Pharmacology  ·  Cardiovascular

Cardioprotective Background Therapy

Antiplatelet agents, statins, renin-angiotensin inhibition, and the case for optimal medical therapy

• Every patient with established coronary artery disease receives cardioprotective background therapy regardless of which antianginal drugs are chosen for symptom relief — the two prescribing decisions answer different clinical questions and are evaluated against different outcomes.
• Aspirin irreversibly inhibits cyclooxygenase-1, disabling thromboxane A2 production for the entire platelet lifespan; clopidogrel irreversibly blocks the platelet P2Y12 receptor through a complementary pathway, and combining the two produces more complete platelet inhibition than either drug alone.
• Statins inhibit hydroxymethylglutaryl-coenzyme A reductase, reducing internal cholesterol synthesis and secondarily upregulating low-density lipoprotein receptors; cardiovascular benefit tracks with the absolute degree of low-density lipoprotein reduction, making high-intensity dosing the default starting point in established coronary artery disease.
• Renin-angiotensin system inhibition reduces blood pressure and harmful cardiac remodeling, and is especially valuable when coronary artery disease coexists with reduced ejection fraction, diabetes, or chronic kidney disease.
• In stable coronary artery disease, optimal medical therapy alone produces outcomes for death and myocardial infarction comparable to adding percutaneous coronary intervention — revascularization provides better symptom relief but not a mortality advantage over medical therapy in most stable patients.