Management of Coronary Artery Disease and Chronic Stable Angina

Yesenia Camero, PharmD, BCPS; Jinwi Ghogomu, PharmD, BCPS, CPh


US Pharmacist. 2017;42(2):27-31. 

In This Article

Guideline-directed Therapy

The goals of treating patients with SIHD are to maximize quality of life and minimize the risk of death. Guidelines for the management of SIHD state that the following fundamental strategies, when combined, can help achieve these goals:[4]

  1. Patient education on the causes, clinical presentation, treatment options, and prognosis of the disease, in order to encourage active participation in treatment decisions

  2. Identification and treatment of conditions that can contribute to or worsen the disease

  3. Modification of risk factors through both pharmacologic and nonpharmacologic strategies

  4. Use of pharmacologic treatments to improve quality of life and/or survival, with particular attention to side effects and drug interactions

  5. Use of cardiac revascularization, when appropriate, to optimize overall health status and improve survival

It is important to remember that not all strategies with evidence of mortality benefit will offer patients improved quality of life. Additionally, some treatments that potentially have no effect on survival are implemented in order to improve symptoms and quality of life.[4]

It is crucial for the patient to have a personalized education plan to optimize care and promote wellness. The education plan must include essential components such as (but not limited to) the importance of medication adherence; a comprehensive review of all therapeutic options; exercise education; self-monitoring skills; and how to recognize an exacerbation.[4] See Figure 1.

Figure 1.

Overview of Therapy for SIHD
SIHD: stable ischemic heart disease.

Lifestyle modification includes daily physical activity, weight management, and dietary restrictions, such as reduction of saturated fats (<7% of total calories), transfatty acids (<1% of total calories), and cholesterol (<200 mg/day). In addition, a moderate-dose or high-dose statin should be prescribed in the absence of contraindications or documented adverse effects. Alternatively, bile acid sequestrants could be used.[4]

All patients should be counseled on the need for weight control, increased physical activity, alcohol moderation, and sodium reduction. Increased consumption of low-fat dairy products and fresh fruits and vegetables should be emphasized. In addition to or after a trial of the above lifestyle modification, if the patient's blood pressure (BP) remains >140/90 mmHg, antihypertensive therapy should be initiated. Recommendations include ACE inhibitors and/or beta-blockers; possible additions include thiazide diuretics or calcium channel blockers, if needed, to achieve a goal BP <140/90 mmHg. Additionally, in patients who consume alcohol, a reasonable quantity of alcohol is one drink (4 oz wine, 12 oz beer, or 1 oz spirits) per day for nonpregnant women and one or two drinks per day for men, unless alcohol is contraindicated (e.g., patients with a history of alcohol abuse/dependence or liver disease).[4]

In patients with a short duration of diabetes mellitus and a long life expectancy, a goal glycosylated hemoglobin (HbA1c) of ≤7% is reasonable. The goal may be adjusted to 7% to 9% depending on age, history of hypoglycemia, presence of microvascular or macrovascular complications, or presence of coexisting medical conditions. Initiation of pharmacologic interventions may be warranted to achieve goal HbA1c, but rosiglitazone, which is associated with an increased risk of cardiovascular complications, should not be initiated in patients with SIHD. Patients who are already receiving this agent and whose blood glucose is well controlled should be counseled about the potential hazards, and a switch to a different agent should be strongly considered.[4]

Physical activity is an integral component of a comprehensive coronary risk-factor modification strategy for patients with SIHD. Clinicians should encourage 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, at least 5 days and preferably 7 days per week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work) to improve cardiorespiratory fitness. Complementary resistance training twice weekly is also a reasonable addition. Goals should be a BMI of 18.5 to 24.9 kg/m2 and a waist circumference <102 cm (40 in.) in men and <88 cm (35 in.) in women (less for certain ethnic groups). The initial goal of weight-loss therapy should be to reduce body weight by approximately 5% to 10% from baseline. When the initial goal is met, further weight loss may be attempted.[4]

Observational studies over the past four decades have furnished incontestable evidence that smoking increases the risk of cardiovascular disease; therefore, smoking cessation and avoidance of exposure to environmental tobacco smoke is of paramount importance for SIHD patients. Referral to an appropriate smoking-cessation program and initiation of pharmacotherapy are recommended as a stepwise approach to smoking cessation.[6]

The World Health Organization and the American Heart Association/American College of Cardiology Foundation recommend annual IM administration of the inactivated influenza vaccine to prevent all-cause mortality and morbidity in patients with underlying cardiovascular conditions. Influenza contributes to a higher risk of mortality and hospitalization in patients with chronic medical conditions such as cardiovascular disease, and it exacerbates underlying medical conditions.[6]