What is the recommended management for a patient with chronic coronary syndrome (stable coronary artery disease)?

Management of Chronic Coronary Syndrome

All patients with chronic coronary syndrome require immediate initiation of aspirin 75–100 mg daily, high-intensity statin therapy targeting LDL-cholesterol <55 mg/dL, an ACE inhibitor, beta-blocker for symptom control, and sublingual nitroglycerin for acute angina relief. 1

Foundation Pharmacotherapy for Event Prevention

Every patient with chronic coronary syndrome must receive the following medications to reduce cardiovascular mortality and major vascular events:

Antiplatelet Therapy

• Aspirin 75–100 mg daily is mandatory for all patients with established coronary disease, particularly those with prior myocardial infarction or revascularization. 1
• Clopidogrel 75 mg daily is the only acceptable alternative when aspirin is absolutely contraindicated. 2, 1
• After coronary stent implantation, dual antiplatelet therapy (aspirin plus clopidogrel) is required for 6 months, shortened to 1–3 months only if life-threatening bleeding risk exists. 1, 3
• Never use dipyridamole—it worsens exercise-induced myocardial ischemia. 2, 1

Lipid-Lowering Therapy

• High-intensity statin therapy must be started immediately in every patient to reduce major vascular events and death. 1
• Target LDL-cholesterol <55 mg/dL (1.4 mmol/L) with at least 50% reduction from baseline. 1, 3
• If maximum tolerated statin dose fails to achieve target, add ezetimibe. 1
• For very high-risk patients still not at goal on statin plus ezetimibe, add bempedoic acid, then a PCSK9 inhibitor if needed. 1

Renin-Angiotensin System Inhibition

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

Pharmacotherapy for Symptom Control

First-Line Anti-Anginal Agents

• Beta-blockers are first-line for controlling heart rate and relieving angina symptoms, especially in patients with prior myocardial infarction. 2, 1
• Do not withhold beta-blockers in diabetic patients—they obtain equal or greater benefit compared with non-diabetic patients. 1
• Sublingual nitroglycerin or nitroglycerin spray must be prescribed to all patients for immediate relief of effort angina. 2, 1

Second-Line Anti-Anginal Agents

• Long-acting calcium channel blockers are appropriate when beta-blockers are contraindicated or poorly tolerated. 2, 1
• Long-acting calcium channel blockers or long-acting nitrates may be added when beta-blocker monotherapy fails to control symptoms. 2, 1
• Long-acting calcium channel blockers are generally preferred over long-acting nitrates for maintenance therapy because they provide sustained 24-hour anti-ischemic effects. 2, 1
• Never use immediate-release or short-acting dihydropyridine calcium antagonists—they increase adverse cardiac events. 2, 1

Emerging Therapies with Proven Cardiovascular Benefit

Glucose-Lowering Agents

• SGLT2 inhibitors with proven cardiovascular benefit are mandatory for patients with type 2 diabetes and chronic coronary syndrome, independent of HbA1c levels. 1, 3
• Semaglutide should be considered in non-diabetic patients with overweight/obesity (BMI >27 kg/m²) to reduce cardiovascular mortality, myocardial infarction, and stroke. 1, 3

Anti-Inflammatory Therapy

• Low-dose colchicine 0.5 mg daily should be considered to reduce myocardial infarction, stroke, and need for revascularization. 1, 3

Lifestyle Interventions

• Exercise-based cardiac rehabilitation is mandatory—it significantly reduces cardiovascular mortality and morbidity while improving risk factor control. 1, 4
• Aerobic physical activity: 150–300 minutes per week of moderate intensity OR 75–150 minutes per week of vigorous intensity. 3
• Annual influenza vaccination is required, especially in elderly patients, to reduce mortality risk. 1, 4
• Smoking cessation interventions must be implemented immediately. 1

Indications for Invasive Coronary Angiography

Urgent invasive coronary angiography with FFR/iFR guidance is required for:

• Severe angina refractory to maximal medical therapy. 1
• Left ventricular ejection fraction <50%. 1
• High-risk anatomical features: left main disease, multivessel disease with reduced LV function, multivessel disease with diabetes, or >10% of LV mass ischemic on non-invasive testing. 1
• Recurrent ischemia with dynamic ST-segment changes, elevated troponin, hemodynamic instability, or major arrhythmias. 1

Revascularization Decision-Making

Mandatory Revascularization Indications

• Left main stenosis with LVEF >35% requires revascularization to improve survival. 1
• Three-vessel disease with LVEF >35% requires revascularization to improve long-term survival and reduce cardiovascular mortality. 1
• Single- or two-vessel disease involving proximal LAD with LVEF >35% requires revascularization to reduce cardiovascular mortality and spontaneous myocardial infarction. 1
• Angina persisting despite guideline-directed medical therapy requires revascularization of functionally significant obstructive disease. 1

Choice of Revascularization Modality

• CABG is preferred over PCI for left main disease and complex multivessel disease due to lower rates of spontaneous myocardial infarction and repeat revascularization. 1
• PCI may be offered for left main disease of low anatomical complexity (SYNTAX score ≤22) when completeness of revascularization is comparable to CABG. 1
• A multidisciplinary Heart Team discussion is mandatory for complex multivessel disease to select the optimal treatment strategy. 1
• Intracoronary imaging (IVUS or OCT) is mandatory when performing PCI on anatomically complex lesions. 1
• Fractional flow reserve or instantaneous wave-free ratio measurement is mandatory to guide lesion selection in multivessel disease. 1

Monitoring and Follow-Up

• Review patient response to medical therapies 2–4 weeks after drug initiation. 1, 4, 3
• Annual clinical follow-up to assess symptoms, functional status, adherence to lifestyle and medical interventions, and monitor for complications. 1
• Simplify medication regimens using fixed-dose combinations to improve adherence. 3

Critical Pitfalls to Avoid

• Do not use chelation therapy—it lacks proven benefit. 2, 1
• Do not perform coronary angiography solely for risk stratification—optimize medical therapy first except in high-risk patients with persistent symptoms. 1
• Do not use coronary CT angiography as a routine follow-up test for patients with established coronary disease. 1
• Do not combine ACE inhibitors with ARBs. 1