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:  

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)  

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: 

1. Educate patients on the importance of a heart healthy diet (e.g. low in fat and sodium) and weight management  

1. Encourage patients to engage in moderate intensity aerobic physical activity for 30 to 60 minutes 5 – 7 days per week 

1. In patients who smoke, recommend smoking cessation and provide counseling on appropriate options and resources  

1. In patients who drink alcohol, recommend limiting alcohol consumption  

1. Recommend resources for stress management to reduce stress-related angina if present  

1. 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 Link:  http://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/ 

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. 

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