The management of chronic coronary artery disease (CAD) is defined by two complementary ideas: revascularization is for symptoms and specific high-risk anatomy rather than routinely for prognosis, and aggressive medical therapy — lipid-lowering and, increasingly, anti-inflammatory — drives long-term outcomes.
Revascularization versus medical therapy
The ISCHEMIA trial established that in stable ischemic heart disease, an initial invasive strategy did not reduce cardiovascular events compared with optimal medical therapy, cementing medical management as the foundation and reserving revascularization for refractory symptoms or specific indications. A provocative counterpoint comes from the PREVENT trial, which found that preventive PCI of non-flow-limiting but high-risk ("vulnerable") plaques — identified by intravascular imaging — reduced target-vessel failure compared with medical therapy alone. This challenges the long-standing principle of treating only flow-limiting lesions and, if confirmed, could expand the role of PCI, though it remains an evolving and debated area.
Lipid-lowering and anti-inflammatory therapy
Statins remain foundational, with ezetimibe, PCSK9 inhibitors (evolocumab, alirocumab), the twice-yearly siRNA agent inclisiran, and bempedoic acid (for statin-intolerant patients) providing additional LDL lowering; novel PCSK9 agents such as lerodalcibep are in development, and lipoprotein(a)-lowering therapies are in outcome trials. The other major shift is the arrival of anti-inflammatory therapy: low-dose colchicine gained FDA approval in 2023 for cardiovascular risk reduction — the first anti-inflammatory drug approved for atherosclerotic cardiovascular disease, on the basis of the LoDoCo2 and COLCOT trials. The 2023 chronic coronary disease guideline accordingly recommends antiplatelet therapy, beta-blockers, renin-angiotensin-aldosterone inhibitors, and colchicine among non-invasive options.
Further reading: ISCHEMIA and its context (Weintraub et al., 2023); PREVENT trial of preventive PCI (Park et al., Lancet 2024); 2023 AHA/ACC chronic coronary disease guideline (Virani et al., Circulation 2023).