Obstructive Coronary Artery Disease

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Obstructive Coronary Artery Disease /Coronary Artery Disease (CAD), also called coronary heart disease (CHD), ischemic heart disease (IHD), or simply heart disease, is a chronic and gradual reduction of blood flow to the heart muscle specially myocardium due to the build-up of accessive plaque (atherosclerosis) in the arteries inner sidewall of the heart and myocardial wall and systolic thickening. It is almost always due to subintimal atheroma deposition, leading to arterial luminal stenosis or occlusion and wall thickening. It is the most common of cardiovascular diseases.[rx] Types include stable angina, unstable angina, myocardial infarction, and sudden cardiac death.[rx] A common symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck, or jaw.[rx]

The condition is usually caused by cholesterol-containing deposits called plaque. It is a waxy substance with a combination of cholesterol, fat, and other substances which stick to the walls lining the blood vessels. Over time they make arteries become harder and narrower and may cause a condition called atherosclerosis. Plaque buildup narrows coronary arteries, thereby decreasing the blood flow to the heart which eventually causes chest pain, shortness of breath, or other signs and symptoms of coronary artery disease. Uncontrolled coronary artery disease or a complete blockage of arteries can cause a heart attack.

Another name

Also known as 

  • Coronary Artery Disease
  • Coronary Microvascular Disease
  • Coronary Syndrome X
  • Ischemic Heart Disease
  • Nonobstructive Coronary Artery Disease
  • Obstructive Coronary Artery Disease
  • Hardening of the arteries
  • Heart disease
  • Narrowing of the arteries

Causes of Obstructive Coronary Artery Disease

Non-Modifiable
  • Age
  • Gender
  • Race
  • Family history
Modifiable
  • Type 2 diabetes mellitus
  • Hypertension
  • Smoking
  • Dyslipidemia
  • Chronic kidney disease
  • Obesity and metabolic syndrome
  • Acute pericarditis
  • Anxiety disorders
  • Aortic stenosis
  • Asthma
  • Dilated cardiomyopathy
  • Emergent treatment of gastroenteritis
  • Esophagitis
  • Hypertensive emergencies in emergency medicine
  • Myocardial infarction
  • Myocarditis
Enhancing factors
  • Abdominal obesity (waist/hip ratio) (greater than 0.90 for males and greater than 0.85 for females)
  • Psychosocial factors such as depression, loss of the locus of control, global stress, financial stress, and life events including marital separation, job loss, and family conflicts
  • Lack of daily consumption of fruits or vegetables
  • Lack of physical activity
  • Premature menopause
  • Preeclampsia
  • Chronic inflammatory conditions (for example rheumatoid arthritis, HIV, psoriasis)
  • Persistently elevated triglycerides
Structural
  • Ischemic cardiomyopathy (most common structural cardiac etiology of syncope)
  • Valvular abnormalities (second most common structural etiology, most commonly aortic stenosis)
  • Nonischemic/Dilated cardiomyopathy (third most common structural etiology)
  • Hypertrophic obstructive cardiomyopathy
  • Aortic dissection
  • Cardiac tamponade
  • Obstructive cardiac tumors
  • Pericardial disease
  • Pulmonary hypertension
  • Pulmonary emboli
  • Arrhythmogenic right ventricular cardiomyopathy
Electrical

Tachyarrhythmia

  • Supraventricular (examples: atrial fibrillation, atrial flutter, paroxysmal supraventricular tachycardia (PSVT), PSVT in the setting of pre-existing accessory conduction pathways)
  • Ventricular (often secondary to mechanical/structural heart disease or channelopathies, such as Brugada)
  • PR interval disorders/accessory conduction pathways (WPW, LGL, Mahaim syndrome, Breijo syndrome)

Bradyarrhythmia

  • Sinus node dysfunction
  • Atrioventricular conduction block (typically second or third degree)
  • Pacemaker malfunction
Inherited channelopathies
  • QT interval disorders (Long or short QT)

    • Romano-Ward syndrome: Autosomal dominant congenital long QT syndrome
    • Jervell and Lange-Nielsen syndrome: autosomal recessive long QT syndrome associated with deafness
  • Brugada syndrome

    • An autosomal dominant mutation in the SCN5A gene, which encodes for voltage-gated sodium channels found in the heart
  • Catecholaminergic polymorphic ventricular tachycardia

    • Autosomal dominant mutation of hRyR2 gene, which encodes for ryanodine receptors
    • Autosomal recessive mutation of CASQ2 gene, which encodes for calsequestrin-2
  • Drug-Induced
    • (bradycardias, tachycardias, QT interval prolongation, cardiotoxins, etc.).

