Treatment

The goal of treatment is to reduce cardiovascular morbidity and mortality, improve ischemic symptoms, and maintain quality of life.

• All patients: pharmacotherapy for CAD

  • Start secondary prevention of CAD, i.e., antiplatelet agents, statins, and management of comorbidities.

  • Start antianginal medication.

• Select patients: revascularization

  • Not routinely recommended for stable CAD

  • Techniques

    • Percutaneous coronary intervention (PCI)

    • Coronary artery bypass grafting (CABG)

All patients with CAD should receive education on risk factor reduction, as well as treatment with antiplatelet agents and antianginal medications

Pharmacotherapy for CAD has two main therapeutic goals, secondary prevention for CAD and symptomatic relief with antianginal treatment. Specific indications and potential effects should be taken into account before prescribing the different drug classes.

Antianginal drugs

• Goal: reduction of myocardial oxygen demand (MVO2)

• First-line agent: beta blockers

• Second-line agents: CCBs, nitrates, ranolazine

  • Consider as initial monotherapy for patients with contraindications to beta blockers (e.g., vasospastic angina).

  • Consider as combination therapy with beta blockers to improve symptom control , e.g., a beta blocker PLUS a nitrate, dihydropyridine CCB , OR ranolazine.

  • CCB (nondihydropyridine) PLUS a nitrate (nondihydropyridine CCBs such as verapamil have a similar effect to beta blockers on cardiac conduction) [27]

• Third-line agent: Consider ranolazine if beta-blockers, CCBs, and nitrates are ineffective or not tolerated.

Decisions regarding revascularization are complex and should be made with a multidisciplinary team of specialists (e.g., interventional cardiologists, cardiac surgeons) on an individual basis. See “Acute coronary syndrome” for revascularization indications of patients with acute symptoms.

• Indications

  • High-risk anatomic lesions involving multiple or critical vessels

  • Activity-limiting symptoms due to any significant coronary artery stenosis that persist:

    • Despite optimal medical treatment

    • OR due to contraindications to pharmacotherapy

• Options

  • CABG

  • PCI

• Prognostic factors

  • Left ventricular function: increased mortality if EF < 50% [33]

  • Involvement of left main coronary artery or involvement of more than one vessel is associated with a worse prognosis

• Stable angina

  • Annual mortality rate: up to 5% [12]

  • 25% of patients will develop acute MI within the first 5 years. [34]

  • High-grade stenosis is associated with an unfavorable prognosis.

Primary prevention of CAD

Similar to other atherosclerotic cardiovascular diseases: See “ASCVD prevention.”

Secondary prevention of CAD

• Lifestyle modifications

  • Smoking cessation

  • Increased physical activity

• Lifelong antiplatelet therapy with aspirin or clopidogrel

• Treatment of comorbidities

  • Hypertension

    • Target BP in hypertension: < 130/80 mm Hg [29]

    • First-line treatment: beta blockers

    • Alternative: ACE inhibitors or angiotensin receptor blockers (ARBs), especially in patients post MI

  • Diabetes mellitus

    • Individualized glycemic goals (e.g., HbA1c < 7%)

    • Consider the use of antihyperglycemics with known protective cardiovascular effects in patients with T2DM. [35]

• Lipid-lowering therapy

  • Moderate- or high-intensity statin therapy

  • Consider second-line lipid-lower therapy if there is a poor response to statin monotherapy.