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 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.
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.