Symptoms of Obstructive Coronary Artery Disease

  • Chest pain (angina) – You may feel pressure or tightness in your chest as if someone were standing on your chest. This pain, called angina, usually occurs on the middle or left side of the chest. Angina is generally triggered by physical or emotional stress. The pain usually goes away within minutes after stopping the stressful activity. In some people, especially women, the pain may be brief or sharp and felt in the neck, arm, or back.
  • Shortness of breath – If your heart can’t pump enough blood to meet your body’s needs, you may develop shortness of breath or extreme fatigue with activity.
  • Heart attack – A completely blocked coronary artery will cause a heart attack. The classic signs and symptoms of a heart attack include crushing pressure in your chest and pain in your shoulder or arm, sometimes with shortness of breath and sweating.
  • Fatigue – A significant change in energy level, something out of the norm that lasts more than a few days. At 70%, unusual fatigue is the single most common long-term symptom for women.
  • Sleep difficulties – Trouble falling asleep, or waking up in the night more than usual, often because of an ache or pain that won’t let you sleep.
  • Shortness of breath – Becoming winded doing the most basic activities, but especially during exercise.
  • Indigestion – Feeling uncomfortably full soon after eating, sometimes with pain or burning in the upper abdomen.
  • Chest discomfort – It may be mild discomfort, it may seem like indigestion.
  • Anxiety – Feeling nervous or apprehensive for no apparent reason, or more than usual.
  • Chest pain or discomfort (angina)
  • Weakness, light-headedness, nausea (feeling sick to your stomach), or a cold sweat
  • Pain or discomfort in the arms or shoulder

An acute coronary event, such as a heart attack, may cause the following symptoms

  • Angina, which can feel like pressure, squeezing, burning, or tightness during physical activity. The pain or discomfort usually starts behind the breastbone, but it can also occur in the arms, shoulders, jaw, throat, or back. The pain may feel like indigestion.
  • Cold sweats
  • Dizziness
  • Light-headedness
  • Nausea or a feeling of indigestion
  • Neck pain
  • Shortness of breath, especially with activity
  • Sleep disturbances
  • Weakness

Women are somewhat less likely than men to experience chest pain. Instead, they are more likely to experience

  • Chest pain – While men having a heart attack often report a crushing or stabbing pain in their chest, many women say they felt pressure, tightness, or aching in their chest or back.
  • Fatigue – More than feeling tired, this overwhelming fatigue makes it hard to do anything.
  • Breathing difficulties – It’s suddenly a struggle to take a full breath.
  • Radiating pain – Pain spreads across the jaw, arm, shoulder or radiating across the back
  • Dizziness
  • Fatigue
  • Nausea
  • Pressure or tightness in the chest
  • Stomach pain
  • Women are also more likely than men to have no symptoms of coronary heart disease.

Chronic (long-term) coronary heart disease can cause symptoms such as the following:

  • Angina
  • Shortness of breath with physical activity
  • Fatigue
  • Neck pain

Diagnosis of Obstructive Coronary Artery Disease

On physical exam, the most common signs encountered are:

  • Rales on lung auscultation indicative of pulmonary edema
  • Decreased breath sounds on lung auscultation suggestive of pleural effusion
  • S3 gallop on heart auscultation indicative of elevated left ventricular end-diastolic pressure
  • Point of maximal impulse displaced laterally on palpation characteristic of increased heart size
  • Jugular venous distention (jugular venous pressure over 8 cm of water) indicative of elevated right atrial pressure
  • Positive hepatojugular reflux (exerting manual pressure on the congested liver causing increased jugular venous pressures)
  • Increased abdominal girth due to ascites
  • Swelling of the scrotum
  • Low blood pressure and rapid heart rate can occur in severely decompensated failure due to decreased cardiac output

The three components in the evaluation of MI are clinical features, ECG findings, and cardiac biomarkers.

Laboratory tests

  • Cardiac troponins should be the only marker ordered
  • CBC
  • Lipid profile
  • Renal function
  • Metabolic panel
  • B-type natriuretic peptide (BNP) – should not be ordered as a marker for MI, but it is better used to stratify risk, especially in patients with MI who develop heart failure.
  • Brain natriuretic peptide (BNP) or NT-proBNP – may be the most helpful as it can differentiate acute heart failure from other causes of shortness of breath. However, this test lacks specificity, and a high level of this hormone is not diagnostic of acute heart failure.
  • Troponin T – (to detect myocardial infarction, although the levels may be high due to heart failure itself), complete blood count, basic metabolic panel (low sodium, in particular, indicates advanced disease) and liver function tests (to detect liver injury due to volume overload).

