Coronary Artery Disease


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Coronary Artery Disease

  1. 1. Guideline for stable anginaCAD and IHD•Coronary artery disease (CAD):• Atherosclerosis is a complex inflammatory, fibroproliferative response•Ischemic heart disease (IHD):•Myocardial oxygen demand exceeds the capacity of coronary artery to deliver anadequate supply of oxygenClinical classification of chest pain•Typical angina(definite)• (1)Substernal chest discomfort with characteristic quality and duration(2)provoked by exertion or emotional stress(3)relieved by rest or nitroglycerin•Atypical angina(probable)• meets 2 of the above characteristics•Noncardiac chest pain• meets £ 1 of the typical angina characteristicsRisk factors for CAD•Age(male>45 y/o, female>55 y/o)•Male•Smoking•LDL-cholestrol•Hypertension•Diabetic mellitus•Family history of CAD•Hyperhomocysteinemia•Obesity•Inactive lifestyleDiagnosisEKG manifestation of stable angina•Resting EKG:• normal in half of patients with chronic stable angina• nonspecific ST-T change with/without abnormal Q wave,or ST elevation duringepisodes of angina pectoris•>50% of patients with normal EKG became abnormal during episodes of anginapectorisTreadmill test1.Indication
  2. 2. in diagnosis of obstructive CAD(adult patients with intermediate pretest probability ofCAD)risk assessment and prognosis in patients with symptoms or previous history of CADafter AMI, prognostic assessmentbefore and after revascularizationinvestigation of heart rhythmexercise test with ventilatory gas analysis2.Contraindication (absolute)AMI(within 2 days)unstable angina not previous stabilized by medical therapyuncontrolled cardiac arrhythmia causing symptomatic hemodynamic changesymptomatic severe aortic stenosisuncontrolled symptomatic heart failureacute pulmonary embolism or pulmonary infarctionacute myocarditis or pericarditisacute aortic dissection3.Contraindication(relative)left main coronary diseasemoderate stenotic valvular heart diseaseelectrolyte abnormalitysevere arterial hypertensiontachyarrhythmia or bradyarrhythmiahypertrophic cardiomyopathy and other forms of outflow tractmetal or physical impairment leading to inability to exercise adequatelyhigh degree AV block4.Sensitivity:68% ,specificity: 77%Myocardial perfusion scan(persantin thallium scan)1.Indicationevaluation of chest pain syndrome for presence of CADevaluation of known stenotic lesion at angiographyevaluation of patient after an AMIevaluation of patient after angioplasty or coronary bypass graftpre-op evaluation of patients with high risk of CADevaluation of myocardium vaibility2.Contraindicationhistory of asthma or severe COPD requiring high doses of theophyllinesevere bradycardia or high degree AV block without protection of pacemaker
  3. 3. implantationunstable anginarecent MIpatient cannot cooperateDobutamine stress echocardiography1.IndicationEvaluate patients with symptoms suggestive of CADEvaluate pateints with known CADRisk stratify patient before noncardiac surgery ,after myocardial infarction , orinterventional procedures and prior to starting an exercise programAmbiguous stress EKG examinationTo evaluate left ventricular global and segmental systolic functionTo identify viable ,hibernating ,or stunned myocardiumTo evaluate hemodynamics in valvular /cardiomyopathic heart disease2.Absolute contraindicationAMI(within 2 days)Unstable anginaUncontrolled cardiac rhythmSymptomatic valvular aortic stenosis(mean resting gradient >50 mmHg)Acute pulmonary embolism or pulmonary infarctionAcute myocarditis or pericarditisAcute aortic dissectionpregnancyCoronary angiography1.Indication Inadequate control of symptoms with optimal medical therapy Patient at high risk as determined with stress testing Evidence of moderate LV dysfunction Preparation for major vascular operation Occupation or lifestyle that involves unusual risk(such as pilot)2. No absolute contraindication3. Relative contraindication unexplained fever untreated infection severe anemia (Hb < 8 g/dl) severe electrolyte imbalance digitalis intoxication previous contrast allergy
