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Coronary Atherosclerosis

Atherosclerotic Coronary 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
  • Other symptoms of coronary artery disease may include shortness of breath, weakness, fatigue and pain radiating in the arms, shoulders, jaw, neck, and/or back.[barnesjewish.org]
  • 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]
  • 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]
  • […] affect the lymph glands and other lymphatic tissue Parkinson's Disease A progressive disorder of the nervous system that affects muscle movement Peripheral Neuropathy, Early-Onset A nervous system condition that causes numbness, tingling, and motor weakness[publichealth.va.gov]
  • […] compensation and health care benefits for diseases that VA has recognized as associated with exposure to Agent Orange and other herbicides: Acute and Subacute Peripheral Neuropathy A nervous system condition that causes numbness, tingling, and motor weakness[web.archive.org]
Congestive Heart Failure
  • 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]
  • heart failure and CV death prior to RA diagnosis and during the first few years of the disease.[doi.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]
  • heart failure, and transient ischemic attack and stroke ( Table 3 ).[doi.org]
  • For example, heart failure (congestive heart failure) may be diagnosed if your heart cannot deliver adequate amounts of oxygen to the body.[uabmedicine.org]
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]
  • 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]
  • 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]
  • […] 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]
Heart Disease
  • INTRODUCTION: Ischemic heart disease (IHD) related to atherosclerotic coronary artery disease (CAD) is one of the most prevalent causes of death in Europe.[ncbi.nlm.nih.gov]
Chest Pain
  • Symptoms Chest pain is the most common complaint in heart attack. Unlike angina, pain does not subside on resting. However, the symptoms may be different.[summitcardiology.com]
  • If left untreated, coronary artery disease can lead to chest pain (angina), shortness of breath, heart attack and possibly death.[barnesjewish.org]
  • 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]
  • She had long-lasting excruciating chest pain after dipyridamole infusion.[doi.org]
  • We postulate that this association should be considered in differential diagnosis of chest pain.[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 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]
  • Smoking Stress Menopause Non-compliance with medicines to treat hypertension and high cholesterol.[summitcardiology.com]
  • Randomised controlled trials of more than six months duration using counselling or education to modify more than one cardiovascular risk factor in adults from general populations, occupational groups or specific risk factors (i.e. diabetes, hypertension[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]
Vascular Disease
  • Convert to ICD-10-CM : 429.2 converts approximately to: 2015/16 ICD-10-CM I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris Approximate Synonyms Arteriosclerotic cardiovascular disease Arteriosclerotic vascular disease[icd9data.com]
  • 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]
  • Generalizing beyond the source observational studies is an important issue for vascular disease risk estimation.[dx.doi.org]
  • Because atherosclerotic vascular disease remains the major cause of death in many countries, it is important that health-care providers support the implementation and maintenance of exercise programs for their patients across the lifespan.[web.archive.org]
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]
  • AHA American Heart Association; ECMO extracorporeal membrane oxygenation; PCI percutaneous coronary intervention; VT ventricular tachycardia.[onlinejacc.org]
  • States of tachycardia increase oxygen demand significantly. which explains why anginal symptoms are frequently exertional.[healio.com]
  • Effect of dietary n-3 polyunsaturated fatty acids on the inducibility of ventricular tachycardia in patients with ischemic cardiomyopathy. Am J Cardiol . 2008;101(6):758-76118328835 PubMed Google Scholar Crossref 9.[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 ).[doi.org]
  • 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]
  • Tobacco (cigarettes, cigars, pipes), but also chewing tobacco, obesity, high blood pressure (hypertension), diabetes, lack of regular exercise, high-fat diet, emotional stress, and type A personality (impatient, aggressive, competitive).[emedicinehealth.com]
Forgetful
  • Sheehan, Does the Body Forget? Adult Health, Life Course Dynamics, and Social Change, Handbook of the Life Course, 10.1007/978-3-319-20880-0_16, (355-368), (2016).[doi.org]

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]
  • 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]
  • Greater increases in HDL-C may occur in individuals with baseline hypertriglyceridemia, 18 but few studies have addressed the effect of exercise in subjects with lipid disorders.[doi.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]
  • Prescription omega-3 fatty acids for the treatment of hypertriglyceridemia. Am J Health Syst Pharm . 2007;64(6):595-60517353568 PubMed Google Scholar Crossref 6. Mita T, Watada H, Ogihara T, et al.[doi.org]
T Wave Inversion
  • Diagnosis of MI required documentation of two or more of: (a) typical ischemic chest pain, pulmonary oedema, syncope or shock; (b) development of pathological Q-waves and/or appearance or disappearance of localized ST-elevation followed by T-wave inversion[doi.org]
  • 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.[doi.org]
  • Noninvasive testing, such as rest echocardiography revealing multiple regional wall motion abnormalities or electrocardiography with diffuse ischemic changes in multiple territories, may reflect CAD with a large ischemic burden and justify diagnostic[doi.org]

Treatment

  • Coronary Artery Disease Treatment While successful and long-term treatment of coronary artery disease includes a modification of risk factors and adoption of a healthier lifestyle, there are several medical and surgical treatments available as well.[barnesjewish.org]
  • 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]

Prognosis

  • Patients with coronary artery disease vary widely in terms of prognosis, which is mainly dependent on ventricular function.[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]
  • 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]
  • 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]

Etiology

  • This is a controversial topic, as no clear etiology has been seen.[healio.com]
  • Another explanation for the reduced effect in stroke may be attributable to the more heterogenic etiology of stroke as opposed to coronary artery disease.[doi.org]
  • Early EMS transport exclusion criteria included: 1) cardiac arrest of noncardiac etiology (e.g., blunt or penetrating traumatic arrest, burn-related, exsanguination, hanging, known overdose); 2) contraindications to mechanical CPR; 3) known pregnancy;[onlinejacc.org]
  • Etiologic factors include a genetic susceptibility, because 15% to 20% of patients have a family history of the disorder. AAA is much more common in men than women (2 to 5 times) and more common in white than in black populations.[dx.doi.org]

Epidemiology

  • Prospective Urban Rural Epidemiology (PURE) Study Investigators.[doi.org]
  • In this review, we summarize the epidemiologic significance of ACS and CAD in patients with CKD, discuss the diagnosis of ACS in this patient population, and review the therapeutic interventions in patients with CKD.[ncbi.nlm.nih.gov]
  • The epidemiologic importance of psychosocial factors in longevity. American Journal of Epidemiology, 114, 451 - 461. Google Scholar Crossref Medline ISI Cohen, S., & Williamson, G. M. ( 1991 ). Stress and infectious disease in humans.[doi.org]
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]
  • 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.[ncbi.nlm.nih.gov]
  • Regarding this case, the authors reviewed the literature on the pathophysiology of rapidly progressive coronary artery disease and the approach for non-significant lesions in patients with acute coronary syndrome, especially in the younger population.[ncbi.nlm.nih.gov]
  • }inwind.it Abstract The classic definition of cardiac syndrome X (CSX) seems inadequate both for clinical and research purposes and should be replaced with one aimed at including a sufficiently homogeneous group of patients with the common plausible pathophysiological[doi.org]
  • 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

  • Preventive Services Task Force Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009 150 396 404 ,, ,, ,.[doi.org]
  • Preventive Services Task Force (USPSTF) for aspirin for the primary prevention of cardiovascular events, as well as the supporting scientific evidence.[doi.org]
  • Centers for Disease Control and Prevention, U.S.[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: 2019-06-28 10:28