Management of Patients with Chronic Coronary Disease (CCD): PART 2 (Medical therapy and Revascularization)
SUMMARY
Chronic coronary disease (CCD) affects 20 million persons in the United States. CCD includes patients with obstructive and nonobstructive coronary artery disease with or without previous heart attacks or revascularization.
- Antiplatelet Therapy
- Beta Blockers
- Renin-Angiotensin-Aldosterone Inhibitors
- Lipid Therapy
- Blood Pressure Management
- Diabetes Management
- Angina Management
- Revascularization
- Women, Pregnancy and Postmenopausal Therapy
- HIV and Autoimmune Disorders
Antiplatelet Therapy
- Aspirin (81mg) is recommended to reduce atherosclerotic events (if no indication for oral anticoagulation)
- Post percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT)- aspirin and clopidogrel for 6 months post PCI is recommended
- Without recent ACS or PCI, DAPT is NOT recommended.
- PPI can be effective in reducing GI bleeding risk in patients on DAPT
- Prasugrel should NOT be used due to increased risk of bleeding in patients with previous stroke or TIA
- In patients who have undergone elective PCI who also require oral anticoagulation, DAPT for 1-4 weeks followed by clopidogrel alone for 6 months in addition to DOAC is advised.
- Chronic non-steroidal anti-inflammatory drugs should NOT be used due to increased cardiovascular and bleeding complications.
Beta Blockers
- In patients with CCD and LVEF <50% with or without previous heart attacks, use of sustained release metoprolol succinate, carvedilol or bisoprolol is recommended
- In patients with prior heart attacks WITHOUT history or current LVEF <50%, angina, arrhythmias, or uncontrolled hypertension, it may be reasonable to stop beta blocker after 2 years since heart attack event
Renin-Angiotensin-Aldosterone Inhibitors
- In patients with CCD who also have hypertension, diabetes, LVEF <40% or chronic kidney disease, use of Angiotensin-converting enzyme inhibitors or Angiotensin II receptor blockers is recommended to reduce cardiovascular events
Lipid Therapy
- High-intensity statin is recommended with goal of achieving >50% LDL-C levels to reduce risk of major adverse cardiovascular events (MACE)
- Effects of statins should be assessed with lipid panel in 4 to 12 weeks after statin initiation or dose adjustment and every 3 to 12 months thereafter to assess response or adherence to therapy
- Addition of non-statin medications (ezetimibe | PCSK9 monoclonal antibody) can be beneficial to further reduce risk of MACE in patients on maximally tolerated statin therapy at high risk with LDL-C >70 mg/dl
- The use of nonprescription or dietary supplements, including fish oil and omega-3 fatty acids or vitamins, is not recommended in patients with chronic coronary disease given the lack of benefit in reducing cardiovascular events.
Blood Pressure Management
- Blood pressure goal in patients with CCD is <130/<80 mmHg to reduce cardiovascular events and all-cause death.
- Nonpharmacological strategies are recommended as first-line therapy to lower BP
| Weight Loss | 1 mmHg drop for every 1 kg reduction in body weight. |
| Healthy Diet(heart healthy diet rich in fruits in vegetables, Mediterranean diet) | 11 mmHg drop in hypertensive patients |
| Dietary Sodium | Goal <1.5 grams/day. Expect 5 mmHg drop in hypertensive patients |
| Dietary Potassium | Aim for 3.5-5 grams/day (if no issues with hyperkalemia). Expect 5 mmHg drop in hypertensive patients |
| Physical Activity | Depending on type of exercise, expect between 4 to 8 mmHg drop in hypertensive patients |
| Alcohol Consumption | Limit to ≤ 1 drink per day for women and ≤ 2 drinks per men. Expect 4 mmHg drop in hypertensive patients |
Diabetes Management
- Use of sodium glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists with proven cardiovascular benefit is recommended
- In patients with CCD and heart failure (reduced or preserved LVEF), SGLT2 inhibitors is recommended, regardless of diabetes status
- Hemoglobin A1c goal of <7% or <8% for older patients at risk of hypoglycemia
Angina Management
- Anti-anginal management includes either monotherapy or combination of beta blocker, calcium channel blocker or long-acting nitrates to achieve symptomatic relief
- In persistently symptomatic patients with angina despite above treatment, ranolazine is recommended.
- In medically refractory angina, enhanced external counter pulsation (EECP) can be considered.
Revascularization
- In patients with CCD with LIFESTYLE-LIMITING angina despite guideline directed medical therapy, revascularization is recommended to improve symptoms
- In patients with significant left main or multivessel disease and severe LV dysfunction (LVEF <35%, coronary artery bypass grafting (CABG) is recommended to improve SURVIVAL.
- In patients with significant left main disease, CABG is recommended to improve SURVIVAL.
- In patients with CCD that are poor surgical candidates, reasonable to choose percutaneous coronary intervention (PCI) to improve symptoms and reduce major adverse cardiac events
- In patients with CCD, diabetes and multivessel CAD with involvement of left anterior descending artery, CABG is recommended over PCI to reduce mortality and repeat revascularizations
- Routine periodic anatomic or ischemic testing without a change in clinical or functional status is not recommended for risk stratification or to guide therapeutic decision-making in patients with chronic coronary disease
Women, Pregnancy and Postmenopausal Therapy
- ACE-inhibitors |ARB| Direct renin inhibitors| Angiotensin receptor neprilysin inhibitors |Aldosterone antagonist in women with CCD during pregnancy or when contemplating pregnancy is contraindicated
- Continuation of statin during pregnancy is debatable
- Systemic postmenopausal hormone therapy is not advised due to increased risk of venous thromboembolism
HIV and Autoimmune Disorders
- Antiretroviral therapy is beneficial to decrease risk of cardiovascular events in patients with CCD and HIV
- Lovastatin and simvastatin should NOT be used concomitantly with protease inhibitors
- In patients with CCD and autoimmune disorders, use of immune modulating therapies to decrease inflammatory disease activity is helpful at decreasing risk of CV events
- In patients with CCD and rheumatoid arthritis, high dose steroids (≥ 5 mg prednisone) should NOT be used long term if alternative therapies available due to increased cardiovascular risk
