Stable Coronary Artery Disease: Treatment

 

Am Fam Physician. 2018 Mar 15;97(6):376-384.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/coronary-artery-disease-cad.

  Related letter: Evidence Supporting Niacin Therapy Is More Nuanced Than Article States

Author disclosure: No relevant financial affiliations.

Stable coronary artery disease refers to a reversible supply/demand mismatch related to ischemia, a history of myocardial infarction, or the presence of plaque documented by catheterization or computed tomography angiography. Patients are considered stable if they are asymptomatic or their symptoms are controlled by medications or revascularization. Treatment involves risk factor management, antiplatelet therapy, and antianginal medications. Tobacco cessation, exercise, and weight loss are the most important lifestyle modifications. Treatment of comorbidities such as diabetes mellitus, hyperlipidemia, and hypertension should be optimized to reduce cardiovascular risk. All patients should be started on a statin unless contraindicated. No data support the routine use of monotherapy with nonstatin drugs such as bile acid sequestrants, niacin, ezetimibe, or fibrates. Studies of niacin and fibrates as adjunctive therapy found no improvement in patient outcomes. Aspirin is the mainstay of antiplatelet therapy; clopidogrel is an alternative. Antianginal medications should be added in a stepwise approach beginning with a beta blocker. Calcium channel blockers, nitrates, and ranolazine are used as adjunctive or second-line therapy when beta blockers are ineffective or contraindicated. Select patients may benefit from coronary revascularization with percutaneous coronary intervention or coronary artery bypass grafting.

Stable coronary artery disease (CAD) refers to a reversible supply/demand mismatch related to ischemia, a history of myocardial infarction (MI), or the presence of plaque documented by catheterization or computed tomography angiography. Patients are considered stable if they are asymptomatic or if their symptoms are controlled by medications or revascularization.1,2 In the United States, approximately 25% of men and 16% of women 60 to 79 years of age have diagnosed or undiagnosed CAD, or a cardiovascular disease (CVD) equivalent such as stroke or peripheral arterial disease.3 CAD is one of the leading causes of mortality in the United States, accounting for 31% of all deaths in 2013.3 However, the CVD mortality rate has declined 28% since 2003 because of advances in treatment, risk factor reduction, and prevention.3 Treatment of stable CAD involves lifestyle changes, risk factor modification, and antiplatelet and antianginal therapy.

WHAT IS NEW ON THIS TOPIC

Stable Coronary Artery Disease

An RCT of 200 patients with severe single-vessel coronary stenosis (≥ 70%) found no differences between groups in exercise time or anginal relief six weeks after percutaneous coronary intervention or a sham procedure.

In a large RCT, older adults with no diabetes mellitus who had cardiovascular disease or at least a 15% 10-year risk of cardiovascular events were randomized to a systolic blood pressure target of 120 or 140 mm Hg. After three years, the group with the lower blood pressure target had less all-cause mortality (NNT = 83) and heart failure (NNT = 125), but more hypotension, acute kidney injury, and electrolyte abnormalities.

In three large randomized trials of high-risk patients with coronary artery disease and diabetes, liraglutide (Victoza), semaglutide (Ozempic), and empagliflozin (Jardiance) decreased cardiovascular deaths (NNT = 43 to 71 over two to three years).


NNT = number needed to treat; RCT = randomized controlled trial.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

High-intensity statin therapy is recommended for all patients younger than 75 years with stable CAD, unless contraindicated.

A

1, 2, 9, 10, 12

Daily low-dose aspirin is recommended for all patients with stable CAD, unless contraindicated.

A

1, 2

Beta blockers should be continued for up to three years after myocardial infarction in patients with abnormal left ventricular function.

B

1, 2

Select patients with uncontrolled symptoms of stable CAD despite optimal medical management may benefit from coronary revascularization with percutaneous coronary intervention or coronary artery bypass grafting.

B

5962


CAD = coronary artery disease.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

High-intensity statin therapy is recommended for all patients younger than 75 years with stable CAD, unless contraindicated.

A

1, 2, 9, 10, 12

Daily low-dose aspirin is recommended for all patients with stable CAD, unless contraindicated.

A

1, 2

Beta blockers should be continued for up to three years after myocardial infarction in patients with abnormal left ventricular function.

B

1, 2

Select patients with

The Authors

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MICHAEL M. BRAUN, DO, is director of inpatient medicine for the Department of Family Medicine at Madigan Army Medical Center, Joint Base Lewis-McCord, Wash....

WILLIAM A. STEVENS, MD, is chief resident in the Department of Family Medicine at Madigan Army Medical Center.

CRAIG H. BARSTOW, MD, is director of the hospitalist fellowship at Womack Army Medical Center, Fort Bragg, N.C.

Address correspondence to Michael M. Braun, DO, Madigan Army Medical Center, 9040 Fitzsimmoms Dr., Tacoma, WA 98431 (e-mail: michael.m.braun.civ@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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