Stable Coronary Artery Disease

Aka: Stable Coronary Artery Disease, Stable Ischemic Heart Disease, Coronary Artery Disease, Atherosclerotic Heart Disease

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II. Definitions

  1. Stable Coronary Artery Disease
    1. Coronary Artery Disease (Angina, Myocardial Infarction, positive angiogram or CTA) AND
    2. Asymptomatic or controlled Angina

III. Epidemiology

  1. Prevalence of Cardiovascular Disease: Over age 60 years (U.S.)
    1. Men: 25%
    2. Women: 16%

IV. Symptoms

  1. See Acute Coronary Syndrome
  2. See Angina

V. Risk Factors

  1. See Cardiac Risk Factors

VI. Differential Diagnosis

  1. See Angina Diagnosis
  2. See Chest Pain

VII. Management

  1. See Cardiac Risk Management
  2. Tobacco Cessation
  3. Influenza Vaccine yearly
  4. Diabetes Mellitus Management
    1. Keep the Hemoglobin A1C less than 7% in Type I Diabetes and <8% in Type II Diabetes
  5. Exercise
    1. See Exercise Prescription
    2. Perform 30-60 min of moderate-intensity aerobic Exercise (e.g. quick walk) on 5-7 days/week
    3. Safe in Stable Coronary Artery Disease
      1. Stress testing is not needed before initiating low-moderate intensity Exercise
      2. Consider cardiac rehabitiliation setting for 8-12 weeks in higher risk patients
  6. Statins for Cholesterol lowering
    1. Specific LDL and HDL targets have been replaced with high-intensity Statin if 10 year CV risk >20%
    2. Non-Statins have provided minimal to no significant benefit in Cardiovascular Risk Reduction
      1. PCSK9 Inhibitors (e.g. Evolocumab) may be effective, but is cost prohibitive in 2018
    3. High intensity Statin (age <75 years with 10 year risk >20%)
      1. Atorvastatin 40-80 mg orally daily
      2. Rosuvastatin 20-40 mg orally daily
    4. Low intensity Statin (age >75 years, or Statin intolerant)
      1. Atorvastatin 10-20 mg orally daily
      2. Rosuvastatin 25-10 mg orally daily
      3. Simvastatin 20-40 mg orally daily
      4. Pravastatin 40-80 mg orally daily
      5. Lovastatin 40 mg orally daily
    5. References
      1. Stone (2014) Circulation 129(25 suppl 2): S1-45 [PubMed]
  7. Hypertension Management
    1. Goal Blood Pressure
      1. CAD, CRF, DM: <130/80
        1. Exercise caution in older adults (allow <140-150/90)
      2. Other patients: <140/90
        1. Consider as goal for most patients after JNC 8
    2. Preferred Antihypertensives
      1. Beta-Blockers (e.g. Metoprolol)
      2. ACE Inhibitors (e.g. Lisinopril) or Angiotensin Receptor Blockers (e.g. Losartan)
      3. Thiazide Diuretics (e.g. Chlorthalidone, Indapamide, Hydrochlorothiazide)
  8. Antplatelet therapy
    1. See Antiplatelet Therapy for Vascular Disease
    2. Aspirin
      1. Doses of 75-162 mg are as effective (and less GI Bleeding) as 325 mg daily
        1. Aspirin 81 mg is sufficient for most patients with stable cardiovascular disease
        2. Berger (2008) Am J Med 121(1): 43-9 [PubMed]
    3. Platelet ADP Receptor Antagonist (e.g. Clopidogrel, Ticagrelor, Prasugrel)
      1. See Platelet ADP Receptor Antagonist
      2. Indicated in known vascular disease if Aspirin contraindicated
      3. Marginally more effective than Aspirin in preventing CV events
        1. (1996) Lancet 348(9038): 1329-39 [PubMed]
      4. Aside from post-coronary stenting, avoid combining with Aspirin in stable cardiovascular disease
        1. Dual Antiplatelet Therapy is more effective CV prevention, but raises the major bleeding risk
        2. Bittl (2016) Circulation 134(10): e156-78 +PMID:27026019 [PubMed]
    4. Avoid NSAIDs (other than Aspirin)
      1. NSAIDs are associated with increased risk of cardiovascular events
      2. Naproxen may be associated with the least Cardiovascular Risk
      3. Even short-term NSAID use 5 years after coronary event increases CAD event risk
        1. Associated with 19 more events in 1000 patients with CAD
      4. References
        1. Antman (2007) Circulation 115(12):1634-42 [PubMed]
  9. Antianginal Management
    1. See Angina
    2. Step 1
      1. Aspirin 81 mg daily (or Platelet ADP Receptor Antagonist if Aspirin contraindicated)
      2. Sublingual Nitroglycerin prn and before Exercise
      3. Beta Blocker (e.g. Metoprolol)
    3. Step 2
      1. Increase Beta Blocker dose OR
      2. Consider Isosorbide monohydrate XR (once daily, least expensive long acting nitrate)
    4. Step 3
      1. Consider adding Dihydropyridine Calcium Channel Blocker (e.g. Amlodipine), if no Systolic Dysfunction
    5. Step 4: Refractory Angina
      1. Consider Stress test or angiography again if need >2 agents
      2. Revascularization may be needed
        1. PCI may improve symptoms but does not reduce mortality in stable coronary disease
        2. CABG is indicated in multi-vessel disease, Diabetes Mellitus, >50% left main Coronary Artery

VIII. References

  1. Braun (2018) Am Fam Physician 97(6): 376-84 [PubMed]
  2. Fihn (2012) Circulation 126(25): 3097-137 [PubMed]

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