Medical Management of Coronary Artery Disease: An Update

Chronic coronary artery disease (CAD) remains a leading cause of global morbidity and mortality, necessitating a nuanced approach to long-term management. While revascularization strategies play a crucial role in select high-risk patients, optimal medical therapy (OMT) is the foundation of care for most individuals with stable disease. This review critically appraises contemporary pharmacological strategies for CAD, integrating the latest information from randomized trials and guideline-directed recommendations. Antihypertensive therapy, particularly renin-angiotensin system inhibitors and beta-blockers, remains central to reducing myocardial workload and preventing adverse cardiovascular events. Lipid-lowering agents, including high-intensity statins, ezetimibe, PCSK9 inhibitors, and inclisiran, have redefined risk stratification by demonstrating incremental reductions in low-density lipoprotein and atherosclerotic progression and event recurrence. The emergence of novel antidiabetic agents-SGLT2 inhibitors and GLP-1 receptor agonists-has expanded the therapeutic landscape, offering cardioprotective benefits independent of glycemic control. Additionally, the growing recognition of inflammation as a driver of CAD progression has led to the exploration of anti-inflammatory agents such as colchicine and interleukin-1 beta inhibitors. Landmark trials, including COURAGE, ISCHEMIA, and FREEDOM, reaffirm the noninferiority of OMT to revascularization in stable CAD, underscoring the need for an individualized approach. Future directions encompass precision medicine, artificial intelligence-driven risk stratification, and gene-based interventions, which may redefine therapeutic paradigms in CAD management.