Treatment of Chronic Small Vessel Ischemia

Pharmacological Management for Event Prevention

The European Society of Cardiology recommends aspirin 75-100 mg daily as the foundation of antithrombotic therapy for patients with chronic ischemic changes 1, 2
Clopidogrel 75 mg daily serves as an alternative in patients with aspirin intolerance 1
Statins are mandatory in all patients with chronic ischemic changes to reduce major vascular events 1, 2
Add ezetimibe if LDL goals are not achieved with maximum tolerated statin dose 1, 2
For very high-risk patients not reaching goals on statin plus ezetimibe, add a PCSK9 inhibitor 1
ACE inhibitors (or ARBs) are recommended, particularly when hypertension, diabetes, or heart failure coexist 1, 2

Exercise-based cardiac rehabilitation is fundamental for achieving risk factor control and reducing cardiovascular mortality 2, 3
Annual influenza vaccination is recommended, especially in elderly patients, to reduce mortality risk 2, 3
Psychological interventions should be implemented to address depression symptoms 2
Cognitive behavioral interventions help individuals achieve and maintain healthy lifestyle changes 2

Beta-blockers and/or calcium channel blockers control heart rate and symptoms 1, 2, 3
Short-acting nitrates provide immediate relief for effort angina 1, 2, 3
Never use nitrates in hypertrophic obstructive cardiomyopathy or with phosphodiesterase inhibitors 1, 2, 3

Proton pump inhibitors are recommended for patients on aspirin who have high gastrointestinal bleeding risk 2

Review patient response to medical therapies at 2-4 weeks after drug initiation 2, 4
Patient education about the disease, risk factors, and treatment strategy is essential for long-term adherence 2, 3

Do not pursue coronary angiography solely for risk stratification in small vessel disease 1
Medical therapy must be optimized before considering any invasive procedures 3