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Coronary Artery Disease

Ischemic Heart Disease

Coronary artery disease results from an inadequate supply of blood to the myocardium, most commonly arising from an obstruction of the coronary arteries due to atherosclerosis.


Presentation

The clinical manifestations of coronary artery disease show a wide range of variation, with some individuals being completely asymptomatic, whilst others may develop stable or unstable angina pectoris. A large number of people may present with myocardial infarction (MI), whereas congestive heart failure and cardiomyopathies are not unusual outcomes. Patients may even present with sudden cardiac death.

The predominant symptom seen in coronary artery disease patients is chest pain (stable angina) that is retrosternal in location and commonly radiates to the left arm and neck [1] [2]. Often associated with shortness of breath, this pain is aggravated by activity and rapidly relieved by rest/nitrates [3] [4].

Unstable angina is characterized by severe and more frequent episodes of chest pain. Chest pain may also be evident on rest.

MI patients often report a protracted course of anginal pain associated with increased sweating. Intermittent claudication, mesenteric angina, transient ischemic attacks and strokes are some of the other common ways in which coronary artery disease presents.

On examination, tachycardia, tachypnea and an irregular pulse may be present. Hypertension or hypotension may be found in these patients. Signs suggestive of congestive cardiac failure may be seen such as limb edema, pulmonary congestion, diaphoresis, abdominal swelling, etc [5]. Murmurs and extra sounds (the third and fourth heart sounds) may also be present. Other signs include central obesity, xanthelasmas, livedo reticularis or diagonal ear creases.

