The treatment of chronic stable CAD should include vigorous lifestyle modification to control risk factors. A low-fat, low-cholesterol diet; regular exercise; and smoking cessation all have been shown to improve outcomes in patients with CAD. In addition, medical therapy to reduce risk factors can prevent myocardial infarction and death in patients with CAD. Long-term medical treatment for most patients with known CAD should include an antiplatelet drug (usually aspirin), a lipid-lowering drug (usually a statin), an angiotensin-converting enzyme (ACE) inhibitor, and a β-blocker (13, 14). Aspirin has been shown to reduce the risk of cardiovascular events in persons with CAD (15), particularly those with a history of previous myocardial infarction. The relative risk reduction was greatest in those with the highest plasma CRP levels, even though aspirin appears to have minimal effects on CRP levels.

American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend that lipid-lowering therapy be initiated in all CAD patients with a baseline LDL cholesterol level greater than 130 mg/dL, with a target LDL cholesterol goal of less than 100 mg/dL. The NCEP Adult Treatment Panel III further recommends that lipid-lowering regimens be increased for all patients with mild to moderate elevation of LDL cholesterol, as well as high-risk patients, to reduce LDL cholesterol to below 70 mg/dL (16). In controlled trials, statin therapy effectively lowered CRP level along with lipid levels. Although the magnitude of risk reduction associated with statin therapy is largest for those with the highest levels of CRP, it is unknown whether CRP reduction per se lowers cardiovascular risk.

For controlling hypertension, β-blockers are recommended, particularly for patients with a prior myocardial infarction. In addition, ACE inhibitor therapy is recommended for CAD patients with diabetes or left ventricular systolic dysfunction. Glycemic control in patients with type 2 diabetes (defined as a fasting blood plasma level ≥ 126 mg/dL) should strive to maintain a hemoglobin A_1c concentration of less than 7%.

Although markers of systemic inflammation are elevated in patients with atherosclerosis, the use of some anti-inflammatory agents has been associated with an increased risk of cardiovascular events. Selective inhibitors of cyclooxygenase (COX)-2 depress prostacyclin (PGI₂) but not COX-1–derived thromboxane A₂. Thus, the effects of thromboxane A₂ may be exaggerated during treatment with COX-2 inhibitors, thereby predisposing patients to heart attack and stroke.

Rofecoxib was removed from use in 2004 after the VIGOR results showed the drug increased heart attack and stroke risk in patients who took the drug for at least 18 months in a colon cancer prevention trial. The circumstances under which COX-2 inhibitors can be safely administered for extended periods to patients at low risk of cardiovascular disease remain to be defined. It is currently unclear to what degree such risk extends to patients treated chronically with lower doses for arthritis because studies of sufficient size and duration to characterize the potential cardiovascular risk in such populations have not been reported.

13. Gibbons RJ, Abrams J, Chatterjee K, Daley F, Deedwania PC, Douglas JS, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients with Chronic Stable Angina). 2002. Available at http://www.acc.org/qualityandscience/clinical/statements.htm.
14. Snow V, Barry P, Fihn SD, Gibbons RJ, Owens DK, Williams SV, et al. Primary care management of chronic stable angina and asymptomatic suspected or known coronary artery disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2004;141:562-7. [PMID: 15466774]
15. Hebert PR, Hennekens CH. An overview of the 4 randomized trials of aspirin therapy in the primary prevention of vascular disease. Arch Intern Med. 2000;160:3123-7. [PMID: 11074741]
16. Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227-39. [PMID: 15249516]

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