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Coronary Artery Atherosclerosis

Practice Essentials

Atherosclerotic coronary heart disease is the single leading cause of death of men and women in the United States and, in fact, around the world. Atherosclerosis is the principal cause of coronary artery disease (CAD), in which atherosclerotic changes are present within the walls of the coronary arteries. See the image below.

Coronary Artery Atherosclerosis. Cardiac catheteri

Coronary Artery Atherosclerosis. Cardiac catheterization and coronary angiography in the left panel shows severe left anterior descending coronary artery stenosis. This lesion was treated with stent placement in the left anterior descending coronary artery, as observed in the right panel.

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Signs and symptoms

The signs and symptoms of coronary artery atherosclerosis include the following:

Chest pain or pressure

Jaw pain

Shortness of breath

Weakness, fatigue, reduced exertional capacity

Dizziness, palpitations

Leg swelling (when left ventricular dysfunction is present)

Weight gain (when left ventricular dysfunction is present)

Diaphoresis

Stable angina pectoris

Intermittent claudication

Tachycardia: Common in persons with acute coronary syndrome (ACS) and acute myocardial infarction (AMI)

Atrial fibrillation

Ventricular tachycardia or ventricular fibrillation

High or low blood pressure

S4 gallop: A common early finding of diastolic dysfunction

S3 gallop: An indication of reduced left ventricular function and a poor prognostic sign

Heart murmurs

Tachypnea

Syncope

Pulmonary edema (in acute cases of myocardial infarction or congestive heart failure)

See Presentation for more detail.

Diagnosis

Laboratory tests:

Complete blood count (CBC)

Chemistry panel

Lipid profile

Thyroid function tests: To exclude thyroid disorders

Blood glucose and hemoglobin A1C (HbA1C) measurement

Myocardial fractional flow reserve (FFR)

Coronary flow reserve (CFR)

C-reactive protein level

Cardiac Troponin (in cases of suspected acute coronary syndrome)

Imaging studies:

Echocardiography

Nuclear imaging

Cardiac computed tomography with CT angiography

Electron beam CT scanning (for calculation of coronary artery calcium score)

Optical coherence tomography imaging

Magnetic resonance imaging

Positron emission tomography

Coronary angiography

See Workup for more detail.

Management

The following are used in the management of angina
:

Nitrates

Beta blockers

Calcium channel blockers

Ranolazine

Other agents used in the treatment of coronary artery stenosis or to aid in the management of coronary artery disease after intervention, or for the presentation of acute coronary syndromes, include the following:

Angiotensin-converting enzyme inhibitors to reduce blood pressure

Antiplatelet agents for acute coronary events

Intravenous glycoprotein IIb/IIIa inhibitors

Aspirin

Thienopyridine antiplatelet agents (e.g., clopidogrel, prasugrel)

Ticagrelor

HMG-CoA reductase inhibitors, or statins, to lower LDL cholesterol levels and stabilize atherosclerotic plaque

PCSK-9 inhibitors in select high-risk patients with known CAD and need for additional LDL lowering

Treatment procedures for coronary artery atherosclerosis include the following:

Coronary artery bypass grafting (CABG)

Percutaneous coronary intervention (PCI)

Percutaneous transluminal coronary angioplasty (PTCA)

In high- and intermediate-risk patients with 3-vessel disease, PCI was associated with significantly higher rates of revascularization and of major adverse cardiac and cerebrovascular events than CABG
; the two procedures were equally effective in the treatment of low-risk patients with 3-vessel disease and in low- and intermediate-risk patients with left main CAD.

See Treatment and Medication for more detail.

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