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CHAPTER 11
Stable Coronary Artery Disease
Abhiram Prasad and Bernard J. Gersh
The main objectives of treatment for stable coronary artery disease (CAD) are the relief of symptoms related to myocardial ischemia and improvement in prognosis. Significant progress has been made over the past four decades in drug therapy, percutaneous coronary intervention (PCI), and coronary artery bypasses grafting (CABG). While this chapter focuses on percutaneous revascularization, it is important to remember that medical therapy and secondary prevention have a central role in the management of coronary atherosclerosis. Secondary prevention via lifestyle modification, treatment of conventional risk factors (Table 11.1), and drug therapy (Figure 11.1) [1–3] reduces cardiovascular mortality, myocardial infarction, unstable angina, onset of heart failure, and the need for revascularization, likely by plaque stabilization and limiting the progression of atherosclerosis.
Table 11.1 Optimal secondary prevention in stable coronary artery disease.
| Risk factor | Goal/recommended intervention |
|---|---|
| Lipid management | The optimal goal of treatment is to lower LDL‐C by at least 50% from baseline and to <1.4 mmol/L (<55 mg/dL) although a lower target LDL‐C of <1.0 mmol/L (<40 mg/dL) may be considered in patients who have experience a second vascular event within 2 years. Statins are recommended in all patients. If treatment goal not reached, then add ezetimibe, and if that fails, combination with a PCSK9 inhibitor is recommended. |
| Blood pressure control | It is recommended that office BP is controlled to target values: systolic BP 120–130 mmHg in general and systolic BP 130–140 mmHg in older patients (aged >65 years). Beta‐blockers and ACE‐inhibitors/angiotensin receptor blockers preferred) |
| Diabetes management | Hemoglobin A1C <7.0% Lifestyle modification ± drug therapy |
| Smoking | Complete cessation. No environmental exposure. Use pharmacological and behavioral strategies to help patients quit smoking. |
| Weight management | Body mass index 18.5–24.9 kg/m2, waist circumference: men <40 inches (<100 cm), and women <35 inches (88 cm) Regular physical exercise and restrict caloric intake |
| Physical activity | 30–60 minutes of moderate‐intensity aerobic activity, such as brisk walking most days, but even irregular activity is beneficial |
Figure 11.1 Suggested stepwise strategy for long term anti‐ischemic drug therapy in patients with chronic coronary syndromes and specific baseline characteristics. The proposed stepwise approach must be adapted to each patient’s characteristics and preferences. Given the limited evidence on various combinations of drugs in different clinical conditions, the proposed options are only indicative of potential combinations and do not represent formal recommendations. BB, beta‐blocker; bpm, beats per minute; CCB, [any class of] calcium channel blocker; DHP‐CCB, dihydropyridine calcium channel blocker; HF, heart failure; LAN, long‐acting nitrate; LV, left ventricular; non‐DHP‐CCB, non‐dihydropyridine calcium channel blocker. aCombination of a BB with a DHP‐CCB should be considered as first step; combination of a BB or a CCB with a second‐line drug may be considered as a first step; bThe combination of a BB and non‐DHP‐CCB should initially use low doses of each drug under close monitoring of tolerance, particularly heart rate and blood pressure; cLow‐dose BB or low‐dose non‐DHP‐CCB should be used under close monitoring of tolerance, particularly heart rate and blood pressure; dIvabradine should not be combined with non‐DHP‐CCB;