Imaging Test

  • 2D echocardiography – is useful to evaluate right and left ventricular size, mean pulmonary artery pressure in left to right shunt, and evaluation of regional or global left ventricular systolic function.
  • Heart angiography – remains the primary diagnostic and therapeutic modality in the assessment of the fistula and embolization with coils and devices. Heart Angiogram is the most promising test to identify blocked arteries. In an angiogram for the heart, your doctor will inject a special dye into the coronary arteries through a long, thin, flexible tube called a catheter. It is threaded through an artery, usually in the leg to the arteries in the heart. The dye outlines narrow spots and artery blockages.
  • Holter monitoring – is a type of ECG where the individual wears a portable monitor for 24 hours while going through regular activities. The device captures any abnormalities and can also suggest inadequate blood flow to the heart.
  • Coronary Angiography – Coronary angiography also called cardiac catheterization, is a minimally invasive study that is considered the gold standard for diagnosing coronary artery disease. This test is performed under local anesthesia and involves injecting X-ray dye or contrast medium into the coronary arteries via tubes called catheters. An X-ray camera films the blood flow to show the location and severity of artery narrowing. This test can show if the blood vessels in your heart have narrowed, your heart is pumping normally and blood is flowing correctly and your heart valves are functioning properly. It also can identify any heart abnormalities you may have been born with or congenital abnormalities.
  • Multidetector computed tomography – is useful for the 3-dimensional anatomic evaluation for origin, patency, and termination of the CAVF.
  • Exercise stress test – If your signs and symptoms occur most often during exercise, your doctor may ask you to walk on a treadmill or ride a stationary bike during an ECG. Sometimes, an echocardiogram is also done while you do these exercises. This is called a stress echo. In some cases, medication to stimulate your heart may be used instead of exercise.
  • Stress Thallium Test – Stress thallium tests have two components — a treadmill stress test and heart scan after injection of a radionuclide material, such as thallium, which allows doctors to see the coronary arteries and the shape and function of the heart. It has been used in this manner safely for many years to demonstrate the amount of blood the heart is getting under various conditions — rest and stress.
  • Nuclear stress test – This test is similar to an exercise stress test but adds images to the ECG recordings. It measures blood flow to your heart muscle at rest and during stress. A tracer is injected into your bloodstream, and special cameras can detect areas in your heart that receive less blood flow.
  • Cardiac catheterization and angiogram – During cardiac catheterization, a doctor gently inserts a catheter into an artery or vein in your groin, neck, or arm and up to your heart. X-rays are used to guide the catheter to the correct position. Sometimes, dye is injected through the catheter. The dye helps blood vessels show up better on the images and outlines any blockages.
  • Cardiac catheterization (left heart catheterization) – During this procedure, your doctor injects a special dye into your coronary arteries through a catheter inserted through an artery in your groin or forearm. The dye helps enhance the radiographic image of your coronary arteries to identify any blockages.
  • Cardiac CT scan – A CT scan of the heart can help your doctor see calcium deposits in your arteries that can narrow the arteries. If a substantial amount of calcium is discovered, coronary artery disease may be likely.
  • Treadmill testing – to measure how well the heart functions when challenged to work harder than normal (during exercise)
  • Nuclear perfusion imaging – to identify areas of the heart that are receiving less blood
  • Nuclear ventriculography – This uses tracers, or radioactive materials, to create an image of the heart chambers. A doctor will inject the tracers into the vein. The tracers then attach to red blood cells and pass through the heart. Special cameras or scanners trace the movement of the tracers.
  • Coronary calcium scan – to measure the amount of calcium in the walls of your coronary arteries. The buildup of calcium can be a sign of atherosclerosis, coronary artery disease, or coronary microvascular disease. This test is a type of cardiac CT scan. Coronary calcium scans can also help assess coronary heart disease risk for people who smoke or for people who do not have heart symptoms.
  • Cardiac MRI (magnetic resonance imaging) – to detect tissue damage or problems with blood flow in the heart or coronary arteries. It can help your doctor diagnose a coronary microvascular disease or nonobstructive or obstructive coronary artery disease. Cardiac MRI can help explain results from other imaging tests such as chest X-rays and CT scans.
  • Cardiac positron emission tomography (PET) scanning – to assess blood flow through the small coronary blood vessels and into the heart tissues. This is a type of nuclear heart scan that can diagnose coronary microvascular disease.
  • Coronary angiography – to show the insides of your coronary arteries. To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization. This procedure is often used if other tests show that you are likely to have coronary artery disease. To diagnose coronary microvascular disease, your doctor will use coronary angiography with guidewire technology. A guidewire with sensors is inserted into the heart’s arteries. The sensors measure how easily blood flows through the small vessels. Usually, measurements are done before and after giving you medicine to enhance blood flow in your heart.
  • Coronary computed tomographic angiography – to show the insides of your coronary arteries rather than an invasive cardiac catheterization. It is a noninvasive imaging test using CT scanning.
  • ECG – The resting 12 lead ECG is the first-line diagnostic tool for the diagnosis of the acute coronary syndrome (ACS). It should be obtained within 10 minutes of the patient’s arrival in the emergency department. Acute MI is often associated with dynamic changes in the ECG waveform. Serial ECG monitoring can provide important clues to the diagnosis if the initial EKG is non-diagnostic at the initial presentation. Serial or continuous ECG recordings may help determine reperfusion or re-occlusion status. A large and prompt reduction in ST-segment elevation is usually seen in reperfusion.
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ECG findings suggestive of ongoing coronary artery occlusion (in the absence of left ventricular hypertrophy and bundle branch block):

