What is the first‑line management for an adult patient diagnosed with coronary artery disease?

First-Line Management of Coronary Artery Disease

All adult patients diagnosed with coronary artery disease must immediately start aspirin 75–100 mg daily, high-intensity statin therapy, an ACE inhibitor, a beta-blocker, and sublingual nitroglycerin for symptom relief, alongside exercise-based cardiac rehabilitation. 1

Immediate Pharmacological Therapy for Event Prevention

Antiplatelet Therapy

• Aspirin 75–100 mg daily is mandatory for every CAD patient to reduce myocardial infarction and death 2, 1
• Clopidogrel 75 mg daily serves as the only alternative when aspirin is absolutely contraindicated 2
• Dipyridamole should never be used as it can worsen exercise-induced myocardial ischemia 2

Lipid-Lowering Therapy

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

ACE Inhibitors

• ACE inhibitors are required for all CAD patients, with particular benefit when hypertension, diabetes, heart failure, or left ventricular dysfunction coexist 2, 1
• Use ARBs only if ACE inhibitors are not tolerated 1
• Never combine ACE inhibitors with ARBs 1

Beta-Blockers

• Beta-blockers are mandatory as first-line therapy, especially in patients with prior myocardial infarction 2, 1
• They reduce cardiac events, control heart rate, and relieve angina symptoms 2, 1
• Diabetes is not a contraindication; diabetic patients benefit equally or more than non-diabetic patients 2

Pharmacological Therapy for Symptom Relief

Short-Acting Nitrates

• Sublingual nitroglycerin or nitroglycerin spray must be prescribed to all CAD patients for immediate relief of effort angina 2, 1
• Never use nitrates in hypertrophic obstructive cardiomyopathy or with phosphodiesterase inhibitors 3

Long-Acting Anti-Anginal Agents

• Calcium channel blockers (long-acting) are appropriate when beta-blockers are contraindicated or poorly tolerated 2, 1
• Long-acting calcium channel blockers or long-acting nitrates can be combined with beta-blockers when beta-blockers alone fail to control symptoms 2
• Long-acting calcium channel blockers are often preferable to long-acting nitrates for maintenance therapy due to sustained 24-hour effects 2

Essential Lifestyle Modifications

Cardiac Rehabilitation

• Exercise-based cardiac rehabilitation is fundamental and must be started immediately to significantly reduce cardiovascular mortality and morbidity 1, 4

Preventive Measures

• Annual influenza vaccination is required, especially in elderly patients, to reduce mortality risk 1, 4
• Smoking cessation interventions must be implemented immediately in all CAD patients 1
• Psychological interventions should address depression symptoms 1

Additional Therapies for Specific Populations

Diabetic Patients

• SGLT2 inhibitors with proven cardiovascular benefit are required for all type 2 diabetic patients with CAD, irrespective of HbA1c levels 1
• Consider GLP-1 receptor agonist semaglutide in non-diabetic CAD patients with BMI > 27 kg/m² to lower cardiovascular mortality, myocardial infarction, and stroke risk 1

Anti-Inflammatory Therapy

• Low-dose colchicine 0.5 mg daily may be used to reduce myocardial infarction, stroke, and need for revascularization 1

Gastrointestinal Protection

• Proton pump inhibitors are recommended for patients on aspirin who have high gastrointestinal bleeding risk 3

Blood Pressure Management

• Target office systolic blood pressure 120–130 mmHg (130–140 mmHg in patients > 65 years) 1

Critical Pitfalls to Avoid

• Do not withhold beta-blockers in diabetic patients—they derive equal or greater benefit 2
• Do not use immediate-release or short-acting dihydropyridine calcium antagonists—they increase adverse cardiac events 2
• Do not use dipyridamole—it worsens myocardial ischemia 2
• Do not use chelation therapy—it has no proven benefit 2
• Medical therapy must be optimized before considering revascularization, except in high-risk patients with severe refractory symptoms 1, 4

Monitoring and Follow-Up

• Review patient response to medical therapies at 2–4 weeks after drug initiation 3, 4
• Clinical follow-up at least annually to assess symptoms, functional status, adherence, and monitor for complications 1
• Patient education about the disease, risk factors, and treatment strategy is essential for long-term adherence 1, 4