Management of Cardiovascular Disease

Core Pharmacological Therapy

The American College of Cardiology recommends that all patients with established cardiovascular disease should receive comprehensive medical therapy consisting of high-intensity statin therapy, antiplatelet therapy, beta-blockers, and ACE inhibitors or ARBs, as this combination provides the greatest reduction in cardiovascular morbidity and mortality 1, 2
Aspirin 75-162 mg daily is mandatory for all patients with coronary artery disease unless contraindicated, as recommended by the American College of Cardiology 2, 1
The American College of Cardiology suggests that clopidogrel 75 mg daily serves as an alternative for patients who are aspirin-intolerant or allergic 2
For patients with acute coronary syndrome or recent PCI with stent placement, the American College of Cardiology recommends dual antiplatelet therapy should be continued for at least 12 months 2
In patients with peripheral artery disease who have undergone revascularization, the American College of Cardiology recommends rivaroxaban 2.5 mg twice daily plus aspirin reduces cardiovascular ischemic events more than aspirin alone 3

The American College of Cardiology recommends high-intensity statin therapy is required to achieve LDL-C <55 mg/dL in all patients with documented coronary artery disease 1, 4
If lipid goals are not achieved with maximum tolerated statin dose, the American College of Cardiology recommends adding ezetimibe 4
For very high-risk patients not reaching goals on statin plus ezetimibe, the American College of Cardiology suggests adding a PCSK9 inhibitor 4

The American College of Cardiology recommends beta-blockers are mandatory in all patients with prior myocardial infarction and should be continued for at least 3 years after the event 3, 2
The American College of Cardiology strongly recommends beta-blockers for all CAD patients, even if asymptomatic, as they provide prognostic benefit regardless of age 1, 5
The American College of Cardiology recommends preferred agents include carvedilol, metoprolol succinate, bisoprolol, or propranolol; avoid atenolol due to inferior outcomes 5

The American College of Cardiology recommends ACE inhibitors should be started and continued indefinitely in all patients with established atherosclerotic cardiovascular disease, particularly those with coronary artery disease 3, 2, 1
The American College of Cardiology recommends ARBs are appropriate alternatives if ACE inhibitors are not tolerated 1
The American College of Cardiology warns never to combine ACE inhibitors with ARBs—this combination is contraindicated 1

In patients with type 2 diabetes and established atherosclerotic cardiovascular disease or kidney disease, the American Diabetes Association recommends adding an SGLT2 inhibitor with proven cardiovascular outcomes benefit to reduce major adverse cardiovascular events 3
The American Diabetes Association recommends targeting HbA1c of approximately 7% is appropriate for most patients 3

The American College of Cardiology recommends targeting blood pressure <140/90 mmHg for patients with stable cardiovascular disease 5
The American College of Cardiology suggests a lower target of <130/80 mmHg may be considered in select individuals with previous stroke, TIA, or prior MI 5
The American College of Cardiology warns against lowering diastolic blood pressure below 60 mmHg, especially in patients with myocardial ischemia, as this may worsen ischemia 1, 5

The American College of Cardiology recommends smoking cessation is mandatory if the patient smokes 1, 4
The American College of Cardiology suggests regular aerobic physical activity of at least 150 minutes per week of moderate intensity 1
The American College of Cardiology recommends a Mediterranean diet supplemented with olive oil and/or nuts reduces major cardiovascular events 1
The American College of Cardiology recommends weight management targeting BMI 18.5-24.9 kg/m² and waist circumference <40 inches in men and <35 inches in women 6, 7

The American College of Cardiology recommends regular follow-up visits every 3-6 months initially to reassess risk status, medication adherence, and achievement of cardiovascular risk factor targets 1
The American College of Cardiology suggests lipid profile assessment 4-12 weeks after initiating or adjusting statin therapy 1

The American College of Cardiology warns against withholding beta-blockers based solely on age—they provide prognostic benefit in CAD regardless of age 1, 5
The American College of Cardiology recommends avoiding atenolol—use alternative beta-blockers with proven outcomes benefit 5
The American College of Cardiology warns against combining beta-blockers with nondihydropyridine calcium channel blockers unless absolutely necessary due to bradyarrhythmia risk 5
The American College of Cardiology recommends avoiding nondihydropyridine calcium channel blockers in patients with left ventricular dysfunction 5
The American College of Cardiology warns against lowering diastolic blood pressure below 60 mmHg or systolic blood pressure below 130 mmHg in octogenarians 1, 5