ST-segment elevation in two contiguous lead (measured at J-point) of

  • Greater than 5 mm in men younger than 40 years, greater than 2 mm in men older than 40 years, or greater than 1.5 mm in women in leads V2-V3 and/or
  • Greater than 1 mm in all other leads

ST-segment depression and T-wave changes

  • New horizontal or down-sloping ST-segment – depression greater than 5 mm in 2 contiguous leads and/or T inversion greater than 1 mm in two contiguous leads with prominent R waves or R/S ratio of greater than 1
  • The hyperacute T-wave amplitude – with prominent symmetrical T waves in two contiguous leads, may be an early sign of acute MI that may precede the ST-segment elevation. Other ECG findings associated with myocardial ischemia include cardiac arrhythmias, intraventricular blocks, atrioventricular conduction delays, and loss of precordial R-wave amplitude (less specific finding).
  • ECG findings alone are not sufficient to diagnose acute myocardial ischemia or acute MI as other conditions such as acute pericarditis, left ventricular hypertrophy (LVH), left bundle branch block (LBBB), Brugada syndrome, Takatsubo syndrome (TTS), and early repolarization patterns also present with ST deviation.

ECG changes associated with prior MI (in the absence of left ventricular hypertrophy and left bundle branch block):

  • Any Q wave in lead V2-V3 greater than 0.02 s or QS complex in leads V2-V3
  • Q wave > 03 s and greater than 1 mm deep or QS complex in leads I, II, aVL, aVF or V4-V6 in any two leads of contiguous lead grouping (I, aVL; V1-V6; II, III, aVF)
  • R wave > 0.04 s in V1-V2 and R/S greater than 1 with a concordant positive T wave in the absence of conduction defect.

Electrocardiogram (EKG) 

EKG is a very basic yet enormously helpful test in the evaluation of coronary artery disease. It measures electrical activity in the cardiac conduction system and is measured by 10 leads attached to the skin at standardized locations. It provides information about both the physiology and anatomy of the heart. It typically has 12 leads on the paper that is printed once the test is performed and each lead correlates with the specific location of the heart. Important information to notice on an EKG is a heart’s rate, rhythm, and axis. After that, information regarding acute and chronic pathologic processes can be obtained. In acute coronary syndrome, one can see ST-segment changes and T wave changes. If an ACS has degenerated into arrhythmias, that can also be seen. In chronic settings, EKG can show information like axis deviation, bundle branch blocks, and ventricular hypertrophy. EKG is also a cost-effective and readily available testing modality that is not user-dependent.

Echocardiography

Echocardiography is an ultrasound of the heart. It is a useful and non-invasive mode of testing that is performed in both acute and chronic and inpatient and outpatient settings. In acute settings, it could tell about wall motion, valvular regurgitation and stenosis, infective or autoimmune lesions, and chamber sizes. It also is useful in the diagnosis of acute pulmonary pathologies like pulmonary embolism. It also evaluates the pericardial cavity. In chronic settings, it can be done to see the same information mentioned above and also a response to the therapy. It also is used in an outpatient setting as part of stress testing. In addition to diagnostics, it also has a role in therapeutics for example, pericardiocentesis could be performed with the needle-guided by echocardiography. This test is user-dependent and could be costly compared to EKG.

