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Myocardial ischemia [5]
Reversible ischemia: Tissue is ischemic but not irreversibly dead and, therefore,
still potentially salvageable.
o Myocardial stunning: acutely ischemic myocardial segments with
transiently impaired but completely reversible contractility
o Hibernating myocardium: a state in which myocardial tissue has
persistently impaired contractility due to repetitive or persistent ischemia
Partially or completely reversible when adequate oxygen supply is
restored (e.g., after angioplasty or coronary artery bypass grafting)
Seen in angina pectoris, left ventricular dysfunction, and/or heart
failure
Irreversible ischemia: tissue necrosis (myocardial scars)
Angina
Angina is the cardinal symptom of CAD. Patients with CAD usually become symptomatic
when the degree of coronary stenosis reaches ≥ 70%.
Dyspnea
Dizzinesss, palpitations
Restlessness, anxiety
Autonomic symptoms (e.g., diaphoresis, nausea, vomiting, syncope)
Stable angina
Symptoms are reproducible/predictable
Symptoms often subside within minutes with rest or after administration
of nitroglycerin
Common triggers include mental/physical stress or exposure to cold
Vasospastic angina
Description
o Angina caused by transient coronary spasms (usually due to spasms
occurring close to areas of coronary stenosis)
o Not affected by exertion (may also occur at rest)
o Typically occurs early in the morning [8]
Epidemiology [9]
Resting ECG
Best initial test for all types of chest pain
Usually normal in stable angina
ST segment depression or T wave inversion/flattening indicates
previous MI or unstable angina and requires further workup (see “Diagnosis of ACS”).
Clinical findings
o The following findings should prompt immediate interruption of stress
testing:
New onset/intensification of chest pain
Severe dyspnea, cyanosis, pallor, ataxia, or altered mental status
Decrease in systolic BP below the resting BP [12]
Cardiac catheterization
Indications
o Persistent symptoms of angina despite appropriate therapy
o Abnormal results of noninvasive testing
o Ambiguous results on noninvasive procedures and in high clinical
suspicion of CAD
Advantages
o Considered the gold standard of CAD diagnosis since it provides:
Information on several parameters (e.g., coronary blood flow,
pressure within heart chambers, cardiac output, oxygen saturation)
Direct visualization of coronary arteries (coronary angiography)
Opportunity for direct therapeutic intervention using percutaneous
coronary intervention (see “Treatment” below)
Additional tests
Holter monitoring
o Can detect silent ischemia
and arrhythmias
o May be used to evaluate heart rate variability and pacemaker/ICD function
Coronary magnetic resonance imaging (CMRI) or coronary computed
tomography angiography (CCTA
Approach [20]
Blood pressure
Heart rate
Inotropy (contractility)
Ejection time
End-diastolic volume
First-line
o Beta blockers (except in vasospastic angina)
Can reduce the frequency of coronary events
Partial beta agonists like pindolol and acebutolol should be used
cautiously.
o Nitrates
Can prevent exertional angina
Suitable for relief of acute angina or for long-term treatment
Second-line
o CCBs: indicated if there are contraindications to beta blockers or in
addition to beta blockers (if angina or hypertension persist)
o Ranolazine: a metabolic modulator that reduces myocardial oxygen
demand without altering the heart rate, blood pressure, contractility, and/or end-
diastolic volume
Indication: stable angina that is refractory to first-line treatment
Mechanism of action
Inhibition of late inward sodium channels on
cardiac myocytes → reduced calcium influx (via sodium-calcium channel pump)
→ reduced wall stress and oxygen demand
Decreased rate of fatty acid beta-oxidation (aerobic process)
with a simultaneous increase in glycolysis (anaerobic process)
[21]
Side effects
Nausea, constipation
Headache, dizziness
Combination therapy
o Indicated if angina persists with monotherapy
o Beta blocker PLUS nitrate
o CCB (nondihydropyridine) PLUS nitrate (CCBs, such as verapamil, have a
similar effect to beta blockers.)
o Beta blocker PLUS CCB (long-acting dihydropyridine, such as nitrendipine)
Revascularization
Indications
o Stable angina, in the presence of:
Activity-limiting symptoms despite optimal medical treatment
Contraindications to medical therapy
Stenosis of critical (e.g., LCA) or multiple coronary arteries
o Acute coronary syndrome
Techniques
o Percutaneous coronary intervention
o Coronary artery bypass grafting