How are patients with coronary artery disease currently managed?

The overarching aims of the treatment of coronary artery disease (CAD) are to reduce symptoms and improve prognosis. The management of CAD includes patient education and interventions to:1,2

  • Control symptoms
  • Limit further progression of atherosclerosis through control of cardiovascular (CV) risk factors
  • Prevent potentially fatal ischaemic events and improve survival

Management of angina symptoms

Control of CAD symptoms involves the use of anti-ischaemic drugs to provide angina relief:1,2

  • First-line therapies consist of short-acting nitrates to cause coronary vasodilatation with beta-blockers and/or calcium channel blockers to control heart rate, increase perfusion to ischaemic areas and promote vasodilation
  • Second-line therapies include long-acting nitrates and ranolazine – an inhibitor of the late sodium current

If symptoms persist despite optimal medical therapy, revascularization may be indicated to provide symptom relief in patients with any coronary stenosis >50%.1,3 Revascularization may also be indicated to improve prognosis in patients with severe stenosis in multiple arteries or in one very significant artery (e.g. the left main coronary artery).3

Cardiovascular risk factor control

CV risk factor control is best achieved as part of coordinated, multidisciplinary programme that should include:1,2,4

  • Patient education
  • Smoking cessation advice and support
  • Lifestyle changes promoting lipid, blood pressure and diabetes control (e.g. regular physical exercise, adopting a healthy diet, following a weight-management programme)
  • Use of medical therapies aiding lipid, blood pressure and diabetes control (e.g. statins, antihypertensives, insulin/glycaemic control medication)
  • Psychosocial management, such as social support and treatment of underlying conditions such as depression and anxiety

Protection against CV events

For protection against major CV events, all patients with CAD should receive:1,2

  • Single antiplatelet therapy with acetylsalicylic acid (ASA), or clopidogrel as an alternative in case of ASA intolerance
  • A statin to reduce blood low-density lipoprotein (LDL) levels

Guidelines also recommend additional therapies for protection against CV events in patients with certain co-morbidities:1,2

  • An angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin receptor blocker [ARB] as an alternative) in patients with hypertension, heart failure (with a left ventricular ejection fraction [LVEF] ≤40%), diabetes or chronic kidney disease
  • Beta-blockers in patients with CAD who have experienced an acute coronary syndrome (ACS) within the previous 3 years or who have heart failure (with a LVEF ≤40%)

Recently, a number of new medications have also been shown to reduce CV events in patients with atherosclerotic disease and co-morbidities,4 including liraglutide and empagliflozin for glucose control in type 2 diabetes, and evolocumab and alirocumab for lipid control (see here for more information). Ongoing trials are also evaluating optimal treatments for secondary prevention of CV events in patients with atherosclerotic disease, and these results are likely to hold great promise for physicians and patients alike.


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