GDMT for CAD

Question 1

If a patient has CCD and change in symptoms or functional capacity that persists despite GDMT, which diagnostic tests should be ordered?

Answer 1

stress PET, cardiovascular MRI, or stress echocardiogram

Invasive coronary angiography

Question 2

How should patients with CCD be risk stratified?

Answer 2

Low, intermediate, or high yearly risk for MI

Question 2

Nutrition recommendations for CAD

Answer 2

Diet emphasizing fruits, vegetables, legumes, nuts, whole grains, and lean protein

Reducing percentage of calories from saturated fat (<6%)(2a)

Minimization of sodium and processed meats (2a)

Limited refined carbohydrates, sugar-sweetened beverages (2a)

Question 3

Tobacco product recommendations for CAD

Answer 3

Assess at every facility visit

Advise to quit at every visit

Behavioral modifications and pharmacotherapy: bupropion, varenicline, or NRT

Varenicline may be better than bupropion or NRT for cessation (2b)

Short term nicotine e-cigarettes to aid cessation may be considered (2b)

Question 4

Alcohol recommendations for CAD

Answer 4

Routinely ask about substance use

Limit alcohol intake (<1 drink/day for women and <2 drinks/day for men) (2a)

Question 5

Sexual health and activity recommendations for CAD

Answer 5

Individualize resumption of sexual activity (2a)

Cardiac rehab and exercise can be useful to reduce risk of cardiovascular complications (2a)

Question 6

Lipid management recommendations for CAD

Answer 6

High intensity statin recommendation for >50% reduction in LDL

If high intensity not tolerated or CI, moderate-intensity statin for 30-49% reduction in LDL

Assess lifestyle and meds by fasting lipids in 4-12 weeks after statin initiation and then every 3-12 months afterwards

If very high risk and on maximum statin with LDL >70, ezetimibe can be added (2a)

If very high risk, LDL >70, or HDL >100 on max statin and ezetimibe, can add PCSK9 monoclonal antibody can be added (2a)

maximum statin with LDL <100 and fasting triglyceride 150-499, icosapent ethyl to reduce death (2b)

not at high risk and on maximal statin with LDL >70, can add ezetimibe

maximal statin with LDL >70 and can’t use ezetimibe or PCSK9 monoclonal antibody are deemed insufficient or not tolerated, can add bempedoic acid or inclisiran

Question 7

Blood pressure management for CCD with CCD

Answer 7

Non-pharm strategies are first-line for elevated BP (120-129/<80)

BP target for hypertension of <130/<80

ACE, ARB, or beta-blockers first line with additional antihypertensives (DHP CCBs, thiazides, and/or mineralocorticoid receptor antagonists)

Question 8

Diabetes and CCD recommendations

Answer 8

if CCD and type 2 DM, SGLT2 inhibitors (gliflozin) or GLP1agonist (glutide)

GLP1 may be higher cost value than SGLT2 inhibitors

Question 9

Heart failure and CCD recommendations

Answer 9

If LVEF <40%, use SGLT2 inhibitor irrespective of DM status

Question 9

Antiplatelet without oral anticoagulant therapy and CCD

Answer 9

CCD and no indication for oral anticoagulant, low dose 81 mg

CCD treated with PCI, dual-anti platelet therapy with aspirin and clopidogrel for 6 months followed by single anti platelet therapy

PCI and drug-eluting stent and 1-3 months of DAPT, P2Y12 inhibitor for 12 months (2a)

Previous MI and low bleeding risk, extended DAPT for 12 months to 3 years to reduce MACE (2b)

Previous MI without stroke, TIA, or ICH history, vorapaxar may be added to aspirin (2b)

Use of DAPT after CABG may be useful to reduce the incidence of saphenous vein graft occlusion

Patients who had PCI and require anticoagulant therapy, DAPT for 1-4 weeks followed by clopidogrel alone for 6 months should be initiated with a DOAC

If undergone PCI and require oral anticoagulant, continue aspirin and clopidogrel for up to 1 month if high thrombotic risk and low bleeding risk (2a)

If low thrombotic risk and require oral anticoagulant, discontinue aspirin and continue DOAC after 1 year (2b) after PCI

If oral anticoagulant required, DOAC mono therapy considered if no acute indication for anti-platelet therapy

Question 10

Antiplatelet therapy and low-dose DOAC recommendation for CCD

Answer 10

If no indication for DOAC or DAPT at high risk for recurrent ischemic events but low-moderate bleeding risk, low dose rivaroxaban added to aspirin

Question 11

DAPT and PPI recommendation

Answer 11

CCD on DAPT, can use PPI to reduce GI bleed

Question 12

Beta-blocker recommendations

Answer 12

CCD and LVEF <40% with or without previous MI, beta blockers recommended

CCD and LVEF <50%, use of sustained release metoprolol succinate, carvedilol, or bisoprolol with titration is preferred

If previous beta-blocker for MI without LVEF <50%, arrhythmias, angina, or uncontrolled hypertension may reassess beta blocker usage

Question 13

renin-angiotensin-aldosterone inhibitors recommendations

Answer 13

CCD and hypertension, CKD, diabetes, LVEF <40% use ACE or ARB

Consider ACE or ARB even if none of above

Question 14

Recommendations for colchicene

Answer 14

may be considered for patients with CCD

Question 15

Recommendations for medical therapy for relief of angina

Answer 15

anti-anginal therapy with beta blocker, CCB, or long-acting nitrate for relief of angina symptoms

If symptomatic after initial treatment, add additional agent from different class (beta blocker, CCB, or long-acting nitrate)

If still symptomatic, add ranolazine

Nitroglycerin spray is recommended for immediate relief short term relief

Question 16

Indications for CABG

Answer 16

Left main disease greater than 50%

Three vessel coronary disease of greater than 70% or with or without proximal LAD involvement

Two vessel disease: LAD plus one other major artery

One or more significant stenosis greater than 70% in a patient with anginal symptoms despite maximal medical therapy

One vessel disease greater than 70% in a survivor of sudden cardiac death with ischemia related ventricular tachycardia