How Coronary Artery Disease Is Treated

Coronary artery disease (CAD) is a serious condition that can have life-altering complications if it is not treated. Lifestyle changes such as exercise and smoking cessation, which can reverse the disease or slow its progression, are usually recommended. Prescriptions, such as statins and beta blockers; specialized procedures, such as angioplasty; or surgeries, such as coronary artery bypass, may also be necessary, depending on the severity of your disease.

Lifestyle

Coronary artery disease develops over time, and you can adapt some of your habits to slow the progression of atherosclerosis and cholesterol buildup. These lifestyle changes have even been shown to help decrease the degree of disease over time. Moreover, other treatments for CAD are unlikely to be helpful in the long term unless you also take the following steps.

• Smoking cessation: Among other deleterious effects on cardiac health, smoking damages the inner lining of the coronary arteries. Stopping will prevent further damage and give your body the opportunity to remodel cells and tissues, including those in the inner lining of your arteries. Over time, your CAD can improve as a result.
• Diabetes control: If you have diabetes, it’s important that you keep your blood sugar at optimal levels. Uncontrolled diabetes can lead to worsening heart disease, as well as other complications. Management of diabetes involves a combination of dietary strategies and medication.
• Heart-healthy diet: Eating a diet that’s low in saturated fats and trans fats can prevent the worsening of CAD. As you work to make this change, choose lean sources of protein, such as seafood, nuts, and fat-free or low-fat dairy products. Fruits, vegetables, and whole grains, all of which are high in antioxidants, are also excellent choices.
• Exercise: Exercise helps to maintain target cholesterol levels. In general, try to get 30 to 60 minutes of activity on most days. If you have a heart arrhythmia or a congenital heart defect, talk to your healthcare provider about any necessary exercise restrictions before you begin a program.
• Stress management: Stress may exacerbate CAD by releasing hormones that raise blood pressure and damage the lining of blood vessels. Managing stress is not an easy feat. At-home strategies include relaxation, time management, focusing on your priorities, building healthy relationships, and avoiding emotionally toxic people and situations. However, many people cannot manage stress without professional help. If you feel that stress is a major part of your life, discuss it with your healthcare provider.

Prescriptions

If you have CAD, there is a very high chance that you may need to take one or more prescription medications. Some of these medications treat CAD itself, actually preventing the disease from worsening inside the blood vessels.

For example, medications may help prevent blood vessel constriction (narrowing) if you have high blood pressure or may help your heart function if you have a damaged heart muscle from a heart attack.

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Reducing CAD Progression

Your healthcare provider may opt for one or more of the following.

• Statins: Statins are used to lower cholesterol. They’re typically prescribed to prevent cholesterol build up in your blood vessels, which is one of the major contributors to CAD. Lipitor (atorvastatin), Lescol (fluvastatin), Altoprev (lovastatin), and Zocor (simvastatin) are some examples. The most common side effect is muscle pain. Less common side effects include liver damage and increased blood sugar levels.
• PCKS9 Inhibitors (evolocumab, alirocumab, and inclisiran): PCSK9 inhibitors have been shown to be highly effective in lowering LDL-C (a type of harmful cholesterol) when used in addition to statins. Praluent (alirocumab) and Repatha (evolocumab) are injections that can be given at home but must be administered at least once a month. Leqvio (inclisiran) must be injected by a healthcare professional but, after two initial doses three months apart, is used only twice per year.
• Ezetimibe: Zetia (ezetimibe) is a non-statin that works to inhibit the absorption of dietary cholesterol by blocking the Niemann-Pick C1-Like 1 protein (NPC1L1). Zetia is used to reduce LDL cholesterol. It may be used alone or in combination with a statin.
• Fibrates (gemfibrozil): Fibrates are used to prevent further heart attacks and strokes in people who already have circulatory system conditions.

Preventing Blood Clots

Blood clots can cause heart attacks and strokes if you have atherosclerotic disease. Prescriptions that can help prevent blood clots include the following.

• Antiplatelet medications: These drugs are used to stop blood clots from forming by preventing the platelets in your blood from sticking together. Plavix (clopidogrel), Effient (prasugrel), and Brilinta (ticagrelor) are examples. Potential side effects include headaches, dizziness, nausea, constipation, diarrhea, indigestion, abdominal pain, nosebleeds, and bruising easily.
• Anticoagulants: Anticoagulants keep blood clots from forming and prevent any blood clots that you have from getting bigger with a mechanism that is different from that of antiplatelets. They also prevent blood clot formation in diseased vessels to reduce the risk of a stroke or heart attack. Examples of anticoagulants include warfarin, heparin, Pradaxa (dabigatran), and Eliquis (apixaban). Side effects may include excessive bleeding, dizziness, weakness, hair loss, and rashes.

Improving Heart Function

This goal is centered around helping to prevent complications related to CAD. Prescription options include the following.

