Management of Chronic Total Occlusion of the Right Coronary Artery

First-Line Additional Therapy

The European Society of Cardiology recommends ACE inhibitors (or ARBs if not tolerated) for patients with coronary artery disease, especially those with symptoms of heart failure or left ventricular dysfunction following myocardial infarction 1, 2
ACE inhibitors have been shown to reduce the risk of cardiovascular death, myocardial infarction, and cardiac arrest by approximately 20% in patients with coronary artery disease 2
If ACE inhibitors are not tolerated due to side effects such as cough, an Angiotensin Receptor Blocker (ARB) is recommended as an effective alternative by the European Heart Journal 1, 3

The European Heart Journal recommends a Mineralocorticoid Receptor Antagonist (MRA) for patients who remain symptomatic despite adequate treatment with a beta-blocker and ACE inhibitor 1
Diuretic therapy should be considered for symptomatic patients showing signs of pulmonary or systemic congestion to relieve heart failure symptoms, as recommended by the European Heart Journal 1, 3
For patients with persistent angina symptoms, consider adding a calcium channel blocker (preferably a dihydropyridine type) as additional therapy, as recommended by Circulation 2

The European Heart Journal recommends ensuring optimal dosing of the current beta-blocker (metoprolol), as beta-blockers are essential components of treatment for both angina relief and reduction of morbidity and mortality in heart failure 1
Evaluate if the statin therapy is achieving target LDL-C levels; if not, consider adding ezetimibe or a PCSK9 inhibitor for patients at very high risk, as recommended by the European Heart Journal 1

For patients with persistent symptoms despite optimal medical therapy, myocardial revascularization should be reconsidered if feasible, as recommended by the European Heart Journal 3
If the patient has evidence of heart failure with reduced ejection fraction (LVEF <35%), consider an angiotensin receptor-neprilysin inhibitor for patients with persistent symptoms despite optimal medical therapy, as recommended by the European Heart Journal 1, 3

When initiating ACE inhibitors, monitor renal function and potassium levels, especially in patients with pre-existing renal impairment, as recommended by the European Heart Journal and Circulation 1, 2
Avoid combining multiple vasodilators in patients with borderline blood pressure to prevent symptomatic hypotension, as recommended by the European Heart Journal 1
When adding MRAs, closely monitor potassium levels, especially when combined with ACE inhibitors or ARBs, as recommended by the European Heart Journal 1, 3