Coronary Artery Disease

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Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Epidemiology 5 Genetics 6 Laboratory 7 Diagnostic-procedures 8 Complications 9 Management 10 Notes 11 More General Terms 12 Additional Terms 13 References

More Specific Terms

• angiographically significant coronary artery disease (CAD)
• coronary artery stenosis
• coronary thrombus
• inherited form of coronary artery disease
• left main coronary artery disease
• multivessel disease
• post cardiac transplant coronary artery disease

Introduction

• Atherosclerotic narrowing of the major epicardial coronary arteries. (A number of disease processes other than atherosclerosis can involve coronary arteries.)

Etiology

• (Risk factors)*
• male age > 45 years
• female age > 55 years
• estrogen deficiency
• elevated LDL cholesterol (> 160 mg/dL)
• low HDL cholesterol (< 35 mg/dL)
• smoking
• hypertension
• elevated homocysteine
• elevated insulin
• diabetes mellitus
• non- coronary athersclerosis [4]
• elevated C-reactive protein
• sleep deprivation may play role [16]

• * also see cardiac risk factor

Epidemiology

• declining rate of death from coronary artery disease due to primary prevention [10], secondary prevention [19] & in coronary care [19]

Genetics

• most cases NOT genetically determined [12]
• implicated genes: TERT, ITGA2, ZC3H12A

Laboratory

• lipid panel
• gene expression model not yet useful [17]

Diagnostic-procedures

• exercise tolerance testing*
• myocardial perfusion study*
• dobutamine stress echocardiography*
• coronary angiography
• other tests may be useful

• exercise stress echocardiography
• dobutamine myocardial perfusion study
• adenosine positron emission tomography
• CT angiography
• cardiac magnetic resonance imaging
• coronary artery calcium

• * see stress testing & imaging findings associated with poor prognosis

Complications

• cognitive decline similar with CABG vs medically management [15]

Management

• pharmacologic agents

• beta-blocker 1st line
• antiplatelet agent(s)

• aspirin 81-325 mg QD or 325 mg QOD
• clopidogrel for aspirin failure
• Aggrenox

• nitrates

• reduction in angina
• increase in exercise tolerance
• do not affect prognosis

• Ca+2 channel blockers

• reactive airway disease intolerant to beta-blockers
• brittle diabetic with episodes of severe hypoglycemia
• patients in whom beta-blockers cause intolerable fatigue or depression

• ACE inhibitors

• in patients with impaired left-ventricular function ( LVEF < 35%)
• may be beneficial for all patients with CAD (see EUROPA trial)
• no added benefit for low-risk patients ( PEACE trial)

• antihypertensive may benefit patients with normal BP ( CAMELOT trial)
• lipid-lowering agents

• goal of LDL cholesterol < 100 mg/dL & < 70 mg/dL in high-risk patients [8]

• statins & beta blockers favorably affect outcomes [11]

• revasuclarization procedures

• indications

• impaired left ventricular function with > 50% stenosis in a major coronary vessel with evidence of myocardial viability in areas or reduced wall motion (by stress MIBI)
• normal left ventricular function with left main, 3 vessel or severe 2 vessel coronary disease
• age is NOT a contraindication

• revascularization improves morbidity & mortality at 6 months in patients > 75 years of age [5]

• percutaneous transluminal coronary angioplasty ( PTCA)

• 5 year relief of angina with PTCA somewhat < with CABG
• stenting diminishes restenosis

• coronary artery bypass graft ( CABG)

• CABG comparable to PTCA except in diabetics
• CABG preferable to PTCA in diabetics

• see Bypass Angioplasty Revascularization Investivation ( BARI)
• outcomes for PCI with coronary stenting similar to CABG for left main coronary artery disease [14]

• exercise superior to angioplasty in patients with stable coronary artery disease
• angioplasty with stenting no better than optimal medical therapy for coronary artery disease [13]
• USPSTF recommends against routine screening with

• resting electrocardiogram
• exercise stress test &/or
• electron-beam computed tomography [6]

Notes

• lipid-lowering for secondary prevention in patients with cardiovascular disease much more effective than for primary prevention [2]
• optimal medical therapy underutilized [18]

More General Terms

• coronary heart disease (CHD)
• arterial/arteriolar/capillary disease

Additional Terms

• atherosclerosis
• cardiovascular risk factor
• coronary artery
• coronary stent/coronary stenting
• coronary syndrome X (microvascular angina)
• factors associated with poor prognosis in patients with CAD
• secondary prevention in patients with cardiovascular disease
• unstable angina (acute coronary syndrome, ACS)