• Angiotensin-converting enzyme (ACE) inhibitors: ACE inhibitors work by relaxing your blood vessels and helping your heart to work more efficiently. They are used in CAD to prevent your coronary blood vessels from having too narrow a lumen (opening), which is more likely to be obstructed by a blood clot. Examples of ACE inhibitors are Lotensin (benazepril), Vasotec (enalapril), captopril, and fosinopril. Potential side effects include a dry cough, high blood potassium levels, dizziness, fatigue, headaches, and loss of your sense of taste.
• Angiotensin II receptor blockers: These medications work by helping your blood vessels dilate so that you are less likely to experience blockage of your coronary vessels. Examples of angiotensin II receptor blockers include Atacand (candesartan), Teveten (eprosartan), Avapro (irbesartan), and Cozaar (losartan). Side effects can include dizziness, high blood potassium levels, and swelling of the body.
• Angiotensin receptor neprilysin inhibitors (ARNIs): Entresto (sacubitril/valsartan) contains a combination of angiotensin II receptor blockers and neprilysin inhibitors that helps your blood vessels dilate, improves blood flow to and lessens the strain on your heart, and reduces the amount of salt your body retains. Potential side effects are dizziness, lightheadedness, or a cough.
• Beta blockers: These medications help reduce your blood pressure by blocking epinephrine to help your heart beat slowly and less forcefully and to dilate your blood vessels. Commonly prescribed beta blockers include acebutolol, Tenormin (atenolol), Kerlone (betaxolol), and Zebeta (bisoprolol). Side effects may include cold hands and feet, fatigue, and weight gain.
• Calcium channel blockers: Calcium channel blockers partially block the effect of calcium on heart muscle cells and blood vessels to reduce blood pressure and slow down the heart rate. Calcium channel blockers include Norvasc (amlodipine), Cardizem and Tiazac (diltiazem), Plendil (felodipine), and Sular (nisoldipine). Side effects can include constipation, headache, perspiration, drowsiness, rash, dizziness, heart palpitations, nausea, and swelling in your feet or legs.
• Diuretics: Diuretics prevent fluid and sodium from building up in your body to decrease your blood pressure. Examples of diuretics include Midamor (amiloride), Bumex (bumetanide), Diuril (chlorothiazide), and Hygroton (chlorthalidone). While they’re generally fairly safe, you will probably notice increased urination. Other possible side effects include low sodium levels in your blood, dizziness, dehydration, headaches, muscle cramps, joint problems, and erectile dysfunction.
• Vasodilators: Also known as nitrates, vasodilators lessen your heart’s workload by allowing your blood vessels to relax and dilate, increasing blood and oxygen to your heart. Because they can have a lot of side effects, vasodilators are generally only prescribed if other methods aren’t working to control your blood pressure. Commonly prescribed vasodilators include Isordil (isosorbide dinitrate), nitroglycerin tablets, and Apresoline (hydralazine). Side effects can include fast heartbeat, heart palpitations, fluid retention, nausea, vomiting, skin flushing, headaches, unusual hair growth, and joint or chest pain.

For Heart Failure or Arrhythmia Due to CAD

• Aldosterone antagonists: These potassium-sparing diuretics are used for heart failure and can help you live longer while improving your symptoms if you have suffered a heart attack due to CAD. Aldactone (spironolactone) and Inspra (eplerenone) are available options. One potential side effect is dangerously high potassium levels in your blood, so close monitoring by your healthcare provider is necessary.
• Antiarrhythmic medications: Antiarrhythmic medications help regulate your heartbeat and are used to treat arrhythmias that can occur if CAD causes a heart attack affecting the pacemaker of the heart. Commonly prescribed antiarrhythmics include Cordarone (amiodarone), Tambocor (flecainide), Rhythmol (propafenone), and quinidine. Side effects may include taste changes, appetite loss, sensitivity to sunlight, diarrhea, and constipation.

Over-the-Counter Therapies

Aspirin (acetylsalicylic acid), an over-the-counter antiplatelet medication, used to be commonly recommended for prevention of blood clots in healthy individuals, though new guidelines state that aspirin should no longer be recommended for primary prevention due to a risk of bleeding that outweighs its benefit. However, aspirin may still be recommended by your healthcare provider if you already have been diagnosed with cardiovascular disease (what’s called secondary prevention). Talk to your provider about whether aspirin is right for you.

Fish oil is another over-the-counter supplement often recommended or prescribed for individuals with elevated triglycerides. The Food and Drug Administration has approved prescription omega-3 fatty acid medications to treat very high triglyceride levels (>500 mg/dL). In 2019, it also approved Vascepa, a fish oil supplement availably by prescription, for people at high cardiovascular risk who meet certain criteria.

Specialist-Driven Procedures

If lifestyle changes and medications aren’t effectively treating your CAD, your healthcare provider may recommend surgery or specialized procedures.

Procedures are especially useful when you have an area of severe CAD in your arteries. If you have not had a heart attack or a stroke, surgical treatment can prevent you from having one. However, even if you have experienced a heart attack or a stroke, interventional treatment is often necessary to prevent additional events resulting from your CAD.

Options that may be considered include the following.

• Percutaneous coronary interventions (PCI): Formerly known as angioplasty with stent, PCI involves stent placement by threading a catheter (thin, flexible tube) with a deflated balloon attached to it through one of your arteries. Once it is positioned in the target location of CAD within an artery, the balloon is then inflated to widen the narrow or blocked regions in your coronary artery and a stent (a small metal mesh tube) is placed. The balloon is then deflated and withdrawn, while the stent remains, expanding the artery to allow blood to flow through your coronary artery much more freely.
• Endarterectomy: For some people with atherosclerotic disease, surgically removing fatty buildup from the arterial walls can “clean” the inside of the artery to open up an area of partial or complete blockage.
• Coronary artery bypass graft (CABG): A CABG is a major surgical procedure that is used when your coronary artery is blocked. Your surgeon will use an artery or vein from your leg, arm, or chest to replace a severely diseased coronary vessel. This procedure reroutes blood around the blockage in your coronary vessel, allowing the blood and oxygen to flow more freely. You may have one or several grafts done, depending upon how many areas of blockage you have.
• Stent placement: A stent is a wire mesh tube that is placed inside an artery, either surgically or percutaneously (through a needle puncture of the skin), remaining in the artery to help keep it open.