This document discusses the treatment of stable coronary artery disease. It recommends lifestyle modifications like exercise, smoking cessation, and weight loss. It also recommends treating comorbidities through medications for blood pressure, cholesterol and blood sugar. Drug therapies include aspirin, clopidogrel, statins, beta blockers, calcium channel blockers, nitrates and ranolazine for angina relief. Revascularization through percutaneous coronary intervention or coronary artery bypass grafting may be considered depending on severity of disease and patient preferences. The goal is to reduce risks and manage symptoms through a combination of medical therapies and addressing modifiable risk factors.

1. Stable Coronary
Artery Disease
20180410 Intern 陳佳菁
TREATMENT

2. Am Fam Physician.
2018;97(6):376-384.
Michael M. Braun, DO, and William A. Stevens, MD
Madigan Army Medical Center, Joint Base Lewis-McCord, Washington Craig
H. Barstow, MD, Womack Army Medical Center, Fort Bragg, North Carolina

3. Ischemia PlaqueHx of MI
Reversible Supply/
Demand Mismatch

4. 1
2
CAD
Asymptomatic
Sx controlled by
Medications or
Revascularization
STABLE ?

5. 20,812
57
2
年年
⽇日
名

6. Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities

7. Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities
1

8. Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities
Reduce
Risk
Modify
Lifestyle
Manage
Comorbid
Condition
Overall &
CVD-related
Mortality

9. Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities
Reduce
Risk
Modify
Lifestyle
Manage
Comorbid
Condition
BP
Cholesterol
Glucose

10. Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities
Reduce
Risk
Modify
Lifestyle
Manage
Comorbid
Condition
Smoking
Activity
Weight
Diet

11. Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities
Reduce
Risk
Modify
Lifestyle
Manage
Comorbid
Condition
HTN
DM

12. Lifestyle Cholesterol BP Diabetes
30-60 min. Moderate-Intensity Aerobic Activity
5-7 days / weeks

13. Lifestyle Cholesterol BP Diabetes
ALL PATIENTS ! ! !
Pharmacotherapy / Programs

14. Lifestyle Cholesterol BP Diabetes
Annual Influenza Vaccination

15. Lifestyle Cholesterol BP Diabetes
CV events, Revascularization,
Stroke: 20%
Statin

16. Lifestyle Cholesterol BP Diabetes
Statin
< 75 yr ≥ 75 yr
HIGH
Intensity
MODERATE
Intensity
American College of Cardiology / American Heart Association, 2013 cholesterol treatment guideline

17. Lifestyle Cholesterol BP Diabetes
American College of Cardiology / American Heart Association
2013 cholesterol treatment guideline

18. Lifestyle Cholesterol BP Diabetes
- Bile acid sequestrants
- Niacin
- Ezetimibe
- Fibrates
Non-statin
Monotherapy

19. Lifestyle Cholesterol BP Diabetes
Combination to Statin:
NO benefit
Non-statin

20. Lifestyle Cholesterol BP Diabetes
Injectable Monoclonal Ab
LDL
PCSK9 INB

21. Lifestyle Cholesterol BP Diabetes
Evolocumab, Alirocumab
Risks of MI, Revascularization
PCSK9 INB

22. Lifestyle Cholesterol BP Diabetes
PCSK9 INBNon-statin
High-risk
Patients

23. Lifestyle Cholesterol BP Diabetes
Eighth
Joint National
Committee
guidelines
2012
ACC/AHA/
European Society
of Cardiology
practice guideline
2017
guideline on high
BP from the ACC/
AHA
150/90mmHg
140/90mmHg
140/80mmHg 130/80mmHg

24. Lifestyle Cholesterol BP Diabetes
SBP (mmHg) 120 140
All-cause Mortality
Heart Failure Risk
Hypotension
Acute Kidney Injury
Electrolyte Abnormality
Additional Medication

25. Lifestyle Cholesterol BP Diabetes
Initial Therapy Race Diabetes
ACEi
ARB
CCB
Thiazide
CCB
ACEi
ARB

26. Lifestyle Cholesterol BP Diabetes
< 65 yr ≥ 65 yr
A1C
< 7%
A1C
7-8%
Metformin
Liraglutide
Semaglutide
Empagliflozin

27. Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities
2

28. 75 to 162 = 325 mg/day
81 mg/day
Low Cost, Known Benefit

29. Clopidogrel - Alternative
Irreversibly Inhibit
Platlet Aggregation

30. All-cause Mortality
Risk of Bleeding
Dual Antiplatlet Therapy

32. Ticagrelor, Prasugrel
More Potent
Only in ACS - PCI

33. ICH ! ! !
CV Mortality, MI, CVA

34. Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities
3

35. Immediate Symptom Relief

36. Long-Term Relief: Initial

37. When Beta Blocker Do not
Control Symptoms

38. If Monotherapy is
Ineffective or Intolerated

39. Nitrates
CCB
β Blockers
Re-
Vascularization
Ranolazine

40. Recent MI, Abnormal left ventricular function
No MI
Improve Survival
Reduce MI Recurrence
3 Years
Reduced CV Rates
Increased CVA Risk
Effective Antianginals
Recommend: Initial Therapy
Cardioselective: β1 Receptors
Heart Failure: Metoprolol succinate, Carvedilol
Beta
Blockers

41. CCB
Intolerant to Beta Blockers
Angina uncontrolled with Beta Blockers
Abnormal LV Function
Reflex tachycardia, Exacerbating ischemia
Increasing harm risk
Amlodipine
Extended-release Nifedipine
Non-DHP
Verapamil, Diltiazem
DHP
Amlodipine, Nifedipine
時機
禁⽤用
短效
長效

42. Nitrate
Quick onset, Immediate relief短效
長效
BB, CCBs
發作次數
運動耐受
短效 NTG 需求
Alternative
Adjunctive

43. Ranolazine Inhibit late inward Na+
Angina, Bradycardia, Low BP
Alternative to: Beta Blockers / CCB
Hepatic Impairment
時機
禁⽤用
QT Prolong注意
Ventricular Diastolic Tension
Myocardial Oxygen Demand
作⽤用

47. Revascularization
PCI
CABG
嚴重程度
⽣生活型態
個⼈人偏好
利利弊分析
FAIL

49. SUMMARY

50. Ischemia PlaqueHx of MI
Reversible Supply/
Demand Mismatch

51. 1
2
CAD
Asymptomatic
Sx controlled by
Medications or
Revascularization
STABLE ?

52. Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities

53. 1 Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities
Lifestyle
Modification
運動 戒菸 減重

54. 1 Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities
Comorbidity
Treatment
⾎血壓 ⾎血脂 ⾎血糖

55. Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities
Statin Non-statin
Monotherapy1

56. Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities
2 Clopidogrel
Aspirin

57. Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities
3
Beta Blocker
CCB Nitrates Ranolazine
Medication

58. 3 Anti-Platlet
Anti-Anginal
治療 Risk Factors
Comorbidities
Re-
Vascularization
PCI
CABG
內
外

60. 謝
謝！