Weakness
  • Weak associations were observed between NBL1-Ab level and apnea-hypopnea index, age, mean SpO2 and arousal index, whereas significantly higher NBL1-Ab levels were observed in OSA patients with a history of CAD than in those without a history of CAD.[ncbi.nlm.nih.gov]
  • The rating scale is: AAA (Extremely Strong), AA (Very Strong), A (Strong), BBB (Good), BB (Marginal), B (Weak), CCC (Very Weak), CC (Extremely Weak), SD or D (Selective Default or Default), R (Regulatory Action), NR (Not Rated).[southerncross.co.nz]
  • Symptoms of coronary artery disease may include: heaviness, tightness, pressure, and/or pain in the chest - behind the breastbone pain radiating in the arms, shoulders, jaw, neck, and/or back shortness of breath weakness and fatigue Diagnosis of Coronary[beaumont.org]
  • Lightheadedness or sudden weakness. Fast or irregular heartbeat. If you experience these symptoms, take them seriously, and call 911 immediately. Our goal is to quickly determine what’s causing your symptoms.[mercy.net]
  • Symptoms include: Heaviness, tightness, pressure or pain in the chest behind the breastbone Pain spreading to the arms, shoulders, jaw, neck or back Shortness of breath Weakness and fatigue Diagnosis In addition to a complete medical history and physical[lifebridgehealth.org]
Congestive Heart Failure
  • Abstract We report the case of a 51-year-old female, in whom coronary artery disease such as occlusion of septal perforators was manifested, on the occasion of hospitalization with congestive heart failure.[ncbi.nlm.nih.gov]
  • For example, heart failure (congestive heart failure) may be diagnosed if your heart cannot deliver adequate amounts of oxygen to the body.[uabmedicine.org]
  • A large number of people may present with myocardial infarction (MI), whereas congestive heart failure and cardiomyopathies are not unusual outcomes. Patients may even present with sudden cardiac death.[symptoma.com]
  • In the REACH registry 6.4% of patients with CAD were hospitalized for unstable angina and 4.6% for congestive heart failure in the first year of follow-up.[thrombosisadviser.com]
Dyspnea
  • A 55-year-old Caucasian male with coronary heart disease was admitted because of dyspnea for 4 weeks.[ncbi.nlm.nih.gov]
  • Although women have more frequent chest pain than men, atypical symptoms such as nausea, dyspnea, and fatigue make it difficult to determine their risk of coronary artery disease (CAD) before testing.[ncbi.nlm.nih.gov]
  • RESULTS: A total of five women enrolled of which four completed the trial, while one was withdrawn by the investigators after developing dyspnea 1 week after treatment. Her symptoms resolved after cessation of the study medication.[ncbi.nlm.nih.gov]
  • […] acute renal failure, significant dissection, perforation, vascular complications requiring intervention, bleeding event within 72 hours, and emergent CABG for failed PCI. 3 Tracked via the Seattle Angina Questionnaire (SAQ-7) 4 Tracked via the Rose Dyspnea[ichom.org]
  • It is characterized by a severe and rapid onset of symptoms that may include chest pain, often radiating to the left arm and left side of the neck, dyspnea, sweating, and palpitations. 410 Acute myocardial infarction 410.0 Acute myocardial infarction[icd9data.com]
Chest Pain
  • Such an association presenting with chest pain mimicking an infarct aneurysm with angina or a takotsubo cardiomyopathy with chest pain is difficult to differentiate clinically.[ncbi.nlm.nih.gov]
  • We postulate that this association should be considered in differential diagnosis of chest pain.[ncbi.nlm.nih.gov]
  • Unstable angina is characterized by severe and more frequent episodes of chest pain. Chest pain may also be evident on rest. MI patients often report a protracted course of anginal pain associated with increased sweating.[symptoma.com]
  • MATERIAL AND METHODS The study groups included 348 consecutive subjects with chest pain but without known coronary artery disease, and who underwent an estimation of CAC score in our hospital.[ncbi.nlm.nih.gov]
  • Although women have more frequent chest pain than men, atypical symptoms such as nausea, dyspnea, and fatigue make it difficult to determine their risk of coronary artery disease (CAD) before testing.[ncbi.nlm.nih.gov]
Hypertension
  • Serum levels and gene polymorphism of IL-22 were investigated in hypertensive patients with no CAD (H-Tens), hypertensive patients with CAD (CAD   H-Tens); 3), CAD patients with no hypertension (CAD); and non-hypertensive with no CAD subjects as a control[ncbi.nlm.nih.gov]
  • The participants were divided into four subgroups including: CAD patients with no hypertension (H - CAD ), hypertensive patients with no CAD (H CAD - ), CAD patients with hypertension (H CAD ) and non-hypertensive non-CAD subjects as control group (H[ncbi.nlm.nih.gov]
  • Abstract The 2015 American Heart Association/American College of Cardiology/American Society of Hypertension Scientific Statement "Treatment of Hypertension in Patients with Coronary Artery Disease" is summarized in the context of a clinical case.[ncbi.nlm.nih.gov]
  • Twenty-six subjects (18%) had a retinal hemorrhage, and 115 (74%) a mild or moderate hypertensive retinopathy. Fifty-five (38%) had diabetes, and 24 (17%) a background (n 20) or proliferative (n 4) diabetic retinopathy.[ncbi.nlm.nih.gov]
  • Traditional Framingham risk factors such as hypertension, hyperlipidemia, diabetes, smoking, as well as lifestyle habits such as unhealthy diet and sedentary lifestyle are all modifiable.[ncbi.nlm.nih.gov]
Vascular Disease
  • Show More Learn More Diagnosing Heart Disease Eating Right for Your Heart FAQ: Heart-healthy Diets FAQ: Heart Transplant Heart and Vascular Disease Prevention Tips Heart and Vascular Disease: The Facts Heart and Vascular Disease: The Risks Heart Disease[ucsfhealth.org]
  • Abstract Favorites PDF Get Content & Permissions CABG Are two internal thoracic grafts better than one in patients with peripheral vascular disease? Nadav, Teich; Pevni, Dmitry; Mohr, Rephael; More Coronary Artery Disease. 30(1):67-73, January 2019.[journals.lww.com]
  • Because the underlying atherosclerosis causal to CAD is a systemic disease, patients with CAD often have ischaemic vascular disease affecting two or more vascular beds (known as polyvascular disease). Coronary syndromes are a spectrum of conditions.[thrombosisadviser.com]
  • Some examples of cardiovascular diseases include ischemic heart disease, heart valve disease, cardiomyopathies, peripheral artery disease, congenital heart disease, and vascular disease of the kidneys. This study is located in Bethesda, Maryland.[nhlbi.nih.gov]
Tachycardia
  • On examination, tachycardia, tachypnea and an irregular pulse may be present. Hypertension or hypotension may be found in these patients.[symptoma.com]
  • 研究成果 : ジャーナルへの寄稿 › 記事 Catheter ablation for verapamil-sensitive fascicular ventricular tachycardia guided by precise mapping using a multi-spline duodecapolar catheter with small electrodes and close spacings Takase, S., Mukai, Y., Honda, N., Chishaki[kyushu-u.pure.elsevier.com]
  • Transient ST-segment depression and chest pain detected during ambulatory monitoring were usually associated with tachycardia ( Figure 3 ). It was noted that 20% of the episodes of ST-segment depression occurred with a heart rate Figure 3.[doi.org]
Exertional Chest Pain
  • Case Report: A 55-year-old white female pharmacist underwent diagnostic coronary arteriography for the assessment of typical exertional chest pain, which had started 18 months previously and had gradually become more frequent and severe despite treatment[doi.org]
Increased Sweating
  • MI patients often report a protracted course of anginal pain associated with increased sweating.[symptoma.com]
  • sweating Lifesaving heart attack care If one of your coronary arteries becomes significantly blocked by plaque, it cuts off blood and oxygen to the heart muscle.[muhealth.org]
Type A Personality
  • Explanatory dynamics based on stress and Type A personality are suggested.[web.archive.org]
  • Explanatory dynamics based on stress and Type A personality are suggested. Austad, S. N. ( 1997 ). Why we age: What science is discovering about the body’s journey through life. New York : John Wiley. Google Scholar Cassandro, V. J. ( 1998 ).[psp.sagepub.com]
  • Mommersteeg, The predictive value of positive affect and Type D personality for adverse cardiovascular clinical outcomes in patients with non-obstructive coronary artery disease, Journal of Psychosomatic Research, 104, (108), (2018).[doi.org]
Tremor
  • Neurologic examination revealed positional tremor and generally reduced tendon reflexes. During 8 weeks, his condition improved under pharmacotherapy.[ncbi.nlm.nih.gov]

