Management of Stable coronary artery disease - Guideline by UK Expert Panel

Management of patients

• Discuss all treatment options with the patient, explaining the risk-benefit profile of all drugs so they can make informed decisions

Prevention—lifestyle modification

• Educate patients on lifestyle changes to prevent future events and improve symptoms:
  
  
  
  • smoking cessation
  
  
  • physical activity
  
  
  • diet
  
  
  
  


• Refer patients for cardiac rehabilitation if not already referred by secondary care and encourage them to maintain attendance and to attend if they have not started despite referral


• Reinforce the importance of lifestyle changes, particularly smoking cessation, at every opportunity

Prevention—medication review and optimisation

• All patients with CAD should be prescribed:
  
  
  
  • statins
  
  
  • antiplatelet and anticoagulant drugs
  
  
  • angiotensin-converting enzyme (ACE) inhibitors
  
  
  • antihypertensive agents
  
  
  
  

Statins

• Rule out familial hyperlipidaemia in patients with markedly raised cholesterol


• Manage lipids in accordance with NICE cardiovascular disease guideline (CG181)
  
  
  
  • step down is no longer a strategy for lipid management
  
  
  • atorvastatin 80 mg once daily is the first-line choice
  
  
  
  


• No other drug class can be substituted for statins, so switch to an alternative statin if patients cannot tolerate side-effects with one agent
  
  
  
  • for patients who develop myalgia, try withdrawing statin treatment for 2 months, a 50% dose reduction, or switch to rosuvastatin initially at 5 mg and titrate up to 20 mg once daily
  
  
  
  

Antiplatelet and anticoagulant drugs

• Prescribe antiplatelet therapy, typically aspirin 75 mg
  
  
  
  • after an acute coronary syndrome (ACS) event, prescribe dual antiplatelet therapy (DAPT) for the first 12 months with aspirin 75 mg + clopidogrel 75 mg once daily, prasugrel 10 mg once daily, or ticagrelor 90 mg twice daily for up to 12 months based on local guidance
  
  
  • for patients at high risk (e.g. aged ≤65 years, previous multivessel disease, CVD, diabetes, or chronic kidney disease (CKD) grade 3 or higher), consider:
    
    
    
    • aspirin 75 mg once daily + 90 mg ticagrelor twice daily for 12 months after an ACS event, then 60 mg twice daily for 36 months
    
    
    • aspirin 75 mg + rivaroxaban 2.5 mg twice daily (lifelong)
    
    
    
    
  
  
  • prescribe a proton pump inhibitor (PPI) to patients aged ≥65 years or with a previous gastrointestinal bleed
  
  
  • educate patients about using gloves and aqueous cream to prevent bruising
  
  
  
  


• At the annual review after 12 months:
  
  
  
  • check concordance; this can be supported by pharmacy medicines use review
  
  
  • continue to treat high-risk patients (see Box 1) aggressively
    
    
    
    • most patients at low risk can discontinue the second antiplatelet drug to be maintained on aspirin 75 mg
    
    
    • do not discontinue antiplatelet therapy completely without specialist advice
    
    
    
    
  
  
  
  

ACE inhibitors

• ACE inhibitors are primarily preventative therapy


• prescribe an ACE inhibitor to all patients unless there are contraindications or other good reasons not to do so


• prescribe an ACE inhibitor if blood pressure (BP) is uncontrolled, the patient has residual risk, and echocardiography showed functional impairment


• Aggressively treat high-risk patients (e.g. aged ≤65 years, previous multivessel disease, CVD, diabetes, or CKD grade 3 or higher):


• aim for BP <130/80 mmHg to minimise the bleeding risk as much as possible


• If patients experience issues specific to ACE inhibitors, alternatives such as an angiotensin receptor blocker (ARB) or sacubitril/valsartan should be considered in line with local guidance


• If patients develop side-effects, consider switching to an alternative agent


• for patients who develop cough, discontinue the ACE inhibitor but maintain aggressive BP management—for example, by switching to an ARB


• if the patient has high BP without left ventricular systolic dysfunction (LVSD), switch to an ARB to maintain BP control


• if the patient is taking the ACE inhibitor because they have LVSD, replace as per guidance on LVSD in NICE chronic heart failure (CHF) guideline (NG106)

Beta-blockers

• Up to 12 months of beta-blockers is ‘unequivocal’ if the patient has substantial damage to the anterior wall
  
  
  
  • beta-blockers may provide a symptomatic benefit in patients with symptoms
  
  
  • patients who discontinue beta-blockers and undergo bypass surgery are at increased risk of sudden death
  
  
  
  


• Continue beta-blockers for heart rate control in patients with AF


• Continue cardioselective beta-blockers in patients with LVSD
  
  
  
  • cardioselective beta-blockers are not contraindicated in people with PAD or chronic obstructive pulmonary disease (COPD)
  
  
  • beta-blockers licensed for LVSD may be appropriate if the patient also has PAD
  
  
  
  


• Switch to dihydropyridine, which has advantages in terms of stroke and infarction, for patients without LVSD, in whom the benefit of long-term use of beta-blockers after myocardial infarction (MI) is less clear cut than for CHF


• All preventative medicines should be reviewed, titrated, and optimised

Box 1: Risk stratification in patients with CAD