References

1. Stedman's Medical Dictionary 27th ed, Williams & Wilkins, Baltimore, 1999.
2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, American College of Physicians, Philadelphia 1998, 2009
3. Journal Watch 20(18):142, 2000 Danesh et al BMJ 321:199, 2000
4. National Cholesterol Education Program [4]
5. Journal Watch 21(21):168, 2001 The TIME investigators, Lancet 358:951, 2001 Aronow et al, Lancet 358:945, 2001
6. Journal Watch 24(9):74, 2004 U.S. Preventive Services Task Force. Screening for coronary heart disease: recommendation statement. Ann Intern Med. 2004 Apr 6;140(7):569-72. PMID: [1]
   - USTSTF [2]
   - Fowler-Brown A, Pignone M, Pletcher M, Tice JA, Sutton SF, Lohr KN; U.S. Preventive Services Task Force. Exercise tolerance testing to screen for coronary heart disease: a systematic review for the technical support for the U.S. Preventive Services Task Force. Ann Intern Med. 2004 Apr 6;140(7):W9-24. Review. PMID: [3]
   - Fowler-Brown A et al [4]
7. Journal Watch 24(11):88, 2004 Hambrecht R, Walther C, Mobius-Winkler S, Gielen S, Linke A, Conradi K, Erbs S, Kluge R, Kendziorra K, Sabri O, Sick P, Schuler G. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation. 2004 Mar 23;109(11):1371-8. Epub 2004 Mar 08. PMID: [5]
8. Journal Watch 25(8):62, 2005 LaRosa JC, Grundy SM, Waters DD, Shear C, Barter P, Fruchart JC, Gotto AM, Greten H, Kastelein JJ, Shepherd J, Wenger NK; Treating to New Targets (TNT) Investigators. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med. 2005 Apr 7;352(14):1425-35. Epub 2005 Mar 8. PMID: [6]
   - Pitt B. Low-density lipoprotein cholesterol in patients with stable coronary heart disease--is it time to shift our goals? N Engl J Med. 2005 Apr 7;352(14):1483-4. Epub 2005 Mar 8. No abstract available. PMID: [7]
9. Mieres JH, Shaw LJ, Arai A, Budoff MJ, Flamm SD, Hundley WG, Marwick TH, Mosca L, Patel AR, Quinones MA, Redberg RF, Taubert KA, Taylor AJ, Thomas GS, Wenger NK; Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation. 2005 Feb 8;111(5):682-96. Epub 2005 Feb 1. <PubMed> PMID: [8] <Internet> [9]
10. Unal B, Critchley JA, Capewell S. Modelling the decline in coronary heart disease deaths in England and Wales, 1981-2000: comparing contributions from primary prevention and secondary prevention. BMJ. 2005 Sep 17;331(7517):614. Epub 2005 Aug 17. PMID: [10]
11. Go AS et al, Statin and beta-blocker therapy and the initial presentation of coronary artery disease. Ann Intern Med 2006; 144:229 PMID: [11]
12. Morgan TM, Krumholz HM, Lifton RP, Spertus JA. Nonvalidation of reported genetic risk factors for acute coronary syndrome in a large-scale replication study. JAMA. 2007 Apr 11;297(14):1551-61. PMID: [12]
13. Prescriber's Letter 14(6): 2007 PCI Plus Medical Therapy in Patients with Stable CAD Detail-Document#: [13] (subscription needed) [14]
    - Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007 Apr 12;356(15):1503-16. Epub 2007 Mar 26. PMID: [15]
14. Seung KB, Park DW, Kim YH, Lee SW, Lee CW, Hong MK et al Stents versus coronary-artery bypass grafting for left main coronary artery disease. N Engl J Med. 2008 Apr 24;358(17):1781-92. Epub 2008 Mar 31. PMID: [16]
    - Jones RH. Percutaneous intervention vs. coronary-artery bypass grafting in left main coronary disease. N Engl J Med. 2008 Apr 24;358(17):1851-3. Epub 2008 Mar 31. No abstract available. PMID: [17]
15. Selnes OA et al, Cognition 6 years after surgical or medical therapy for coronary artery disease. Ann Neurol 2008, 63:581 PMID: [18]
    - Yaffe K & Covinsky KE Coronary bypass surgery and long-term cognitive decline. Ann Neurol 2008, 63:547 PMID: [19]
16. King CR et al, Short Sleep Duration and Incident Coronary Artery Calcification JAMA. 2008;300(24):2859-2866. PMID: [20]
17. Rosenberg S et al. Multicenter validation of the diagnostic accuracy of a blood-based gene expression test for assessing obstructive coronary artery disease in nondiabetic patients. Ann Intern Med 2010 Oct 5; 153:425. PMID: [21]
18. Borden WB Patterns and Intensity of Medical Therapy in Patients Undergoing Percutaneous Coronary Intervention JAMA. 2011;305(18):1882-1889 PMID: [22]
19. Schmidt M et al. 25 year trends in first time hospitalisation for acute myocardial infarction, subsequent short and long term mortality, and the prognostic impact of sex and comorbidity: A Danish nationwide cohort study. BMJ 2012 Jan 25; 344:e356 PMID: [23]
    - Smolina K et al. Determinants of the decline in mortality from acute myocardial infarction in England between 2002 and 2010: Linked national database study. BMJ 2012 Jan 25; 344:d8059 PMID: [24]
    - Bandosz P et al. Decline in mortality from coronary heart disease in Poland after socioeconomic transformation: Modelling study. BMJ 2012 Jan 25; 344:d8136 PMID: [25]
    - Tunstall-Pedoe H. The decline in coronary heart disease; did it fall or was it pushed? BMJ 2012 Jan 25; 344:d7809 PMID: [26]
20. Coronary Disease: NIH Institute and Center Resources [27]
21. National Guideline Clearinghouse
    - The primary and secondary prevention of coronary artery disease. American College of Chest Physicians evidence- based clinical practice guidelines (8th edition). ngc-guideline: [28]
    - Coronary heart disease (CHD): symptoms, diagnosis and treatment. (Finnish Medical Society Duodecim) ngc-guideline: [29]
    - Stable coronary artery disease. (Institute for Clinical Systems Improvement) ngc-guideline: [30]
    - VA/DoD clinical practice guideline for management of ischemic heart disease. ngc-guideline: [31]
    - Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease. American Heart Association ngc-guideline: [32]
    - Coronary artery disease (CAD) clinical practice guidelines. Kaiser Permanente Care Management Institute ngc-guideline: [33]
    - Cardiac arrhythmias in coronary heart disease. A national clinical guideline. Scottish Intercollegiate Guidelines Network ngc-guideline: [34]
    - Secondary prevention of coronary artery disease. University of Michigan Health System. ngc-guideline: [35]

coronary artery disease (CAD)