What is the recommended treatment for coronary artery disease?

Treatment of Coronary Artery Disease

All patients with coronary artery disease must immediately receive aspirin 75-100 mg daily, high-intensity statin therapy, and short-acting nitrates, combined with exercise-based cardiac rehabilitation—this combination reduces major vascular events and mortality. 1

Immediate Pharmacological Therapy for Event Prevention

Antiplatelet Therapy

• Aspirin 75-100 mg daily is mandatory for all CAD patients, particularly those with prior myocardial infarction or revascularization 2, 1
• Clopidogrel 75 mg daily serves as the only alternative in aspirin-intolerant patients 2, 1
• After coronary stent implantation, dual antiplatelet therapy (aspirin plus clopidogrel 75 mg daily after appropriate loading) is required for 6 months, regardless of stent type, unless life-threatening bleeding occurs 2, 1

Lipid-Lowering Therapy

• Statins are mandatory in every CAD patient to reduce major vascular events and mortality 2, 1
• Target LDL-cholesterol < 55 mg/dL (1.4 mmol/L) with at least 50% reduction from baseline 1
• Add ezetimibe when maximum tolerated statin dose fails to achieve LDL goals 2, 1
• For very high-risk patients still not at goal on statin plus ezetimibe, add a PCSK9 inhibitor 2 or bempedoic acid 1

Blood Pressure Management

• ACE inhibitors (or ARBs if ACE-inhibitor intolerant) are required for all CAD patients, especially when hypertension, diabetes, heart failure, or left ventricular dysfunction coexist 2, 1
• Target office systolic blood pressure 120-130 mmHg (130-140 mmHg in patients > 65 years) 1
• Never combine ACE inhibitors with ARBs 1

Additional Therapies for High-Risk Patients

• SGLT2 inhibitors with proven cardiovascular benefit are required for all CAD patients with type 2 diabetes, irrespective of baseline or target HbA1c 1
• In non-diabetic CAD patients with overweight/obesity (BMI > 27 kg/m²), consider GLP-1 receptor agonist semaglutide to lower cardiovascular mortality, myocardial infarction, and stroke risk 1
• Low-dose colchicine 0.5 mg daily may be used to reduce myocardial infarction, stroke, and need for revascularization 1

Pharmacological Therapy for Symptom Relief

First-Line Agents

• Beta-blockers are first-line for controlling heart rate and relieving angina, particularly after recent myocardial infarction 2, 1, 3
• Calcium channel blockers are appropriate when beta-blockers are contraindicated or poorly tolerated; they may be combined with beta-blockers 2, 1, 3
• Short-acting nitrates (sublingual nitroglycerin) must be prescribed to all CAD patients for immediate relief of effort angina 2, 1, 3

Critical Contraindications

• Never use nitrates in hypertrophic obstructive cardiomyopathy or with phosphodiesterase inhibitors 2, 3
• Avoid combining ivabradine with non-dihydropyridine calcium channel blockers 3

Gastrointestinal Protection

• Proton pump inhibitors are required for patients receiving aspirin monotherapy, dual antiplatelet therapy, or oral anticoagulation who are at high risk of gastrointestinal bleeding 2

Lifestyle Modifications (Mandatory, Not Optional)

• Exercise-based cardiac rehabilitation is fundamental and significantly reduces cardiovascular mortality and morbidity while improving risk factor control 2, 1, 3
• Annual influenza vaccination is required, especially in elderly patients, to reduce mortality risk 2, 1, 3
• Smoking-cessation interventions must be implemented immediately in all CAD patients 1
• Psychological interventions are recommended to address depression symptoms 2, 1
• Cognitive behavioral interventions help achieve and maintain healthy lifestyle changes 2, 4

Indications for Revascularization

Mandatory Revascularization for Prognosis (LVEF > 35%)

• Left main stenosis that is functionally significant requires revascularization to improve survival 1
• Functionally significant three-vessel disease requires revascularization to improve long-term survival and lower cardiovascular mortality and spontaneous myocardial infarction 1
• Functionally significant single- or two-vessel disease involving the proximal left anterior descending artery requires revascularization to reduce long-term cardiovascular mortality and spontaneous myocardial infarction 1

Revascularization for Symptom Relief

• When angina persists despite guideline-directed medical therapy, revascularization of functionally significant obstructive disease is required 2, 1
• Severe angina refractory to maximal medical therapy warrants urgent invasive coronary angiography 1