Stress Test

The stress test is a relatively non-invasive test to evaluate for coronary artery disease. It is used in the setting of suspected angina or angina equivalent and is helpful in ruling in or out coronary pathology when interpreted in an appropriate setting. During the test, the heart is artificially exposed to stress and if the patient gets certain abnormal EKG changes in ST segments or gets symptoms of angina, the test is aborted at that point and coronary artery disease is diagnosed. EKGs are obtained before, during, and after the procedure, and the patient is continuously monitored for any symptoms. There are mainly two types of stress tests; exercise stress test and pharmacologic stress test. In exercise stress tests, the patient has to run on a treadmill until he achieves 85% of the age-predicted maximal heart rate. If a patient develops exertional hypotension, hypertension (>200/110 mmHg), ST-segment elevations or depression, or ventricular or supraventricular arrhythmias.

Chest X-ray

Chest X-ray is an important component of the initial evaluation of cardiac disease. The standard imaging films include standing posteroanterior (PA) and left lateral decubitus. Sometimes, anteroposterior (AP) projection is obtained especially in inpatient settings with the patient lying down, however, this interpretation of AP films is significantly limited. Proper analysis of PA and AP views provides useful and cost-effective information about the heart, lungs, and vasculature. Interpretation should be done in a stepwise pattern so that important information is not overlooked.

Blood Work

Blood work aids in establishing the diagnosis and assessing therapeutic responses. In acute settings, cardiac enzymes and B-type natriuretic peptides are often done along with complete blood counts and metabolic panels. BNP provides information about volume overload of cardiogenic origin however it has its limitations. It can be falsely elevated in kidney diseases and falsely low in obesity. Cardiac enzymes like CK and troponin provide information about an acute ischemic event. In chronic settings, lipid panel provides important prognostic information. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) aid in assessing disease like acute pericarditis. Liver function tests (LFT) can be done to evaluate for an infiltrative process that can affect the liver and heart simultaneously like hemochromatosis. Liver tests are also done to assess increased right heart pressures, especially in chronic settings.

Cardiac Catheterization

Cardiac catheterization is the gold standard and most accurate modality to evaluate ischemic coronary heart disease. It is however an invasive procedure with associated complications. Not everyone is a candidate for the procedure. In non ACS settings, patients with intermediate pretest probability for CAD are usually the right candidates for it. In the ACS setting, all STEMI patients and selected NSTEMI patients get an emergent cardiac catheterization. This procedure is done in a cardiac catheterization lab, is expertise dependent, and is done under moderate sedation. There is contrast exposure in the procedure which could cause serious allergic reactions and kidney injury.

Treatment of Obstructive Coronary Artery Disease

Nonpharmacological

Your doctor may recommend that you adopt lifelong heart-healthy lifestyle changes, including:

  • Fish and fish oil – Fish and fish oil are the most effective sources of omega-3 fatty acids. Fatty fish — such as salmon, herring, and light canned tuna — contain the most omega-3 fatty acids and, therefore, the most benefit. Fish oil supplements may offer benefits, but the evidence is strongest for eating fish.
  • Flax and flaxseed oil – Flax and flaxseed oil also contain beneficial omega-3 fatty acids, though studies have not found these sources to be as effective as fish. The shells on raw flaxseeds also contain soluble fiber, which can help with constipation. More research is needed to determine if flaxseed can help lower blood cholesterol.
  • Other dietary sources of omega-3 fatty acids – Other dietary sources of omega-3 fatty acids include canola oil, soybeans, and soybean oil. These foods contain smaller amounts of omega-3 fatty acids than do fish and fish oil, and evidence for their benefit to heart health isn’t as strong.
  • Aiming for a healthy weight – Losing just 3% to 5% of your current weight can help you manage some coronary heart disease risk factors, such as high blood cholesterol and diabetes. Greater amounts of weight loss can also improve blood pressure readings.
  • Being physically active – Routine physical activity can help manage coronary heart disease risk factors such as high blood cholesterol, high blood pressure, or overweight and obesity. Before starting any exercise program, ask your doctor what level of physical activity is right for you.
  • Heart-healthy eating – such as the DASH (Dietary Approaches to Stop Hypertension) eating plan. A heart-healthy eating plan includes fruits, vegetables, and whole grains and limits saturated fats, trans fats, sodium (salt), added sugars, and alcohol.
  • Managing stress – Learning how to manage stress, relax, and cope with problems can improve your emotional and physical health.
  • Quitting smoking – Although these resources focus on heart health, they include basic information about how to quit smoking. For free help and support to quit smoking, you can call the National Cancer Institute’s Smoking Quitline at 1-877-44U-QUIT (1-877-448-7848). Talk to your doctor if you vape. There is scientific evidence that nicotine and flavorings found in vaping products may damage your heart and lungs.
  • Get enough good-quality sleep – The recommended amount for adults is 7 to 9 hours of sleep a day.
  • Become more active, and stay active, all through life – A good goal is at least 150 minutes (2.5 hours) of moderate exercise each week, or 75 minutes (1.25 hours) of vigorous aerobic exercise each week. Or aim to be active for 30 minutes a day, most days of the week. Check with your doctor before you launch a new workout program if you’ve never worked out before.
  • Keep your weight within the normal range on a Body Mass Index (BMI) chart – If you’re overweight, losing just 5 percent to 10 percent of your current weight will lower your risk of developing coronary artery disease.
  • Find healthy outlets for your stress – Some stress is unavoidable in life. But it tends to push us toward not-so-great habits (overeating, drinking, sitting too much). You’ll be more heart-healthy if you can offload stress in ways you enjoy and that are good for you, such as exercise, meditation, and relaxing with friends, says McEvoy. A stress-management program can help.
  • Manage blood pressure – Blood pressure should be checked regularly, especially in those who have blood pressure higher than normal or have a history of heart disease. Follow the doctor’s advice in managing blood pressure with drugs and diet.
  • Manage cholesterol – You have to manage blood cholesterol levels regularly to keep a check. It includes observing the levels of LDL, HDL, and TG. Know more about good cholesterol and bad cholesterol and the foods that help in managing them.
  • Manage blood sugar levels – In patients who are diabetic, tight blood sugar management can help manage coronary artery disease.
  • Following a healthy diet – Eat healthy food that includes plant-based foods, such as fruits, vegetables, whole grains, legumes, and nuts, and also food that is low in saturated fat, cholesterol, and sodium. This can help you control your weight, blood pressure, and cholesterol. Avoid saturated fat and trans fat, excess salt, and excess sugar.