Workup

Coronary artery disease requires emergency management and must be strongly suspected in patients presenting with any of the symptoms mentioned.

An electrocardiogram (ECG) is the most important investigation to be performed for such individuals within 10 minutes of presentation. ST segment elevations ≥ 1 mm present in 2 or more contiguous leads is strongly suggestive of an ST-segment elevation MI (STEMI) [6] [7]. Pathologic Q waves may develop over time. With a specificity of 90%, serial ECG measurements may help confirm the diagnosis or may even guide the treatment strategy. A pulse oximetry and chest radiography may aid in diagnosis.

Detection of serum cardiac markers suggestive of myocardial necrosis are highly suggestive of MI. Troponins I and T are the markers of choice and show a high sensitivity and specificity (can detect levels as low as 1 pg/ml) at detecting STEMI [8]. Other serum cardiac markers that may be helpful include myoglobin and creatine kinase-MB.

A diagnostic coronary angiography combined with percutaneous coronary intervention (PCI) procedures has proven to be life-saving for people with MI. Patients with STEMI may benefit from PCI (angioplasty, placement of stents) when they present within 3 hours of onset of angina. Long term outcomes for unstable angina and NSTEMI patients are also improved by delayed (within 24-48 hours) coronary angiography.

Routine investigations aren’t of much help in coronary artery disease; however, a fasting lipid profile must be done in all such patients. Cardiac stress testing, echocardiography and/or cardiac nuclear imaging studies may also be beneficial in these individuals.

