Pharmacist Disease State Guides
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      Coronary Artery Disease

      Disease State Overview

      Coronary artery disease (CAD) is the most common type of heart disease which results from damage or disease to the coronary arteries. This damage can lead to a narrowing or blockage of the coronary arteries, commonly caused by atherosclerosis. There are several modifiable and non-modifiable CAD risk factors which are outlined below:  

      CAD Risk Factors

      Non-Modifiable 

      • Older age
      • Male sex
      • Family history of atherosclerotic disease

      Modifiable 

      • Hypertension
      • Diabetes
      • Hyperlipidemia
      • Cigarette smoking
      • Overweight or obesity
      • High stress
      • Unhealthy diet

      Risk of Condition 

      CAD can eventually lead to Ischemic Heart Disease (IHD) if the coronary arteries become narrowed enough to reduce or completely obstruct blood flow and oxygen supply to the heart. IHD can be asymptomatic or present as angina or a myocardial infarction. Additional complications of CAD include heart failure and arrhythmias.  

      Medication 

      Role of Medication 

      Current guidelines published by the American College of Cardiology and the American Heart Association (ACC/AHA) and the American Family Physician recommend a handful of agents to manage CAD and IHD. Treatment goals include slowing the progression of atherosclerosis, relieving symptoms if present, managing comorbid conditions, and reducing the risk of first time or recurrent major adverse cardiovascular events (MACE). Choice of therapy should be based on multiple factors including medication side effect profile, insurance coverage, patient preference, patient’s age, race, comorbid conditions, and concurrent medications.  

       

      Recommendations for Coronary Artery Disease & Stable Ischemic Heart Disease (SIHD)  

      Lipid Lowering Agents

      • Purpose: reduce risk of first time or recurrent major cardiovascular event 

        • Agents:
          • High-intensity statins (< 75 years of age)  
          • Moderate-intensity statins (> 75 years of age or unable to tolerate high-intensity statin) 

      Antihypertensive Agents 

      • Purpose: prevent cardiovascular events by controlling blood pressure  
        • Agents:
          • ACE inhibitors* (indicated in patients with HTN, DM, CKD, abnormal left ventricular function, systolic HF, or recent MI) 
          • ARBs* (indicated in patients unable to tolerate an ACE inhibitor)  
          • Beta blockers* (first line in patients with history of MI, ACS, systolic HF, angina, a fib, or atrial flutter)  
          • Calcium channel blockers (indicated for patients who cannot tolerate a beta blocker) 
            • BP Goal: < 130/80 mmHg  

      Antiplatelet Agents

      • Purpose: reduce the risk of recurrent major adverse cardiovascular events (MACE) and cardiovascular death by decreasing platelet formation in blood 
        • Agents:
          • *Aspirin
            • *Demonstrates mortality benefit in CAD 
          • Clopidogrel (indicated for patient’s intolerant or allergic to aspirin) 
          • Dual antiplatelet therapy - P2Y12 inhibitor plus aspirin (patients who undergo PCI with stent placement) 

      Antianginal Agents

      • Purpose: provide relief from symptoms associated with myocardial ischemia
        • Agents:
          • Beta blockers* (initial therapy for long-term relief)  
          • Short-acting nitroglycerin (indicated for immediate symptom relief) 
          • Calcium channel blockers (indicated for patients unable to tolerate a beta blocker or added to a beta blocker if symptoms are not controlled)  
          • Long-acting nitrates (indicated for patients unable to tolerate a beta blocker or added to a beta blocker if symptoms are not controlled) 
          • Ranolazine (indicated for patients unable to tolerate a beta blocker or added to a beta blocker if symptoms are not controlled) 

      Abbreviations used: ACE= angiotensin converting enzyme, ARB = angiotensin II receptor antagonist, HTN = hypertension, DM = diabetes mellitus, CKD = chronic kidney disease, HF = heart failure, MI = myocardial infarction, ACS = acute coronary syndrome, a fib = atrial fibrillation, PCI = percutaneous coronary intervention  

      Adherence 

      Medication adherence is an essential component of treating CAD. Discuss barriers to adherence and provide appropriate solutions. You may use the DRAW tool within the Worksheets & Forms category in this Knowledge Base.

      Monitoring 

      Patients with CAD should receive routine follow-up with their health care provider at least annually. Follow-up should include the following:  

      1. Assessment of symptoms  
      2. Monitoring for possible CAD complications such as heart failure or arrhythmias  
      3. Adherence assessment to both medications and lifestyle changes  
      4. Screening for new or worsening comorbidities including, but not limited to, diabetes, depression, and CKD   

      It is important to educate patients on the importance of self-monitoring. Self-monitoring may include the following:  

      1. Home blood pressure monitoring  
      2. Home blood glucose monitoring  
      3. Tracking dietary intake and exercise  

      Lifestyle Education 

      Lifestyle modifications are important in the management of CAD. Discussion points may include: 

      • Educate patients on the importance of a heart healthy diet (e.g. low in fat and sodium) and weight management  
      • Encourage patients to engage in moderate intensity aerobic physical activity for 30 to 60 minutes 5 – 7 days per week 
      • In patients who smoke, recommend smoking cessation and provide counseling on appropriate options and resources  
      • In patients who drink alcohol, recommend limiting alcohol consumption  
      • Recommend resources for stress management to reduce stress-related angina if present  
      • Emphasize the importance of tight glycemic control in diabetic patient 

      Additional Points 

      Many patients with CAD have risk factors for other types of heart disease, vascular disease, and stroke. In patients without established atherosclerotic cardiovascular disease (ASCVD), consider assessing their ASCVD risk utilizing the calculator made available by the American College of Cardiology. 

      ASCVD Risk Score Calculator

      Atherosclerotic Cardiovascular Disease (ASCVD) Conditions 

      Acute Coronary Syndrome (ACS)  

      1. Heart Attack  

        1. ST-Segment Elevation Myocardial Infarction (STEMI) 
        2. Non-ST-Segment Elevation (NSTEMI) 

      2. Unstable Angina 

      Stroke or Transient Ischemic Attack (TIA) 

      Stable Angina 

      Coronary or other Arterial Revascularization  

      1. Percutaneous Coronary Intervention (PCI) 

      2. Coronary Artery Bypass Grafting (CABG) 

      Peripheral Artery Disease (PAD) 

      Patients should also be educated on the signs and symptoms of a heart attack as well as appropriate steps to take should they experience these symptoms, keeping in mind that symptoms can present differently in women compared to men. Educate patients to call 911 if they experience any of these warning signs listed below. 

      Heart Attack Warning Signs

      • Chest Pain or Discomfort 
      • Discomfort in other areas of the upper body including back or jaw
      • Shortness of breath 
      • Other: cold sweat, nausea/vomiting, lightheadedness 

       

       

      Resources  

      1. American Heart Association. Warning Signs of a Heart Attack.  
        https://www.heart.org/en/health-topics/heart-attack/warning-signs-of-a-heart-attack. 
      2. Arnett DK et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019; 140(11): e596-e646. 
        https://www.ahajournals.org/doi/10.1161/CIR.0000000000000678  
      3. Braun, M, et al. Stable Coronary Artery Disease. American Family Physician.  
        https://www.aafp.org/afp/2018/0315/p376.html   
      4. Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2023;82(9):833-955. doi:10.1016/j.jacc.2023.04.003 
        https://www.ahajournals.org/doi/10.1161/CIR.0000000000001168