Special Considerations for Reduced LVEF (≤ 35%)

• The decision between revascularization and medical therapy alone requires multidisciplinary Heart Team evaluation of coronary anatomy, relationship between disease and ventricular dysfunction, comorbidities, life expectancy, risk-benefit balance, and patient preferences 1
• In surgically eligible patients with multivessel disease and LVEF ≤ 35%, CABG is recommended over medical therapy alone to improve long-term survival 1

Choice of Revascularization Modality

CABG vs. PCI Decision-Making

• For patients at low surgical risk with significant left main coronary stenosis, CABG is preferred over medical therapy alone and is the overall favored revascularization strategy compared with PCI, owing to lower rates of spontaneous myocardial infarction and repeat revascularization 1
• When left main disease is of low anatomical complexity (SYNTAX score ≤ 22) and PCI can achieve completeness of revascularization comparable to CABG, PCI may be offered as an alternative because of lower invasiveness and non-inferior survival 1
• In complex multivessel disease, a Heart Team discussion—including interventional cardiology, cardiac surgery, and non-interventional cardiology representatives—is mandatory to select the optimal treatment strategy 1

Risk Stratification Tools

• Calculate the SYNTAX score to assess anatomical complexity of multivessel obstructive disease 1
• Calculate the STS (Society of Thoracic Surgeons) score to estimate in-hospital morbidity and 30-day mortality after CABG 1

Procedural Guidance for PCI

• Intracoronary imaging (intravascular ultrasound or optical coherence tomography) is mandatory when performing PCI on anatomically complex lesions, particularly left main stem, true bifurcations, and long lesions 1
• Intracoronary pressure measurement (fractional flow reserve, instantaneous wave-free ratio, or quantitative flow ratio) is mandatory to guide lesion selection for intervention in patients with multivessel disease 1
• Post-procedural FFR or iFR assessment should be considered to identify patients at high risk of persistent angina and subsequent clinical events 1

Special Populations

Heart Failure with CAD

• Diuretics are required for symptomatic patients with signs of pulmonary or systemic congestion 2
• Beta-blockers are essential for both angina relief and reducing morbidity/mortality in heart failure 2
• ACE inhibitor therapy is required in patients with symptomatic heart failure or asymptomatic LV dysfunction following MI 2
• An ARB is recommended as an alternative in patients who do not tolerate ACE inhibition 2
• An MRA is required in patients who remain symptomatic despite adequate treatment with an ACE inhibitor and beta-blocker 2

Device Therapy

• An implantable cardioverter-defibrillator is required in patients with documented ventricular dysrhythmia causing hemodynamic instability, as well as in patients with symptomatic heart failure and LVEF < 35% 2
• CRT is required for symptomatic heart failure patients in sinus rhythm with QRS duration ≥ 150 ms and LBBB morphology, and LVEF < 35% despite optimal medical therapy 2

Atrial Fibrillation with CAD

• When oral anticoagulation is initiated in a patient with AF who is eligible for a NOAC, a NOAC (apixaban 5 mg b.i.d., dabigatran 150 mg b.i.d., edoxaban 60 mg o.d., or rivaroxaban 20 mg o.d.) is recommended in preference to a VKA in combination with antiplatelet therapy 2
• Long-term oral anticoagulation is required in patients with AF and CHA₂DS₂-VASc score > 2 in males and > 3 in females 2
• Ticagrelor or prasugrel must not be used as part of triple antithrombotic therapy with aspirin and an oral anticoagulant 2

Monitoring and Follow-Up

• Review patient response to medical therapies at 2-4 weeks after drug initiation 2, 4, 3
• Patient education about the disease, risk factors, and treatment strategy is essential for long-term adherence 2, 4, 3
• Periodic visits to a cardiovascular healthcare professional are required to reassess risk status, evaluate lifestyle-modification measures, adherence to cardiovascular risk factor targets, and development of comorbidities 2
• Involvement of multidisciplinary healthcare professionals (cardiologists, GPs, nurses, dieticians, physiotherapists, psychologists, and pharmacists) is recommended 2, 3

Critical Pitfalls to Avoid

• Coronary angiography must not be performed solely for risk stratification; medical therapy must be optimized before considering revascularization, except in high-risk patients with persistent symptoms 1, 4, 3
• Coronary CT angiography is not recommended as a routine follow-up test for patients with established CAD 2, 1
• Left ventricular ejection fraction < 50% identifies a higher-risk subgroup requiring more aggressive management 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