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

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

Secondary event prevention and risk stratification is an important aspect in the management of patients with stable coronary artery disease. A UK multidisciplinary expert panel comprising of  Fay M et al have developed a guideline for Secondary event prevention and risk stratification in Stable coronary artery disease.

CAD remains the greatest cause of morbidity and mortality worldwide although a combination of multiple strategies to prevent and treat coronary artery disease (CAD) has led to a relative reduction in cardiovascular mortality over recent decades

Key recommendations of consensus guideline for long-term management of patients with stable coronary artery disease (CAD) are-

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


  • 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)


  • 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 

In patients with CAD, the following factors increase the risk of an event and require more intensive management:

  • Increasing age
  • The number of vascular beds involved
  • History of previous events and intervention
  • All sequelae/complications such as heart failure
  • All concomitant risk factors—hypertension, diabetes, CKD, PAD,
  • stroke/TIA, obesity, and smoking

CAD=coronary artery disease; CKD=chronic kidney disease; PAD=peripheral arterial disease; TIA=transient ischaemic attack

Prevention—Any cardiovascular comorbidity like CKD, PAD, stroke/transient ischaemic attack, LVSD, atrial fibrillation (AF) etc.may be managed according to the prescribed NICE guideline for that condition.

Symptom management 

  • Identify symptoms that are affecting the quality of life or that may indicate comorbid disease, e.g. dyspnoea on exertion, orthopnoea, palpitations, and claudication
  • Prescribe beta-blockers and other anti-anginal for symptom control
  • For patients with tachycardia:
    • aim for 60–70 bpm in patients with stable angina
    • beta-blocker is the first-line choice
    • if tachycardia persists, titrate the beta-blocker or switch to dihydropyridine
  • If patient experiences chest pain within a month of discharge:
    • check concordance with drugs
    • optimise treatment in line with NICE chest pain guideline (CG95)
    • advise the patient about the use of glyceryl trinitrate (GTN) for chest pain and when to call an ambulance
    • if pain worsens despite treatment modifications, refer to cardiology
  • All medicines to manage symptoms should be reviewed, titrated, and optimised
  • If there is a step-change in symptoms:
    • in patients with known residual ischaemia in whom revascularization was deferred because the condition was considered too complicated for surgery or the patient declined surgery:
      • trial a higher dose or add in a second anti-anginal drug, e.g. GTN
      • refer for specialist advice, as necessary, to re-evaluate residual CAD
    • if symptoms worsen over a course of months after 12 months despite beta-blocker or dihydropyridine:
      • add in a new drug (e.g. a long-acting nitrate or ivabradine in line with CG126)
      • elective referral for specialist opinion
    • if symptoms rapidly progress over days and weeks:
      • check for co-morbidities
      • add in a new drug (e.g. a long-acting nitrate or ivabradine in line with CG126)
      • urgent referral for cardiological advice

Annual review

  • An annual review is important to:
    • assess symptoms
    • assess and reinforce the importance of concordance with medicines and lifestyle changes, including smoking cessation
  • Box 2 summarises key points to cover during ongoing and annual surveillance of patients with CAD

Box 2: Ongoing annual surveillance in patients with CAD

  • Atorvastatin 80 mg once daily or rosuvastatin initially at 5 mg and titrated up to 20 mg
  • Aspirin 75 mg once daily
  • Systolic blood pressure aim for <130 mmHg
  • Consider ACE inhibitor/ARB in patients with T2DM
  • Seek other evidence of cardiovascular disease, checking glycated haemoglobin, and asking direct questions about chest pain, palpitations, or orthopnoea
  • If symptoms are deteriorating, review patient management according to algorithm

ACE=angiotensin-converting enzyme; ARB=angiotensin receptor blocker; CAD=coronary artery disease; T2DM=type 2 diabetes mellitus

Different tools for risk stratification have been developed and validated in patients with CAD. A stepwise approach, considering the characterisation of both ischaemic and bleeding risk is advisable in these patients to better guide both the immediate and long-term medical management strategies.

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Source: self

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