Use "ABCDs" to optimize medications for stable coronary artery disease
Overview
Recent evidence suggests coronary stents don't improve chest pain more than optimal medications in patients with stable coronary artery disease. Remember these "ABCDs: A- antiplarelet; B- blood pressure; C- cholesterol; D- diabetes; S- symptom relief" to help manage patients with angina or who've had a heart attack more than a year ago...
Management approach
Antiplatelet
Recommend aspirin 75 to 81 mg/day. Higher doses aren't more effective and increase bleeding risk. Keep in mind, dual antiplatelet therapy (aspirin plus clopidogrel, etc) should be saved for patients with a recent stent or heart attack.
Blood pressure management
For blood pressure, suggest aiming for less than 130/80 mmHg if tolerated.
- Recommend starting with an Angiotensin-converting enzyme inhibitors (ACEI) or Angiotensin II Receptor Blockers (ARBs), especially in patients with kidney disease plus a beta-blocker for angina symptoms.
- Suggest adding a thiazide or dihydropyridine calcium channel blocker (amlodipine, etc) if needed to further control BP.
Cholesterol
Advise using a high-intensity statin (atorvastatin 80 mg, etc) for patients 75 or younger to lower CV risk, or at least a moderate-intensity statin (atorvastatin 20 mg, etc) for patients over 75.
| Table (1). Recommendations of Statins | |
|---|---|
| Medication | Indication |
| High-intensity: atorvastatin (Lipitor, 40 to 80 mg per day) or rosuvastatin (Crestor, 20 to 40 mg per day) | Patients younger than 75 years |
| Moderate-intensity: atorvastatin (10 to 20 mg per day), rosuvastatin (5 to 10 mg per day), simvastatin (Zocor, 20 to 40 mg per day) | Patients 75 years and older, or in whom high-intensity statins are not tolerated |
Diabetes
Recommend starting with metformin in type 2 patients with CV disease. If that's not enough to reach A1C goals, (Victoza) to reduce CV risk.
Symptom relief
If beta-blockers aren't enough to control angina, recommend adding a dihydropyridine CCB. Or advise switching to verapamil or diltiazem if a beta-blocker isn't tolerated. Suggest adding a long-acting nitrate if needed.
- In general, recommend isosorbide mono-nitrate EXTENDED-release once daily (Monomack). It's low-cost and gives a 12-hour nitrate-free interval to limit tolerance.
- Ensure patients have a rapid-acting nitrate (Nitroglycerin, Dinitra, etc) for angina attacks.
References
- Braun MM, et al. Stable Coronary Artery Disease: Treatment. Am Fam Physician. 2018;97(6):376-384.
- Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;68(10):1082-1115.
