CORONARY ARTERY DISEASE

1. What is Coronary Artery Disease?

Coronary Artery Disease (CAD) is a cardiovascular condition where the coronary arteries, responsible for supplying oxygen and nutrients to the heart muscle, become narrowed or blocked by atherosclerotic plaques. These plaques are made up of cholesterol, fat, calcium, and other substances that gradually accumulate in the artery walls, restricting blood flow. Over time, this can lead to angina (chest pain) or heart attacks when blood flow to the heart is significantly reduced or blocked.

9. Lifestyle Modifications for Coronary Artery Disease

The European Society of Cardiology (ESC) provided detailed lifestyle recommendations and interventions in its 2021 guidelines on cardiovascular disease (CVD) prevention in clinical practice.

Smoking Cessation:

Quitting smoking significantly improves outcomes (36% reduction in the risk of death).

Patients should also avoid exposure to passive smoke.

Brief advice from doctors to stop smoking compared to no treatment, doubles the likelihood of smoking cessation in the short term.

Diet and Alcohol:

Increasing consumption of fruits and vegetables for a more plant based diet.

≥200g fruit everyday (2–3 servings) 

≥200g vegetables everyday (2–3 servings)

Consuming 35-45 grams of fiber per day, preferably from whole grains.

Eating fish 2 times per week.

Limit saturated fats trans unsaturated fats, preferably with no intake from processed foods.

Restricting salt intake to 5g per day.

Avoiding energy-dense foods such as sugar-sweetened soft drinks.

Light-to-moderate alcohol intake (1-2 drinks per day max). High alcohol consumption was associated higher mortality.

Limit red meat to at most 350−500g/week 

Although guidelines did not recommended daily fish oil supplement, 7% lower risk of cardiovascular event was observed with fish oil intake in recent analysis.

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Weight Management:

Sustaining a modest weight reduction of 5 − 10% from the initial body weight yields beneficial outcomes.

Physical Activity:

Exercise is often referred to as a 'polypill' because of its numerous beneficial effects

Exercise improves angina through enhanced oxygen delivery to heart muscle.

Increasing exercise capacity is a predictor of increased survival.

Even irregular leisure-time physical activity can help.

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Aerobic Exercise:

It is advisable for adults to engage in a weekly total of 150–300 minutes of moderate-intensity aerobic physical activity, or 75–150 minutes of vigorous-intensity aerobic physical activity, or a balanced combination of both, distributed over the course of the week.

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Resistance Exercise:

Incorporating resistance exercise alongside aerobic physical activity is highly beneficial.

To achieve optimal results, individuals are encouraged to include one to three sets of 8–12 repetitions in their routine, using an intensity level set at 60–80% of their personal 1-repetition maximum.

This regimen should be integrated at least twice a week, involving a range of 8–10 exercises that target various major muscle groups.

For older adults or those who may have lower fitness levels, a more manageable starting point is recommended, such as one set of 10–15 repetitions at 40–50% of their 1-repetition maximum.

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Adherence to lifestyle modifications and medications is often challenging but are essential to avoid complications. Annual influenza vaccination is recommended.

10. Medications for Coronary Artery Disease

Anti-ischemic Drugs

Nitrates:

Short-acting nitrates (e.g., nitroglycerin) provide immediate relief for acute effort angina.

Long-acting nitrates (e.g., nitroglycerin, isosorbide dinitrate) are considered second-line therapy for angina relief when initial therapy with a beta-blocker or non-dihydropyridine CCB is unsuitable or insufficient.

Prolonged use of long-acting nitrates may lead to tolerance and requires nitrate-free intervals.

Side effects and contraindications should be considered.

Beta-blockers:

Dosage is adjusted to maintain a heart rate of 55-60 b.p.m. at rest.

Beta-blockers can be combined with DHP CCBs to reduce tachycardia.

Caution is advised when combining beta-blockers with verapamil or diltiazem.