  4. 4. severe coagulopathyactive infective endocarditisacute renal failureTREATMENTMedication for stable angina1.Platelet inhibitorA.aspirin B.ticlopidine or clopidogrel if allergy to or intolerance to aspirin side effect of ticlopidine : neutropenia,thrombocytopenia, pancytopenia2.Lipid- lowering agent in primary and secondary prevention of CAD to lower LDL-C level to 100md/dL among patients with known CAD to measure liver enzyme and creatine kinase 6 weeks after lipid lowering agent3.Nitrate reducing preload and afterload of left ventricle NTG can be used when activities known to precipitate angina are anticipated Side effect:headache, flushing, dizziness, weakness, postural hypotension Interaction :sildenfil and nitrates can lead to severe hypotension4.Beta blocker decreased rate -pressure product and oxygen demand, symptomatic improvement Avoid among patients with known coronary spasm Side effect:bronchoconstriction, masking of hypoglycemic reaction, depression, bradycardia, precipitation of heart failure,libido, alter lipid profile(HDL ,LDL) Interaction:severe bradycardia and hypotension occurred with concomitant use of calcium blocker5.Calcium channel blocker(diltiazem and verapamil) decrease angina attack, decreased rate -pressure product and oxygen demand side effect:hypotension, flushing, dizziness, headache, impaired LV function, bradycardia interaction: digitalis level are increased by calcium channel blockerCABGSignificant left main coronary disease3 -vessel disease.The survival benefit is greater in patients with abnormal LVfunction(EF less than 50%)2- vessel disease with significant proximal left anterior descending CAD and eitherabnormal LV function (EF less than 50%), or demonstrable ischemia on noninvasivetesting
  5. 5. Patients with 1- or 2 -vessel CAD without significant proximal left anteriordescending CAD but with a large area of viable myocardium and high-risk criteria onnoninvasive testingFor recurrent stenosis associated with large area of viable myocardium and /or highrisk criteria on noninvasive testingPCIPatients with 2- or 3- vessel disease with significant proximal left anterior descendingCAD ,who have anatomy suitable for catheter based therapy,normal LV function andwho do not have treated diabetesPatients with 1- or 2 -vessel CAD without significant proximal left anteriordescending CAD but with a large area of viable myocardium and high-risk criteria onnoninvasive testingFor recurrent stenosis associated with large area of viable myocardium and /or highrisk criteria on noninvasive testing Unstable anginaRecent onset of effort anginaEffort angina with changing pattern i.e. increased frequency or durationResting anginaBraunwald Classification of unstable anginaCCS classification of unstable anginaRisk stratification of patients with unstable angina1.High risk One of the following must be present:  prolonged ongoing rest pain(>20 mins): moderate or high likelihood of CAD  pulmonary edema:most likely caused by ischemia  rest angina with dynamic ST change ≥1mmAngina with new or worsening rales ,S3,or MR murmurAngina with hypotension No high risk feature but must have one of following:  Prolonged rest pain (>20 min) that resolves  Rest angina(>20 min or relieved with rest or sublingual NTG)  Nocturnal angina  Angina with dynamic T waves changes  New onset ,severe angina within 2 weeks with moderate or high likelihood of CAD  Pathological Q waves or resting ST depression in multiple lead groups age older than 65 years
  6. 6. 2.Low risk no high or intermediate risk features present increased frequency or duration of angina angina provoked by less exertion new-onset angina(within 2 weeks- 2 months) normal or unchange ECGReference1. Management of patients with chronic stable angina. ACC/AHA 2003 pocketguideline2.Roberto AO. et al. Diagnosis and management of patients with chronic ischemicheart disease.Hurst’s “THE HEART” 10th ed. MaGraw-Hill Co;2001:1207-12363. Bernald JG. et al. Chronic coronary artery disease. Braunwald “Heart disease” 6thed. W.B. Saunder ;Co.2001:1272-13524.Nuclear cardiology.Cardiology clinic.May 1994;12:2