Latest Management of Coronary Artery Disease

Fuster and Hurst's The Heart, 15th Edition - Overview of chronic CAD management

Part 1: Chronic Coronary Syndromes (CCS) / Stable CAD

1. Lifestyle Measures (Class I)

• Physical activity: 30-60 minutes of moderate-intensity aerobic exercise (e.g. brisk walking) 5-7 days/week. Cardiac rehabilitation reduces cardiovascular mortality by ~26% and hospital admissions by ~18% vs. usual care (meta-analysis of 63 RCTs, n=14,486).
• Diet: Replace saturated/trans fats with unsaturated fats; reduce dietary cholesterol; add plant stanols/sterols (2 g/day) and soluble fiber (>10 g/day).
• Smoking cessation: Mandatory - both non-pharmacological and pharmacological support.
• Weight management: Avoid excessive weight fluctuations, which are independently harmful in CAD.
• Alcohol: Moderate consumption; avoid marijuana and air pollution.
• Depression screening: Escitalopram treatment after recent ACS with depression reduced MACE in a randomized trial.

2. Pharmacological Therapy - Secondary Prevention

Antiplatelet Therapy

• Aspirin 75-162 mg/day: Class I for all CCS patients. Reduces major vascular events, MI (RR 0.69), and stroke (RR 0.81) vs. placebo (16 RCTs, ~17,000 patients).
• Dual antiplatelet therapy (DAPT): Low-dose aspirin + P2Y12 inhibitor maintained after PCI. Duration varies: typically 6-12 months post-PCI; may be shortened for high bleeding risk or extended for high ischemic risk.
• Newer P2Y12 inhibitors (ticagrelor, prasugrel) are preferred over clopidogrel in high-risk settings (Class I, 2025 ACC/AHA ACS Guideline).

Lipid-Lowering Therapy

• High-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg): Class I for all CCS patients, regardless of baseline LDL. Target LDL-C <55 mg/dL (1.4 mmol/L) with ≥50% reduction from baseline (2024 ESC CCS Guideline).
• Add-on non-statin therapy (2025 ACC/AHA ACS update, Class I): If LDL-C remains ≥70 mg/dL on maximally tolerated statin:
  • Ezetimibe (Class I)
  • PCSK9 inhibitors (evolocumab, alirocumab) - Class I for very high risk with inadequate LDL control on statin + ezetimibe
  • Inclisiran (siRNA, newer agent) - emerging option

Beta-Blockers

• Class I for all patients with prior MI or LV systolic dysfunction (EF ≤40%). Reduce heart rate, myocardial oxygen demand, and arrhythmia risk.
• In CCS without prior MI or LV dysfunction: primarily used for symptom control of angina.
• Target resting heart rate 55-60 bpm in angina.

Renin-Angiotensin-Aldosterone System (RAAS) Inhibitors

• ACE inhibitors (or ARBs if ACE-I intolerant): Class I for all CCS patients with LV EF ≤40%, hypertension, or diabetes.
• Perindopril, ramipril, and lisinopril have the strongest evidence in CAD.

Nitrates

• Sublingual nitroglycerin: Immediate relief of acute angina attacks (Class I).
• Long-acting nitrates: For angina prophylaxis; tolerance develops - nitrate-free intervals required.

Calcium Channel Blockers (CCBs)

• Amlodipine or diltiazem: First-line anti-anginal when beta-blockers are contraindicated or insufficient. Vasospastic (Prinzmetal) angina: CCBs are the cornerstone treatment.

Ranolazine

• Late sodium channel blocker; reduces anginal episodes when standard anti-anginals are inadequate. Does not affect heart rate or blood pressure. Particularly useful in patients where HR-lowering agents are not tolerated.

Ivabradine

• Selectively reduces heart rate via If channel inhibition. Used in CCS with EF ≤35% who remain symptomatic on maximally tolerated beta-blockers (Class IIa).

Influenza Vaccination

• Recommended annually in all CCS patients (Class I, 2023 AHA/ACC CCD Guideline) - reduces risk of cardiovascular events.

3. Revascularization in Stable CAD

Part 2: Acute Coronary Syndromes (ACS) - 2025 ACC/AHA Updates

Initial Evaluation and Risk Stratification

• 12-lead ECG within 10 minutes of first medical contact.
• High-sensitivity troponin for rapid rule-in/rule-out (0h/1h or 0h/2h algorithms).
• Risk scores: TIMI, GRACE for NSTEMI; guides invasive timing.

Antiplatelet and Antithrombotic Therapy (ACS)

Reperfusion for STEMI

• Primary PCI: Preferred if door-to-balloon ≤90 min (or ≤120 min if transferred). Class I.
• Fibrinolysis: When PCI unavailable within 120 min of first medical contact. Immediate transfer for rescue PCI if fibrinolysis fails.
• Complete revascularization: Now Class I - treat significant non-culprit stenoses (can be same procedure or staged). Single-procedure multivessel PCI is slightly preferred for STEMI.
• Manual aspiration thrombectomy: Class III (no benefit - should NOT be performed routinely).

Cardiogenic Shock

• Emergency PCI of the culprit vessel: Class I.
• Routine PCI of non-infarct arteries at time of primary PCI in cardiogenic shock: Class III (not recommended).
• Mechanical circulatory support (MCS): Guidance updated; intra-aortic balloon pump, Impella, VA-ECMO considered based on patient hemodynamics.

NSTEMI - Invasive Strategy Timing

• Immediate invasive (<2h): Refractory angina, hemodynamic instability, electrical instability.
• Early invasive (<24h): GRACE score >140, troponin rise, dynamic ST changes.
• Elective invasive (24-72h): Intermediate risk NSTEMI.
• Conservative strategy: Elderly, high bleeding risk, stable low-risk NSTEMI.

Long-Term/Discharge Therapies After ACS

Part 3: Special Populations

Summary of Key 2024-2025 Guideline Updates

1. Unified STEMI+NSTEMI guideline - first time both ACS types in a single ACC/AHA document (2025).
2. Intracoronary imaging (IVUS/OCT) upgraded to Class I for left main and complex PCI lesions.
3. LDL targets more aggressive: Statin + ezetimibe (Class I) if LDL ≥70 on statin; PCSK9i if still elevated.
4. Complete revascularization in STEMI/NSTEMI now Class I.
5. Ticagrelor/prasugrel preferred over clopidogrel (Class I) for PCI.
6. SGLT2 inhibitors and GLP-1 agonists are integral to CAD management in diabetics.
7. Colchicine (anti-inflammatory therapy) has Class IIa evidence post-MI.
8. Aspiration thrombectomy remains Class III - no benefit.

• 2025 ACC/AHA ACS Guideline (Rao et al., Circulation 2025 - PMID 40014670)
• 2024 ESC Guidelines for Chronic Coronary Syndromes (Vrints et al., Eur Heart J 2024 - PMID 39210710)
• 2023 AHA/ACC Guideline for Chronic Coronary Disease (Virani et al., Circulation 2023 - PMID 37471501)
• Fuster and Hurst's The Heart, 15th Edition - Chapter 21 (Stable Ischemic Heart Disease)