What is the optimal medical and interventional management for a patient with coronary artery disease?

Optimal Management of Coronary Artery Disease

All patients with coronary artery disease require lifelong statin therapy targeting LDL-C <55 mg/dL, aspirin 75-100 mg daily (or clopidogrel 75 mg if aspirin-intolerant), beta-blockers and/or calcium channel blockers for symptom control, plus aggressive lifestyle modification including 150-300 minutes weekly of moderate-intensity aerobic exercise. 1, 2, 3

Foundation Medical Therapy (Mandatory for All Patients)

Antiplatelet Therapy

• Aspirin 75-100 mg daily lifelong for patients with prior myocardial infarction or revascularization 1, 2
• Clopidogrel 75 mg daily is equally safe and effective as aspirin monotherapy and should be used as first-line alternative in aspirin-intolerant patients 1, 3
• Dual antiplatelet therapy (aspirin + clopidogrel) for 6 months after percutaneous coronary intervention, shortened to 1-3 months only in patients at high bleeding risk but not high ischemic risk 1, 2
• Aspirin 75-100 mg daily lifelong is mandatory after coronary artery bypass grafting 3

Lipid-Lowering Therapy (Aggressive Targets)

• Statins are mandatory in all patients with coronary artery disease 1, 2
• Target LDL-C <1.4 mmol/L (55 mg/dL) with ≥50% reduction from baseline 3
• Add ezetimibe if goals not achieved with maximum tolerated statin dose 1, 2
• Add PCSK9 inhibitor (evolocumab or alirocumab) for very high-risk patients not achieving goals on statin plus ezetimibe 1, 2, 3
• Consider bempedoic acid as additional option for lipid lowering 3

ACE Inhibitors/ARBs

• ACE inhibitors (or ARBs if ACE-intolerant) are mandatory in patients with heart failure, left ventricular dysfunction following myocardial infarction, diabetes, or hypertension 1, 2
• ACE inhibitors reduce symptoms and mortality in symptomatic heart failure or asymptomatic left ventricular dysfunction post-MI 1

Antianginal Therapy for Symptom Control

First-Line Agents

• Short-acting sublingual nitroglycerin for immediate relief of acute angina episodes 2, 3
• Beta-blockers and/or calcium channel blockers as first-line chronic therapy, selected based on heart rate, blood pressure, left ventricular function, and comorbidities 1, 2, 3
• Beta-blockers are particularly essential in patients with heart failure or prior myocardial infarction due to mortality benefit 1

Second-Line Agents (If First-Line Inadequate)

• Long-acting nitrates, ivabradine (if sinus rhythm with heart rate ≥70 bpm on beta-blockers), ranolazine, or trimetazidine may be added 2
• Avoid combining ivabradine with non-dihydropyridine calcium channel blockers due to excessive bradycardia risk 2
• Avoid nitrates in hypertrophic cardiomyopathy or when co-administered with phosphodiesterase-5 inhibitors 2

Emerging Therapies with Proven Cardiovascular Benefit

SGLT2 Inhibitors

• SGLT2 inhibitors with proven cardiovascular benefit are mandatory for patients with type 2 diabetes and coronary artery disease to reduce cardiovascular events, independent of glycemic control 3

GLP-1 Receptor Agonists

• Semaglutide should be considered in patients without diabetes but with overweight/obesity (BMI >27 kg/m²) to reduce cardiovascular mortality, myocardial infarction, or stroke 3

Anti-Inflammatory Therapy

• Colchicine 0.5 mg daily should be considered in patients with atherosclerotic coronary artery disease to reduce myocardial infarction, stroke, and need for revascularization 3

Lifestyle Modifications (Non-Negotiable)

Exercise Prescription

• Aerobic physical activity: 150-300 minutes per week of moderate intensity OR 75-150 minutes per week of vigorous intensity 2, 3
• Exercise-based cardiac rehabilitation is mandatory and reduces mortality 2, 3
• Reduce sedentary time throughout the day 3

Multidisciplinary Approach

• Involve cardiologists, primary care physicians, nurses, dieticians, physiotherapists, psychologists, and pharmacists 2
• Mobile health interventions (text messages, apps, wearable devices) improve adherence to lifestyle changes and medical therapy 2

Risk Factor Control

• Comprehensive management of hypertension, hyperlipidemia, diabetes, anemia, and obesity 1, 2
• Smoking cessation is mandatory 1, 2
• Annual influenza vaccination, especially in elderly patients 1, 2

