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Summary
For the diagnostics and management of acute chest pain, see “Acute coronary syndrome” and
“Chest pain.” See also “Atherosclerosis” and “Myocardial infarction.”
Definition
Coronary artery disease
Chest pain and angina
Epidemiology
Etiology
Atherosclerosis is the most common cause (see “Risk factors for atherosclerosis”).
Pathophysiology
Myocardial ischemia [8]
Angina
Stable angina
Anginal equivalents [1][11]
Possible manifestations
o Pain referred to the left arm, neck, jaw, epigastric region, or back.
o Gastrointestinal discomfort
o Dyspnea
o Dizziness, palpitations
o Restlessness, anxiety
o Autonomic symptoms (e.g., diaphoresis, nausea, vomiting, syncope)
Diagnostics
Initial evaluation
Clinical evaluation
o frequency of angina episodes
o Physical examination may be normal; look for:
Clinical features of peripheral vascular disease
Resting ECG [12]
Pretest probability
Overview
Noninvasive testing
o cardiac stress testing
Invasive testing: coronary angiography
Description
Heart rate is monitored throughout the study [18]
o Estimated maximum heart rate = 220 – age (in years)
o Target heart rate = 85% of the maximum heart rate
Evidence of stress-induced ischemia
Modality Findings
Myocardial
perfusion Decreased myocardial perfusion after stress
scan (e.g., SPECT,
PET)
Test
characteristi Cardiac exercise stress test Cardiac pharmacological stress test
cs
protocol). [19] es (e.g., dobuta
Metabolic mine)
equivalents (METs) o Vasodilators (e.
: A measure g., dipyridamole
of energy , adenosine,
expenditure used to or regadenoson)
estimate exercise
tolerance. [17]
o 1
ME
T =
3.5
mL
O2/
kg/
min
ute
o Ap
pro
Comparison of cardiac stress tests [12][1][13][15][2]
Test
characteristi Cardiac exercise stress test Cardiac pharmacological stress test
cs
x. 5
ME
Ts
are
req
uire
d to
fulf
ill
eve
ryd
ay
acti
viti
es,
suc
h as
cli
mbi
ng
flig
ht
of
stai
rs.
to assess ischemia o Echocardiograp
hy
Comparison of cardiac stress tests [12][1][13][15][2]
Test
characteristi Cardiac exercise stress test Cardiac pharmacological stress test
cs
o Radionuclide
myocardial
perfusion
imaging:
a nuclear
OR exercise stress
scan that uses a
imaging: cardiac
radioactive
(e.g., echocardiograp
tracer to
hy, radionuclide
evaluate myocar
myocardial
dial viability,
perfusion imaging,
detect ischemia,
or CMR) are used to
and
assess ischemia
assess perfusion
and LV function
o CMR
ECG monitoring is typically
Contraindic
ations Physical impairment If using dobutamine:
to exercise obstructive cardiomyopathy, aorti
Hemodynamically c dissection, tachyarrhythmias
significant arrhythmi If using adenosine, regadenoson,
as or dipyridamole:
Unstable o Active bronchos
angina or acute MI ( pasm or reactive
days) o Low systolic BP
Acute heart disease: AV block, third-
e.g., degree AV
Comparison of cardiac stress tests [12][1][13][15][2]
Test
characteristi Cardiac exercise stress test Cardiac pharmacological stress test
cs
block, or sinus
node disease in
patients without
active endocarditis, a pacemaker
days of MI
Specif
ic Cyanosis, pallor, ata
criteri
a for xia, dizziness,
test Wheezing, cyanosis, pallor
termi or near-syncope
nation Systolic BP < 80 mm Hg
Severe dyspnea
For dobutamine only:
Moderate to
o Exaggerated
severe angina
hypertensive
Decrease
response
in systolic BP > 10
Cli
nic mm Hg below the
al Syst
patient's resting
with an exaggerated
o Target heart
hypertensive
rate exceeded
response (relative
indication).
EC
G Consider Chest
Comparison of cardiac stress tests [12][1][13][15][2]
Test
characteristi Cardiac exercise stress test Cardiac pharmacological stress test
cs
if excessive downslo
pain with excessive downsloping
ping ST
ST depression or horizontal ST
depression or horizo
depression of > 0.2 mV (2
ntal ST
mm) at any point
depression of > 0.2
Symptomatic second-degree AV
mV (2 mm) is
block or third-degree AV block
detected.
