Once you’ve received a diagnosis of coronary artery disease—whether or not you’ve had a heart attack—you face the question of what’s the best way to treat it. This question is complex, and the answer continues to evolve as new therapies become available and new studies clarify which patients benefit most from which treatments.

However, one basic principle holds true: you’ll need a close, continuing relationship with your primary care physician and a cardiologist. The goals of treatment are to keep your condition stable, prevent further damage to your heart, and, ideally, reverse some of the atherosclerosis in your coronary arteries.

It’s not surprising that measures for preventing heart disease are also effective in controlling it. All patients with coronary artery disease need to exercise and to discuss the progress of their exercise program regularly and in detail with their physicians.

Aerobic exercise, such as walking, bicycling, or swimming, can help you lose weight or maintain a normal weight and increase the amount of work you can do with less strain on your heart. You’ll also need to follow a heart-healthy diet, use strategies to control stress, and—it almost goes without saying—not smoke.

Along with healthy eating and regular exercise, medications are the first-line treatment for controlling coronary artery disease. Some drugs help prevent angina or eliminate chest pain during angina episodes. Others lower blood pressure or help prevent blood clots. Most people with heart disease need to take more than one medication. The specific combination of drugs will depend on your particular symptoms and risk factors.

Beta-Blockers

Beta-blockers are among the most commonly used drugs for controlling interruptions in blood flow to the heart and high blood pressure, and for good reason—these drugs have been shown to improve survival rates after heart attacks, and they are especially effective at minimizing chest pain brought on by exercise.

There are many types of beta-blockers on the market, but all act by interfering with adrenaline, a hormone that normally stimulates the heart to beat faster and stronger. Beta-blockers slow the heart rate and decrease cardiac output, lowering blood pressure and decreasing the amount of work the heart must do.

By lowering the oxygen needs of the heart, beta-blockers help prevent or relieve ischemia. People with asthma, heart failure, or diabetes should be cautious when taking beta-blockers because they could worsen these conditions.

However, some of the newer beta-blockers are less likely to cause side effects because they act more selectively on the heart than on other parts of the body. Despite these problems, beta-blockers are so effective in treating coronary artery disease that doctors often try them in patients with problems such as heart failure or diabetes because the benefits outweigh the risks.

Nitroglycerin

Nitroglycerin and other nitrate compounds help prevent or stop ischemia in several ways. They relax the muscles in the walls of the blood vessels, causing arteries and veins to dilate. When the coronary arteries dilate in response to nitroglycerin, the heart’s blood supply increases.

Nitrates also reduce the heart’s work by lowering the body’s blood pressure and the pressure within the heart’s chambers. As a result, the heart requires less oxygen and places fewer demands on the coronary arteries. Nitroglycerin comes in many forms: pills, an aerosol, a skin patch, and an ointment that can be applied to the skin.

Angiotensin Converting Enzyme (ACE)

Inhibitors ACE inhibitors are a class of blood pressure drugs that works by dilating blood vessels. In addition to controlling high blood pressure, ACE inhibitors have long been prescribed for people with heart failure. Recent studies have shown that these drugs also help people with coronary artery disease and those at high risk for developing it.

The HOPE (Heart Outcomes Prevention Evaluation) trial, an ongoing study of heart disease prevention, has found that ACE inhibitors not only dilate blood vessels but also help slow the progression of atherosclerosis.

Calcium Channel Blockers

Like beta-blockers, calcium channel blockers control high blood pressure. Calcium channel blockers are vasodilators, meaning they dilate the coronary arteries. By doing so, they increase blood flow to the heart and cut its workload by reducing blood pressure and the force of the heart’s contractions.

In contrast to beta-blockers, there is thus far no evidence that calcium channel blockers improve survival after a heart attack in patients with coronary artery disease. But they are useful for patients who don’t get adequate relief from beta-blockers or nitrates. And calcium channel blockers are more effective than beta-blockers for preventing angina due to episodes of coronary artery constriction, often called coronary spasm.

Aspirin

One of the pleasant surprises of the past two decades is the benefit of aspirin for patients with coronary artery disease. This common, inexpensive drug helps protect survivors of heart attack and stroke from subsequent heart attacks and death, and it even helps reduce the number of deaths that occur within the first hours following a heart attack.

Aspirin appears to work by preventing platelets from clumping together, which can block the blood flow to the heart. Randomized trials have provided clear evidence of aspirin’s value in both preventing and treating cardiovascular diseases.

Early studies focused on patients who’d already suffered a heart attack or stroke, or on people with unstable forms of angina or a history of transient ischemic attacks (TIAs)—brief and reversible strokelike episodes. For such patients, regular aspirin use significantly decreased the risk for fatal and nonfatal strokes or heart attacks.

A standard dose of aspirin to prevent heart attack is 81 mg per day. Despite aspirin’s benefits, it also has some drawbacks. It can increase the risk for the less common form of stroke caused by bleeding into the brain, and it also makes significant gastrointestinal bleeding more likely. What does that mean for you?

The U.S. Preventive Services Task Force, an independent panel of experts that reviews the evidence for prevention strategies and makes recommendations based on that evidence, supports the use of aspirin for people who already have heart disease or don’t yet have it but are at relatively high risk.