Revascularization Strategy

Indications for Invasive Coronary Angiography

Invasive coronary angiography with FFR/iFR guidance is indicated for: 1, 2, 3

• Symptoms refractory to optimal medical therapy
• High-risk features on non-invasive testing (≥10% ischemic myocardium on stress imaging)
• Left main disease ≥50% stenosis on coronary CTA
• Three-vessel disease with ≥70% stenosis
• Two-vessel disease with ≥70% stenosis including proximal left anterior descending artery
• Proximal left anterior descending artery disease ≥70% with FFR-CT ≤0.8
• Deteriorating left ventricular systolic function without reversible cause

Revascularization Method Selection

• Coronary artery bypass grafting for left main stenosis ≥50%, three-vessel disease, or two-vessel disease with proximal left anterior descending involvement 1
• Percutaneous coronary intervention for single or two-vessel disease without proximal left anterior descending involvement in symptomatic patients 1
• Functional assessment (FFR/iFR) must be used to evaluate stenoses before revascularization unless very high grade (>90% diameter stenosis) 1

Important Caveat

Revascularization benefit is confined to patients with persistent symptoms despite optimal medical therapy - the severity of symptoms does not always correlate with severity of obstructive disease, particularly in women 1, 2

Risk Stratification and Diagnostic Testing

Initial Assessment

• Resting echocardiography to quantify left ventricular function in all patients 1, 3
• Risk stratification using stress imaging (preferred) or coronary CTA for patients with suspected or newly diagnosed disease 1, 2, 3
• Exercise stress ECG acceptable only if significant exercise capacity exists and ECG is interpretable 3

Functional Assessment of Intermediate Stenoses

• Fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) for intermediate-grade stenosis (40-90%) without evidence of ischemia on non-invasive testing 1
• CT-FFR or myocardial CT perfusion may be considered for moderate stenosis (50-69%) if results will change management 1

Coronary CTA Limitations

• Coronary CTA is not recommended when extensive coronary calcification is present due to poor image quality 1
• Coronary CTA is not recommended as routine follow-up test for established disease 1

Special Populations

Spontaneous Coronary Artery Dissection (SCAD)

• Conservative medical approach is preferred except in very high-risk patients (left main, proximal vessel involvement, multivessel SCAD, or hemodynamic instability) 1
• Beta-blockers are recommended due to association with reduced recurrent SCAD 1
• Aggressive antihypertensive therapy is essential as hypertension predicts recurrent SCAD 1
• Dual antiplatelet therapy benefit is questionable in medically managed SCAD patients 1

Patients with Heart Failure

• Diuretics for pulmonary or systemic congestion 1
• Mineralocorticoid receptor antagonist if symptomatic despite ACE inhibitor and beta-blocker 1
• Cardiac resynchronization therapy for symptomatic patients in sinus rhythm with QRS ≥150 ms and left bundle branch block morphology, LVEF <35% despite optimal medical therapy 1
• Implantable cardioverter-defibrillator for symptomatic heart failure with LVEF <35% to reduce sudden death 1

Women

• Similar guideline-directed preventive therapy as men 2
• Avoid systemic post-menopausal hormone therapy due to lack of cardiovascular benefit and increased thromboembolic risk 2
• Recognize that symptom severity does not always correlate with obstructive disease severity in women 2

Patients with Diabetes

• More extensive coronary calcification and complex anatomy 4
• Vasodilating beta-blockers preferred to avoid adverse metabolic effects 4

HIV Patients

• Attention to interaction between antiretroviral treatment and statins 2

Gastrointestinal Protection

• Proton pump inhibitor in patients receiving aspirin monotherapy, dual antiplatelet therapy, or oral anticoagulant monotherapy who are at high risk of gastrointestinal bleeding 1

Follow-Up and Monitoring

Timing of Reassessment

• Review response to medical therapies 2-4 weeks after drug initiation 2, 3
• Annual visits to assess risk factor control, lifestyle modification adherence, and disease status changes 1, 2, 3
• Reassess disease status in patients with deteriorating left ventricular function or new/worsening symptoms 1, 3

Adherence Strategies

• Simplify medication regimens using fixed-dose combinations to improve adherence 2, 3
• Mobile health interventions to support adherence 2

Critical Pitfalls to Avoid

• Never classify chest pain as non-cardiac without thorough evaluation including objective exclusion of myocardial ischemia 2
• Never perform invasive coronary angiography solely for risk stratification without clinical indication 1
• Never use ticagrelor or prasugrel as part of triple antithrombotic therapy with aspirin and oral anticoagulant 1
• Assess bleeding risk using validated tools before initiating antithrombotic therapy 2
• Recognize that deferred revascularization based on FFR/iFR in acute coronary syndrome patients has worse outcomes compared to stable disease 1