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Antiplatelet Therapy

Optimize Stable Coronary Artery Disease Management with the "ABCDs" Approach

Optimize medications for stable coronary artery disease using the ABCDs approach.

Recent evidence suggests coronary stents don't improve chest pain more than optimal medications in patients with stable coronary artery disease. Remember these "ABCDs: A- antiplatelet; B- blood pressure; C- cholesterol; D- diabetes; S- symptom relief" to help manage patients with angina or who've had a heart attack more than a year ago.

RxPharm-adv

Antiplatelet. Recommend aspirin 75 to 81 mg/day. Higher doses aren't more effective and increase bleeding risk. Dual antiplatelet therapy (aspirin plus clopidogrel, etc.) should be reserved for patients with a recent stent or myocardial infarction.

Figure 1..

Algorithm for antiplatelet therapy in patients with stable coronary artery disease. Am Fam Physician. 2018;97(6):376-384

Blood pressure. Suggest aiming for less than 130/80 mmHg if tolerated...

  • Start with an ACE inhibitor (ACEI) or angiotensin II receptor blocker (ARB), especially in patients with chronic kidney disease, plus a beta-blocker for angina symptoms.
  • Add a thiazide or dihydropyridine calcium channel blocker (amlodipine, etc.) if needed to further control BP.

Cholesterol. Advise using a high-intensity statin (atorvastatin 80 mg, etc.) for patients 75 or younger to lower cardiovascular risk, or at least a moderate-intensity statin (atorvastatin 20 mg, etc.) for patients over 75.

Medication Indication
High-intensity: atorvastatin (Lipitor, 40 to 80 mg/day) or
rosuvastatin (Crestor, 20 to 40 mg/day)		 Patients younger than 75 years
Moderate-intensity: atorvastatin (10 to 20 mg/day),
rosuvastatin (5 to 10 mg/day),
simvastatin (Zocor, 20 to 40 mg/day)		 Patients 75 years and older,
or in whom high-intensity statins are not tolerated

Diabetes. Recommend starting with metformin in type 2 diabetes patients with cardiovascular disease. If that's not enough to reach A1C goals, add liraglutide (Victoza) to reduce cardiovascular risk.

Symptom relief. If beta-blockers aren't enough to control angina, recommend adding a dihydropyridine CCB. Switch to verapamil or diltiazem if a beta-blocker isn't tolerated. Add a long-acting nitrate if needed. Recommend isosorbide mononitrate extended-release once daily (Monomack) for its low cost and 12-hour nitrate-free interval to limit tolerance. Ensure patients have a rapid-acting nitrate (Nitroglycerin, Dinitra, etc.) for angina attacks.

Figure 2..

Algorithm for management of stable coronary artery disease. Am Fam Physician. 2018;97(6):376-384

RxPharm-adv

Take-home points

Managing coronary artery disease involves strategic medication use for stable angina...

  1. Recommend aspirin 75 to 81 mg/day for antiplatelet therapy, avoiding higher doses to reduce bleeding risk.
  2. Reserve dual antiplatelet therapy (aspirin plus clopidogrel) for patients with a recent stent or myocardial infarction.
  3. Aim for blood pressure below 130/80 mmHg, starting with ACE inhibitors or ARBs, especially in chronic kidney disease patients.
  4. Advise high-intensity statins (atorvastatin 80 mg, etc.) for patients 75 or younger, and moderate-intensity statins for those over 75.
  5. Start metformin in type 2 diabetes patients with cardiovascular disease, adding liraglutide (Victoza) if needed to meet A1C goals.
  6. Ensure angina symptom relief by using beta-blockers, adding dihydropyridine CCBs if necessary, and providing rapid-acting nitrates for acute attacks.

References

  1. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;68(10):1082-1115. doi:10.1016/j.jacc.2016.03.513
    2. Show more references

Keywords: Coronary stents, Chest pain, Stable coronary artery disease, Antiplatelet therapy, Blood pressure management, Cholesterol control, Diabetes management, Symptom relief, Aspirin, ACE inhibitors, ARBs, Beta-blockers, Statins, Metformin, Angina, Cardiovascular risk.

Senior clinical pharmacist, "Pharmacy Practice Department, Tanta University Hospital, Egypt". Medical content writer.