Hypertriglyceridemia
  • Health-care providers should identify for patients the importance of physical activity as primary or adjunctive therapy for such medical conditions as hypertension, hypertriglyceridemia, glucose intolerance, and obesity.[web.archive.org]
  • Antisense inhibition of apolipoprotein C-III in patients with hypertriglyceridemia. N. Engl. J. Med. 373, 438–447 (2015). 82. Tsimikas, S. et al.[doi.org]
  • Hypertriglyceridemia and elevated lipoprotein(a) are risk factors for major coronary events in middle-aged men. Am J Cardiol. 1996 ; 77 :1179–1184. Crossref Medline Google Scholar 20 Rosengren A, Wilhemsen L, Eriksson E, et al.[doi.org]
T Wave Inversion
  • The ECG can show ST segment shifts and/or T-wave inversions as signs of heart ischemia or injury. However, there are electrically silent areas in the standard monitors.[emedicine.com]
Ischemic Changes
  • No ischemic changes on the electrocardiogram were noted for either patient. Patient 1 had an exercise stress test that was negative for any inducible ischemia whereas patient 2 had no obstructive lesion seen on coronary angiography.[ncbi.nlm.nih.gov]
  • The VA Cooperative Study included 686 CAD patients with stable angina, electrocardiographic signs of previous infarction or ischemic changes in exercise, and at least one major coronary artery with 50% stenosis.[dx.doi.org]

Treatment

  • The studies had evaluated 2024 patients who received psychosocial treatment vs 1156 control subjects.[ncbi.nlm.nih.gov]
  • Results: The studies had evaluated 2024 patients who received psychosocial treatment vs 1156 control subjects.[doi.org]
  • Despite our general understanding, however, optimal treatment of this cohort remains elusive.[ncbi.nlm.nih.gov]
  • RESULTS: This research, based on past syndromes research and real clinical effective chronic SCAD cases, aim to build a TCM diagnosis and treatment information database.[ncbi.nlm.nih.gov]
  • In our opinion, staged off-pump coronary arterial revascularisation followed by definitive surgical treatment for the malignancy is a safe and effective treatment modality in patients with coronary artery disease and oncological diseases. 2014 BMJ Publishing[ncbi.nlm.nih.gov]

Prognosis

  • Patients with coronary artery disease vary widely in terms of prognosis, which is mainly dependent on ventricular function.[ncbi.nlm.nih.gov]
  • Expert opinion: Compared with traditional diagnostic tools, circulating miRNAs have many strongpoints, suggesting that circulating miRNAs can serve as promising biomarkers for the early diagnosis and prognosis of CAD.[ncbi.nlm.nih.gov]
  • The aim of this study was to reassess the value of PEDF in predicting the severity and prognosis of newly diagnosed stable CAD in a Chinese population.[ncbi.nlm.nih.gov]
  • Abstract The presence and extent of myocardial ischemia are the major determinants of prognosis in patients with coronary artery disease (CAD).[ncbi.nlm.nih.gov]
  • In addition, follow-up SPECT/CTA fusion imaging plays a role in predicting prognosis by displaying clearly the relationship between postoperative vessel and myocardial blood supply.[ncbi.nlm.nih.gov]

Epidemiology

  • KEYWORDS: Cardiovascular; challenging patients; epidemiology; kidney transplant[ncbi.nlm.nih.gov]
  • This article examines the epidemiology, clinical presentation, screening tools, and treatment recommendations for these patients.[ncbi.nlm.nih.gov]
  • Abstract Epidemiological studies suggest retinal microvascular abnormalities predict cardiac events. This study examined microvascular features associated with coronary artery abnormalities.[ncbi.nlm.nih.gov]
  • Such information also has important applications in clinical medicine and drug discovery by using a Mendelian randomization approach to interrogate the causal nature of many factors found to associate with CAD risk in epidemiological studies.[ncbi.nlm.nih.gov]
  • Epidemiology of Chronic CAD 2. The Global Perspective of Ischemic Heart Disease Section 2: Pathogenesis 3. Genetics of Coronary Atherosclerosis 4. Basic Mechanisms of Atherogenesis 5. Coronary Microvascular Dysfunction 6.[elsevier.com]
Sex distribution
Age distribution