The principal side effects include fatigue, depression, bradycardia, heart block, bronchospasm, and more.

Calcium channel blockers:

Verapamil and diltiazem improve symptoms and myocardial ischemia.

Long-acting nifedipine is a potent arterial vasodilator and is often combined with beta-blockers.

Amlodipine is an effective once-a-day antianginal and antihypertensive agent.

Ivabradine:

Used to treat angina and ischemia

Can be combined with other antianginal drugs for better symptom and heart rate control

Trimetazidine:

It improves effort-induced myocardial ischemia.

It's considered a second-line drug for patients that are not well-controlled by other medications.

Event Prevention

Antiplatelet drugs:

Platelet activation and aggregation drive coronary thrombosis.

Dual antiplatelet therapy (DAPT) with aspirin and an oral P2Y12 inhibitor is key after MI and/or PCI.

Low-dose aspirin:

Recommended daily dose is 75-100 mg for CAD patients.

No need for platelet function testing.

Avoid other non-selective non-steroidal anti-inflammatory drugs in aspirin-intolerant patients.

Oral P2Y12 inhibitors:

Clopidogrel, prasugrel, and ticagrelor are used.

Clopidogrel slightly benefits over aspirin with similar safety.

Prasugrel offers more predictable and greater antiplatelet effect.

Ticagrelor has consistently high P2Y12 inhibition and faster onset.

Duration of dual antiplatelet therapy:

After PCI for stable angina, 6 months of DAPT achieves a balance of efficacy and safety in most patients.

Premature discontinuation of a P2Y12 inhibitor is discouraged.

Extended therapy beyond 12 months with clopidogrel or prasugrel may reduce ischaemic events but increases bleeding risk.

Long-term therapy with ticagrelor, 60 or 90 mg b.i.d., in stable patients ≥1 year after MI is effective, with more bleeding seen with the 90 mg dose.

Gastric Protection 

Reduce gastrointestinal bleeding risk in antiplatelet drug-treated patients.

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May enhance safety but linked to hypomagnesemia.

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Role of monitoring serum magnesium levels uncertain.

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Proton pump inhibitors that inhibit CYP2C19, like omeprazole and esomeprazole, may hinder clopidogrel's effects.

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Cholesterol Medication

Patients with established CAD, irrespective of LDL-C levels, are considered at very high risk and require statin treatment.

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Goal: Lower LDL-C by at least 50% from baseline to <1.4 mmol/L (<55 mg/dL); <1.0 mmol/L (<40 mg/dL) may be considered for some patients.

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If target LDL-C isn't reached, addition of ezetimibe is an option, reducing cholesterol and cardiovascular events. (no significant impact on mortality)

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Dietary supplements like phytosterols can lower LDL-C but haven't proven to improve clinical outcomes.

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PCSK9 inhibitors (evolocumab and alirocumab) effectively reduce cholesterol and lower LDL-PCSK9 inhibitors reduce cardiovascular and ischaemic events with little impact on mortality. Cost and long-term safety limit their use.

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High-dose atorvastatin reduces peri-procedural events for PCI patients, regardless of statin use.

Renin−angiotensin−aldosterone System Blockers

ACE inhibitors can reduce mortality, MI, stroke, and HF in patients with LV dysfunction, previous vascular disease, and high-risk diabetes.

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ACE inhibitors (or ARBs in case of intolerance) recommended for CCS patients with hypertension, LVEF ≤40%, diabetes, or CKD unless contraindicated.

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Sacubitril/valsartan is recommended as a replacement for an ACE inhibitor in HF patients (LVEF ≤35%) who remain symptomatic despite optimal treatment.

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Aldosterone blockade with spironolactone or eplerenone recommended for post-MI patients receiving ACE inhibitor, beta-blocker, LVEF ≤35%, and diabetes or HF. Caution in patients with impaired renal function (eGFR <45 mL/min/1.73 m²) and serum potassium levels ≥5.0 mmol/L.