Acute Management

Reperfusion therapy is indicated in all patients with symptoms of ischemia of less than 12-hours duration and persistent ST-segment elevation. Primary percutaneous coronary intervention (PCI) is preferred to fibrinolysis if the procedure can be performed <120 minutes of ECG diagnosis. If there is no immediate option of PCI (>120 minutes), fibrinolysis should be started within 10 minutes of STEMI after ruling out contraindications. If transfer to a PCI center is possible in 60 to 90 minutes after a bolus of the fibrinolytic agent and the patient meets reperfusion criteria, a routine PCI can be done, or a rescue PCI can be planned. If fibrinolysis is planned, it should be carried out with fibrin-specific agents such as tenecteplase, alteplase, or reteplase (class I).

  • Aspirin – Aspirin is anti-thrombotic and reduces the risk of cardiovascular disease by irreversibly binding with the platelets. However, the use of low-dose aspirin (75 to 100 mg orally) for primary prevention is getting more controversial recently. Previous U.S. guidelines recommended aspirin for primary prevention in the settings of significant ASCVD risk factors. However, according to the recent ACC/AHA 2019 guidelines, the use of aspirin may be considered in patients (40 to 70 years old) with significant risk factors for cardiovascular disease and no risk of bleeding. The strength of recommendation is comparatively weaker, and a thorough evaluation with risk versus benefit assessment is necessary. These guidelines for primary preventions should undergo evaluation based on the individual patient basis, and risk versus analysis should always be based on the physician’s best clinical judgments.
  • Relief of pain, breathlessness, and anxiety  The chest pain due to myocardial infarction is associated with sympathetic arousal, which causes vasoconstriction and increased workload for the ischemic heart. Intravenous opioids (e.g., morphine) are the analgesics most commonly used for pain relief (Class IIa). The results from the CRUSADE quality improvement initiative have shown that the use of morphine may be associated with a higher risk of death and adverse clinical outcomes. The study was done from the CIRCUS (Does Cyclosporine Improve outcome in STEMI patients) database, which showed no significant adverse events associated with morphine use in a case of anterior ST-segment elevation MI. A mild anxiolytic (usually a benzodiazepine) may be considered in very anxious patients (class IIa). Supplemental oxygen is indicated in patients with hypoxemia (SaO2 <90% or PaO2 <60mm Hg) (Class I).
  • Intravenous Nitrates  Intravenous nitrates are more effective than sublingual nitrates with regard to symptom relief and regression of ST depression (NSTEMI). The dose is titrated upward until symptoms are relieved, blood pressure is normalized in hypertensive patients, or side effects such as a headache and hypotension are noted.
  • Beta-blockers This group of drugs reduces myocardial oxygen consumption by lowering heart rate, blood pressure, and myocardial contractility. They block beta receptors in the body, including the heart, and reduce the effects of circulating catecholamines. Beta-blockers should not be used in suspected coronary vasospasm.
  • Platelet inhibition Aspirin is recommended in both STEMI and NSTEMI in an oral loading dose of 150 to 300 mg (non-enteric coated formulation) and a maintenance dose of 75 to 100 mg per day long-term regardless of treatment strategy (class I). Aspirin inhibits thromboxane A2 production throughout the lifespan of the platelet.
  • Selective Beta-blockers. These drugs slow your heart rate and decrease your blood pressure, which decreases your heart’s demand for oxygen. If you’ve had a heart attack, beta-blockers reduce the risk of future attacks.
  • Calcium channel blockers – These drugs may be used with beta-blockers if beta-blockers alone aren’t effective or instead of beta-blockers if you’re not able to take them. Calcium channel blockers to lower blood pressure by allowing blood vessels to relax. These drugs can help improve symptoms of chest pain.