Pathophysiology

  • The purpose of this review is to provide an overview of the pathophysiological, analytical, and clinical characteristics of MPO and to summarize the state of art about the possible clinical use of MPO as a marker for diagnosis and risk stratification[ncbi.nlm.nih.gov]
  • Further studies are needed to clarify the unique pathophysiology of CAD in women and, in turn, create more specific guidelines for its diagnosis, management, and treatment in this patient population.[ncbi.nlm.nih.gov]
  • Moving forwards, genetic testing could enable precision medicine approaches by identifying subgroups of patients at increased risk of coronary artery disease or those with a specific driving pathophysiology in whom a therapeutic or preventive approach[ncbi.nlm.nih.gov]
  • In the present review, we would like to present the metabolic perspective of pathophysiology of coronary artery disease and heart failure, and metabolic therapy by using trimetazidine and ranolazine. Copyright 2017. Published by Elsevier B.V.[ncbi.nlm.nih.gov]
  • Understanding the genetic architecture of CAD and MI has proven to be difficult and costly due to the heterogeneity of clinical CAD and the underlying multi-decade complex pathophysiological processes that involve both genetic and environmental interactions[ncbi.nlm.nih.gov]

Prevention

  • Expert commentary: Limited evidence at present has shown that cardiac rehabilitation and exercise has potential in preventing cognitive decline.[ncbi.nlm.nih.gov]
  • To prevent reoccurring cardiovascular events, young patients and men are two groups which health professionals need to concentrate in motivating to quit smoking.[ncbi.nlm.nih.gov]
  • The value of CPAP therapy as second prevention for CAD needs further investigation.[ncbi.nlm.nih.gov]
  • Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer [Putting Prevention into Practice] 10/15/2016 Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: Recommendation Statement [U.S.[aafp.org]
  • Hena Patel, Sonal Chandra, Sarah Alexander, Jeffrey Soble and Kim Allan Williams, Plant-Based Nutrition: An Essential Component of Cardiovascular Disease Prevention and Management, Current Cardiology Reports, 19, 10, (2017).[doi.org]

References

Article

  1. Kreiner M, Okeson JP, Michelis V, et al. Craniofacial pain as the sole symptom of cardiac ischemia: a prospective multicenter study. J Am Dent Assoc 2007; 138:74.
  2. Constant J. The clinical diagnosis of nonanginal chest pain: the differentiation of angina from nonanginal chest pain by history. Clin Cardiol 1983; 6:11.
  3. Kearney MT, Charlesworth A, Cowley AJ, MacDonald IA. William Heberden revisited: postprandial angina-interval between food and exercise and meal composition are important determinants of time to onset of ischemia and maximal exercise tolerance. J Am Coll Cardiol 1997; 29:302.
  4. Schiffer F, Hartley LH, Schulman CL, Abelmann WH. Evidence for emotionally-induced coronary arterial spasm in patients with angina pectoris. Br Heart J 1980; 44:62.
  5. Cook DG, Shaper AG. Breathlessness, angina pectoris and coronary artery disease. Am J Cardiol 1989; 63:921.
  6. Goldberger AL. Myocardial Infraction: Electrocardiographic Differential Diagnosis, 4th, Mosby Yeark Book, St. Louis 1991.
  7. Goldberger AL. Clinical Electrocardiography: A Simplified Approach, 6th, Mosby, St. Louis 1999.
  8. Macrae AR, Kavsak PA, Lustig V, et al. Assessing the requirement for the 6-hour interval between specimens in the American Heart Association Classification of Myocardial Infarction in Epidemiology and Clinical Research Studies. Clin Chem 2006; 52:812.

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Last updated: 2018-06-21 23:44