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...
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. 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
Levine, G.N., Bates, and others (2016). 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: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation, 134(10). Available at: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000404.