Coronary Heart Disease: Treatment

Diet and lifestyle changes to modify risk factors (eg, smoking, obesity, hypertension, lack of physical activity, and dyslipidemia) are the cornerstone of treatment, with medications playing an adjunctive role. Unfortunately, counseling of patients regarding the importance of diet and exercise in the prevention of heart disease remains suboptimal.¹²

Prevention Strategies

Important preventive steps include the following:

• Blood pressure control. (See Hypertension.)
• Reduction of plasma lipids. (See Hyperlipidemia.)
• Smoking cessation.
• Dietary change. (See Nutritional Considerations.)

Pharmacologic Agents

Drugs are used to reduce the symptoms of angina, as well to control specific risk factors.

Nitrates (sublingual nitroglycerin vs. oral forms) are vasodilators, and provide greatest benefit through decreased preload (venodilation).

Beta-blockers (eg, propranolol, atenolol, metoprolol) decrease myocardial oxygen demand by decreasing contractility and heart rate.

Calcium-channel blockers (diltiazem, verapamil, nifedipine, amlodipine) relax arterial smooth muscle, resulting in decreased afterload.

Antiplatelet therapy. For those who can tolerate aspirin, 81 mg to 325 mg daily is prescribed to decrease CHD event risk. Clopidogrel 75 mg daily is an alternative for persons unable to tolerate aspirin, or for those who have had CHD events despite aspirin. Clopidogrel may also be combined with low-dose aspirin (81 mg daily) for high-risk patients and aspirin failures, and after stent placement.

Lipid-lowering agents, such as the following, may also be prescribed. (See Hyperlipidemia.)

• HMG CoA reductase inhibitors (statins).
• Cholesterol absorption inhibitors (ezetimibe, colesevelam).
• Bile acid sequestrants (cholestyramine, colestipol).
• Fibrinates (gemfibrozil, fenofibrate).
• Nicotinic acid.

Surgery and Other Mechanical Interventions

For high-risk CHD patients, including those with prominent symptoms, severe multivessel coronary artery disease (CAD), acute coronary syndromes, or MI, coronary revascularization may be achieved with percutaneous transluminal coronary angioplasty, intracoronary stent placement, or coronary artery bypass graft (CABG) surgery. For most categories of patients, stenting and CABG have similar success rates for relief of symptoms and control of CHD event risk. The need for subsequent revascularization is usually lower after CABG than after angioplasty or stent placement.