A Brief Synopsis of AFP's Medical Management of Stable Coronary Artery Disease"

A brief synopsis of; Medical Management of Stable Coronary Artery Disease
MATTHEW PFLIEGER, DO, Clinica Family Health Services, Denver, Colorado, BRADFORD T. WINSLOW, MD, Swedish Family Medicine Residency Program, Littleton, Colorado, KYLE MILLS, PharmD, Bend Memorial Clinic, Bend, Oregon, IRA M. DAUBER, MD, South Denver Cardiology Associates, Denver, Colorado
http://www.aafp.org/afp/2011/0401/p819.pdf
Am Fam Physician. 2011 Apr 1;83(7):819-826.

    Okay, so your patient survived an "event". Now what? Angina, MI, or a documented plaque is called coronary artery disease. This article discusses treatment for stable CAD. Before medication is given, the patient needs lifestyle modification. This includes tobacco cessation, alcohol reduction, a low salt and saturated fat diet, 2-3 servings of fruits and vegetables, exercise and weight loss. 
     Once your get the patient to improve their lifestyle the best they can, its' time for the drugs. Lipid therapy is a very important factor in CAD treatment. Statins are the first medication that should be used and it is effective in lowering LDL. Patients should try and get their LDL below 100 mg/dL. Those who are high risk should try and get it down to below 70 mg/dL.  Side effects are rhabdomyolysis and myalgia.  Triglycerides and HDL are also important parameters. Nicotinic acid can be considered if the triglyceride level stays above 200 mg/dL or if the HDL below 40 mg/dL. Fibrates and ezetimibe have had mixed results. It has been shown, however, that patients already on a statin who continue to have an LDL above 200 mg/dL and an HDL below 40 mg/dL may benefit from fenofibrate. 
     The JNC7 recommends a BP below 140/90 for patients with CAD. The AHA recommends a BP below 130/80. According to this article, beta blockers are a first line therapy. Beta blockers are effective because they lower heart rate, increase diastolic filling time, lower cardiac oxygen demand, and decrease contractility. Newer research has questioned the usefulness of beta blockers. 
     ACE inhibitors are another helpful medication. It prevents the conversion of angiotensin I to angiotensin II, reducing vasoconstriction, lowering peripheral vascular resistance, and preventing ventricular dilation.  It should be used in all CAD patients already on beta blockers. ARB's can be used as an alternative to ACE inhibitors. Using ACEIs and ARBs together can adversely affect the kidneys without any additional benefit.
     Ca channel blockers can be used if beta blockers cannot be tolerated. Short acting nifedipine should be avoided.  Long acting Ca channel blockers do offer benefit. They cause coronary vasodilation, decrease myocardial oxygen demand, and reduce anginal symptoms.
     Antiplatelet therapy is another important aspect of CAD therapy. Aspirin and clopidogrel are the two medications most commonly used. There is no benefit over one or the other. Aspirin is typical used first, with clopidogrel used if there is a contraindication or intolerance. Clopidogrel is  recommended when the patient had a recent MI or having stent placement.