehensive lifestyle intervention 4

Vaccination

• Annual influenza vaccination is recommended, especially in elderly patients, to reduce mortality risk 2

Indications for Revascularization

High-Risk Anatomical Features Requiring Revascularization

• In CAD patients with LVEF >35%, myocardial revascularization is mandatory for functionally significant left main stem stenosis to improve survival 1
• In CAD patients with LVEF >35%, myocardial revascularization is mandatory for functionally significant three-vessel disease to improve long-term survival and reduce cardiovascular mortality and spontaneous myocardial infarction 1
• In CAD patients with LVEF >35%, myocardial revascularization is mandatory for functionally significant single- or two-vessel disease involving the proximal LAD to reduce long-term cardiovascular mortality and spontaneous myocardial infarction 1

Revascularization for Refractory Symptoms

• In CAD patients with persistent angina despite guideline-directed medical treatment, myocardial revascularization of functionally significant obstructive CAD is mandatory to improve symptoms 1

Special Consideration: Reduced LVEF

• In CAD patients with LVEF ≤35%, choose between revascularization or medical therapy alone after careful evaluation by the Heart Team of coronary anatomy, correlation between CAD and LV dysfunction, comorbidities, life expectancy, individual risk-to-benefit ratio, and patient perspectives 1
• In surgically eligible CAD patients with multivessel disease and LVEF ≤35%, myocardial revascularization with CABG is recommended over medical therapy alone to improve long-term survival 1

Choice of Revascularization Modality

Left Main Disease

• In CAD patients at low surgical risk with significant left main coronary stenosis, CABG is recommended over medical therapy alone to improve survival and is the overall preferred revascularization mode over PCI, given the lower risk of spontaneous myocardial infarction and repeat revascularization 1
• In CAD patients with significant left main coronary stenosis of low complexity (SYNTAX score ≤22), in whom PCI can provide equivalent completeness of revascularization to that of CABG, PCI is recommended as an alternative to CABG given its lower invasiveness and non-inferior survival 1

Multivessel Disease

• For complex clinical cases, a Heart Team discussion is mandatory, including representatives from interventional cardiology, cardiac surgery, and non-interventional cardiology, aimed at selecting the most appropriate treatment to improve patient outcomes and quality of life 1
• Calculate the SYNTAX score to assess the anatomical complexity of multivessel obstructive CAD 1
• Calculate the STS score to estimate in-hospital morbidity and 30-day mortality after CABG 1

Procedural Guidance

• Intracoronary imaging guidance by IVUS or OCT is mandatory when performing PCI on anatomically complex lesions, particularly left main stem, true bifurcations, and long lesions 1
• Intracoronary pressure measurement (FFR or iFR) or computation (QFR) is mandatory to guide lesion selection for intervention in patients with multivessel disease 1
• FFR or iFR should be considered at the end of the procedure to identify patients at high risk of persistent angina and subsequent clinical events 1

Follow-Up and Monitoring

Regular Assessment

• 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 4, 3
• Review patient response to medical therapies at 2-4 weeks after drug initiation 2
• Lipid profile assessment 4-12 weeks after initiating statin therapy to evaluate response 4

Surveillance for Disease Progression

• Repeat stress imaging or invasive coronary angiography with functional testing is recommended in the presence of worsening symptoms and/or increased risk status 4
• Periodic resting ECG is recommended in asymptomatic diabetic patients for detection of conduction abnormalities, atrial fibrillation, and silent MI 3

Critical Pitfalls to Avoid

• Do not use ticagrelor or prasugrel as part of triple antithrombotic therapy with aspirin and oral anticoagulation 4, 3
• Do not combine ACE inhibitors with ARBs 2, 4, 3
• Do not neglect proton pump inhibitor in patients on antiplatelet therapy at high gastrointestinal bleeding risk 4, 3
• Do not use coronary CTA as a routine follow-up test for patients with established CAD 2, 4
• Do not perform invasive coronary angiography solely for risk stratification without clinical indication 2, 4
• Percutaneous revascularization without comprehensive risk factor modification is a suboptimal therapeutic strategy 5