Coronary angiography [12][22]
Indications
o Chronic stable angina
High clinical suspicion for CAD
Abnormal results from noninvasive testing
Persistent symptoms of angina despite appropriate therapy
Uses
o Direct visualization of coronary arteries
o To determine the feasibility of direct therapeutic intervention
using percutaneous coronary intervention
o Cardiac catheterization can provide information on several
parameters; coronary blood flow; cardiac output
Approach [12]
Antianginal drugs
First-line agent: beta blockers
Second-line agents: CCBs, nitrates, ranolazine
o combination therapy; beta blocker PLUS a nitrate
Blood pressure ↓ ↓ ↓
↑
Heart rate ↓ Unchanged or slightly ↓
(reflectory)
↑
Inotropy (contractility) ↓ Unchanged
(reflectory)
Ejection time ↑ ↓ Unchanged
Unchanged o
End-diastolic volume ↓ Unchanged or slightly ↓
r↑
Overall effect
↓ ↓ ↓↓
on MVO2
Therap
Drug
eutic Example agents Specific indications and effects
class
goal
Aspirin DOSAGE
[12]
Clopidogrel DOSA
contraindications
Antipla Recommended for all patients
telet to aspirin [12]
agents with CAD
Dual antiplatelet
therapy with aspirin
and clopidogrel may
be used in certain
Seconda
ry circumstances. [27]
preventi
on
Preferred: ACE
e.g., lisinopril DOS o Hypertension
e.g., losartan DOS disease
OSAGE
Seconda Beta
ry blocker Carvedilol DOSA Consider for all patients with stable
preventi s
on and GE angina.
antiangi
nal Metoprolol DOSA Further indications
treatme
nt GE o After MI or acute
GE patients with
normal LVEF
o LVEF ≤
Pharmacotherapy for CAD [12]
Therap
Drug
eutic Example agents Specific indications and effects
class
goal
40% with heart
failure or prior MI
o Consider as first-
line antihypertensive
therapy in patients
with CAD and hypert
ension. [28]
in patients with CAD. [12]
Partial beta agonists such
as pindolol and acebutolol should be
Antiang CCBs
inal Dihydropyridines: Add to beta blockers if symptoms
treatme
nt e.g., amlodipine DO persist despite adequate dose titration.
DOSAGE symptomatic
e.g., verapamil DO defects.
SAGE, diltiazem D Avoid short-acting dihydropyridines,
Adverse effects
include headache, dizziness, palpitation
s, flushing, peripheral edema,
and constipation.
Pharmacotherapy for CAD [12]
Therap
Drug
eutic Example agents Specific indications and effects
class
goal
Nitrates
Short-acting nitrate: Short-acting nitrates:
gual exertional angina
Long-acting nitrates acute angina
: Long-acting nitrates: adjunctive or
o Iso alternative long-term treatment to beta
e flushing, and hypotension.
din
itra
te
OS
o Iso
sor
bid
mo
no
nitr
ate
OS
G
Pharmacotherapy for CAD [12]
Therap
Drug
eutic Example agents Specific indications and effects
class
goal
to first-line treatment
Reduces MVO2 without altering heart
rate or BP [29]
o Inhibition of late
inward sodium chann
els on
cardiac myocytes → r
educed calcium influx
via sodium-calcium c
hannel pump
Metabo Ranolazine DOSA → reduced wall stress
lic
modula GE and MVO2 [30]
tors
o Decreased rate
of fatty acid beta-
oxidation (aerobic
process) with a
simultaneous increase
in glycolysis (anaerob
ic process) [31]
o Adverse effects
include nausea, consti
pation, headache, dizz
iness, bradyarrhythmi
as, and QT
prolongations.
Revascularization for stable CAD [12][25]
Acute coronary syndrome
Indications
o High-risk anatomic lesions involving multiple or critical vessels
o Activity-limiting symptoms due to any significant coronary artery
stenosis that persist:
Despite optimal medical treatment
OR due to contraindications to pharmacotherapy
Options
o CABG
o PCI
FEEDBACKYour notes
Shared NotesManage
Prognosis
Prognostic factors
o Left ventricular function: increased mortality if EF < 50%
o Involvement of left main coronary artery or involvement of more than one
vessel is associated with a worse prognosis
FEEDBACKYour notes
Shared NotesManage
Prevention
Lifestyle modifications
Lifelong antiplatelet therapy with aspirin or clopidogrel
Treatment of comorbidities
o Hypertension
First-line treatment: beta blockers
especially in patients post MI
o Diabetes mellitus
Individualized glycemic goals (e.g., HbA1c < 7%)
Lipid-lowering therapy
o See “Treatment of hypercholesterolemia in adults.”
FEEDBACKYour notes
Vasospastic angina
Description
Etiology
Diagnosis [38][11]
Cardiac biomarkers
o Measure serial troponin I and/or troponin T levels during periods of acute
chest pain
Criteria Description
following:
Criteria Description
o Precipitated by hyperventilation
changes [11][38]
Coronary
spasm on angiography o Can occur spontaneously during coronary angiography
unavailable transient ischemic ECG changes and equivocal coronary artery spasm criteria, i.e., changes are seen
Treatment [11][41]
General recommendations
o Smoking cessation
o Avoid beta-blockers
Pharmacotherapy: The goal is to prevent spasms and arrhythmias, and to improve
symptoms during acute attacks. [11][39]
o calcium channel blockers
o Alternatively:
Long-acting nitrates
Prognosis
The persistence of symptoms is common.