When balancing the risk of heart disease versus aspirin’s risks, the tipping point seems to be about 6 percent: for people with a ten-year heart disease risk of 6 percent or higher, the benefits of taking aspiring outweigh the harm. For people with a risk below 6 percent, they don’t.

Using the 6 percent rule, an aspirin a day probably makes sense for the following people:

• Anyone who has had a heart attack.
• Anyone diagnosed with coronary artery disease, peripheral artery disease, or a stroke or ministroke due to a blocked artery.
• Adults with diabetes, because this condition often leads to heart disease.
• Adults with the “metabolic syndrome,” a combination of obesity, high blood pressure, and high levels of cholesterol and blood sugar.
• Healthy people with a 6 percent or greater chance of having a heart attack over the next ten years, including many men over age forty and women who have passed menopause

Although this list makes it look as if everyone should be taking aspirin, that’s certainly not the case. It isn’t a good option if you are prone to gastrointestinal bleeding or have had a hemorrhagic stroke, even if your heart attack risk is above 6 percent.

Plavix

Plavix (clopidogrel bisulfate) is a drug that inhibits the action of platelets, much as aspirin does. It has been shown to reduce the risk of cardiovascular events only in people who’ve already had a heart attack or stroke, or who have the artery narrowing known as peripheral vascular disease.

The Food and Drug Administration (FDA) has approved Plavix for use in people with a recent heart attack or stroke, established vascular disease, or a newly placed stent to open up a closed coronary artery. Plavix has some serious side effects, particularly excessive bleeding.

This is especially dangerous if the bleeding occurs in the brain, where it could result in a hemorrhagic stroke. The drug also causes skin rashes and diarrhea in some users.

In at least one study of patients with a recent heart attack, stroke, or vascular disease, Plavix was slightly better than aspirin at preventing a subsequent serious cardiovascular event. It also caused less stomach upset and bleeding in the stomach than aspirin. But Plavix is much more expensive than aspirin and hasn’t been tested as widely or as well.

Hormone Replacement Therapy (HRT)

Until recently, doctors often prescribed hormone replacement therapy to postmenopausal women, not only to help control the symptoms of menopause, but also to reduce their risk for coronary artery disease.

They had reason for doing so—numerous large observational studies concluded that those taking estrogen after menopause were one-third to one-half as likely to have heart attacks or develop cardiovascular disease as those who didn’t. But more recent randomized controlled trials burst the HRT bubble.

Several large trials have concluded that hormone replacement therapy doesn’t help prevent heart problems and may even cause them. The American Heart Association now advises physicians not to prescribe hormone replacement therapy solely to prevent heart attacks and strokes in women with cardiovascular disease.

But some experts believe that future research may still determine that, for some women, hormone replacement therapy helps prevent heart disease. Most of the clinical trials thus far have focused on women well beyond menopause—the average age has been sixtyseven.

But hormone replacement therapy might be beneficial when started by younger women who have just gone through menopause. Until more and better information is available, women should discuss hormone replacement therapy with their doctor.

The decision is personal and should be based on a woman’s postmenopausal symptoms as well as her risks for breast cancer, endometrial cancer, heart disease, osteoporosis, and other hormone-related conditions. Here are the recommendations that I generally give to my patients:

• If you have heart disease, don’t start hormone replacement therapy just to treat this condition or to prevent a heart attack. Instead, focus on proven prevention strategies such as eating healthily, getting more exercise, controlling blood pressure, and lowering cholesterol. Estrogen that was prescribed to treat high cholesterol should be replaced with a cholesterol-lowering medication.

• If you’ve been on hormone replacement therapy for several years, you should discuss with your doctor whether you still need this treatment, but you’re probably past the early period of increased risk.

The American Heart Association recommends that women stop hormone replacement therapy at least temporarily following a heart attack or if they are confined to bed for some reason, and that they start again only for reasons other than heart health.

Also, women who take hormone replacement therapy face a small increased risk for breast cancer. So it’s a good idea to work with your doctor to evaluate your risk for breast cancer.

• If you don’t have heart disease, base your decision about whether to use hormone replacement therapy on its proven ability to relieve menopausal symptoms. But keep in mind that there are a variety of alternatives to taking an estrogen pill for these problems.

Selective Estrogen Receptor Modulators

These new drugs, sometimes called “designer estrogens,” appear to affect blood lipids in much the same way that estrogen does but possibly without the increased risk for breast cancer and endometrial cancer associated with hormone replacement therapy.

Raloxifene (Evista), one of these drugs, has been shown to decrease levels of LDL, but unlike estrogen does not reliably elevate HDL cholesterol, though it may increase one of the HDL subfractions. Also unlike estrogen, raloxifene doesn’t elevate triglyceride levels.

Raloxifene is approved for osteoporosis prevention, and recent preliminary studies suggest that it may be effective at reducing breast cancer risk. Like estrogen, however, it does increase the risk of blood clots in the legs.

Overall, I don’t use raloxifene as a primary treatment for lipid problems, but if a woman needs a drug to treat her osteoporosis, raloxifene’s generally favorable effects on lipids make it a reasonable choice. If further trials show that this drug does help prevent breast cancer, its use may become much more widespread.

Cholesterol-Lowering Drugs

Of course, cholesterol-lowering drugs can significantly help lower your risk of heart disease.