  • Ranolazine – This medication may help people with chest pain (angina)to treat coronary microvascular disease and the chest pain it may cause. It may be prescribed with a beta-blocker or instead of a beta-blocker if you can’t take it.
  • Nitroglycerin – Nitroglycerin tablets, sprays, and patches can control chest pain by temporarily dilating your coronary arteries and reducing your heart’s demand for blood.
  • Diuretics – Sometimes known as water pills, diuretics work by flushing excess water and salt from the body through urine.
  • Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) – These similar drugs decrease blood pressure and may help prevent the progression of coronary artery disease. Angiotensin-2 receptor blockers (ARBs) work in a similar way to ACE inhibitors. They’re used to lower your blood pressure by blocking angiotensin-2. Mild dizziness is usually the only side effect. They’re often prescribed as an alternative to ACE inhibitors, as they do not cause a dry cough.
  • Medication to manage blood cholesterol – Blood cholesterol is the main reason behind the plaque formation that clogs the arteries. Your doctor may recommend drugs to manage bad cholesterol (LDL) or improve good cholesterol (HDL). He may also recommend medication to manage triglycerides (TGs). Your doctor may choose from a range of cholesterol-lowering medications including statins, niacin, fibrates, and bile acid sequestrants.
  • Medicines to control blood sugar – such as empagliflozin, canagliflozin, and liraglutide, help lower your risk for complications if you have coronary heart disease and diabetes.
  • Most P2Y12 inhibitors – are inactive prodrugs (except for ticagrelor, which is an orally active drug that does not require activation) that require oxidation by the hepatic cytochrome P450 system to generate an active metabolite that selectively inhibits P2Y12 receptors irreversibly. Inhibition of P2Y12 receptors leads to inhibition of ATP-induced platelet aggregation. The commonly used P2Y12 inhibitors are clopidogrel, prasugrel, and ticagrelor.
  • The loading dose for clopidogrel – is 300 to 600 mg loading dose followed by 75 mg per day.
  • Prasugrel – 60 mg loading dose, and 10 mg per day of a maintenance dose have a faster onset when compared to clopidogrel.Patients undergoing PCI should be treated with dual antiplatelet therapy (DAPT) with aspirin + P2Y12 inhibitor and a parenteral anticoagulant. In PCI, the use of prasugrel or ticagrelor is found to be superior to clopidogrel. Aspirin and clopidogrel are also found to decrease the number of ischemic events in NSTEMI and UA.
  • Heparin, enoxaparin, and bivalirudin – The anticoagulants used during PCI are unfractionated heparin, enoxaparin, and bivalirudin. The bivalirudin is recommended during primary PCI if the patient has heparin-induced thrombocytopenia.
  • Lipid-lowering treatment  It is recommended to start high-intensity statins that reduce low-density lipoproteins (LDLs) and stabilize atherosclerotic plaques. High-density lipoproteins are found to be protective.
  • Antithrombotic therapy Aspirin is recommended lifelong, and the addition of another agent depends on the therapeutic procedure done, such as PCI with stent placement.
  • ACE inhibitors – are recommended in patients with systolic left ventricular dysfunction, or heart failure, hypertension, or diabetes. Beta-blockers are recommended in patients with LVEF less than 40% if no other contraindications are present. Antihypertensive therapy can maintain a blood pressure goal of less than 140/90 mm Hg.
  • Mineralocorticoid receptor antagonist therapy – is recommended in a patient with left ventricular dysfunction (LVEF less than 40%).
  • Glucose lowering therapy – in people with diabetes to achieve current blood sugar goals.
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Surgery

The following surgical procedures can open or replace blocked arteries if they have become very narrow, or if symptoms are not responding to medications:

  • Laser surgery – This involves making several very small holes in the heart muscle. These encourage the formation of new blood vessels.
  • Coronary bypass surgery – A surgeon will use a blood vessel from another part of the body to create a graft that bypasses the blocked artery. The graft may come from the leg, for example, or an inner chest-wall artery.
  • Angioplasty and stent placement – A surgeon will insert a catheter into the narrowed part of the artery and pass a deflated balloon through the catheter to the affected area. When they inflate the balloon, it compresses the fatty deposits against the artery walls. They may leave a stent, or mesh tube, in the artery to help keep it open.
  • Percutaneous coronary intervention (PCI) – to open coronary arteries that are narrowed or blocked by the buildup of atherosclerotic plaque. A small mesh tube called a stent is usually implanted after PCI to prevent the artery from narrowing again.
  • Coronary artery bypass grafting (CABG) – to improves blood flow to the heart by using normal arteries from the chest wall and veins from the legs to bypass the blocked arteries. Surgeons typically use CABG to treat people who have severe obstructive coronary artery disease in multiple coronary arteries.
  • Transmyocardial laser revascularization or coronary endarterectomy – to treat severe angina associated with coronary heart disease when other treatments are too risky or did not work.
  • Heart transplant – Occasionally, when the heart is severely damaged and medicine is not effective, or when the heart becomes unable to adequately pump blood around the body (heart failure), a heart transplant may be needed.


Lifestyle and home remedies

Lifestyle changes can help you prevent or slow the progression of coronary artery disease.

  • Stop smoking – Smoking is a major risk factor for coronary artery disease. Nicotine constricts blood vessels and forces your heart to work harder, and carbon monoxide reduces oxygen in your blood and damages the lining of your blood vessels. If you smoke, quitting is one of the best ways to reduce your risk of a heart attack.
  • Smoking cessation – is the most cost-effective secondary measure to prevent MI. Smoking has a pro-thrombotic effect, which has a strong association with atherosclerosis and myocardial infarction.
  • Diet, alcohol, and weight control A diet low in saturated fat with a focus on whole grain products, vegetables, fruits, and fish is considered cardioprotective. The target level for bodyweight is body mass index of 20 to 25 kg/m2  and waist circumference of <94 cm for the men and <80 cm for the female.
  • Control your blood pressure – Ask your doctor for a blood pressure measurement at least every two years. He or she may recommend more frequent measurements if your blood pressure is higher than normal or you have a history of heart disease. Optimal blood pressure is less than 120 systolic and 80 diastolic, as measured in millimeters of mercury (mm Hg).
  • Check your cholesterol – Adults should get a baseline cholesterol test when in their 20s and at least every five years after. Ask your doctor what your cholesterol levels should be. Most people should aim for an LDL cholesterol level below 130 milligrams per deciliter (mg/dL), or 3.4 millimoles per liter (mmol/L). If you have other risk factors for heart disease, your target LDL cholesterol may be below 100 mg/dL (2.6 mmol/L). Ask your doctor what level LDL is best for you. If your test results aren’t meeting your targeted levels, you may need more frequent cholesterol tests.
  • Keep diabetes under control – If you have diabetes, tight blood sugar management can help reduce the risk of heart disease.
  • Eat heart-healthy foods – Eat plenty of fruits, vegetables, whole grains, legumes, and nuts. Avoid saturated fats and trans fats and reduce salt and sugar. Eating one or two servings of fish a week also may help keep your heart healthy.
  • Avoid or limit alcohol – If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women and up to two drinks a day for men.
  • Get moving – Exercise helps manage weight and control diabetes, high cholesterol, and high blood pressure — all risk factors for coronary artery disease. Get at least 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity a week, or a combination of moderate and vigorous activity.
  • Maintain a healthy weight – Being overweight increases your risk of coronary artery disease. Losing even just a small amount of weight can help reduce risk factors for coronary artery disease.
  • Participate in cardiac rehabilitation – If you’ve had surgery, your doctor may suggest you participate in cardiac rehabilitation — a program of education, counseling, and exercise training that’s designed to help improve your health.
  • Manage stress – Reduce stress as much as possible. Practice healthy techniques for managing stress, such as muscle relaxation and deep breathing.
  • Get your flu shot – Get your flu (influenza) vaccine each year to reduce your risk of having influenza.

Regular medical checkups are also important. Some of the main risk factors for coronary artery disease — high cholesterol, high blood pressure, and diabetes — have no symptoms in the early stages. Early detection and treatment can help you maintain better heart health.

Alternative medicine

Other supplements may help reduce your blood pressure or cholesterol level, two contributing factors to coronary artery disease. These include:

  • Alpha-linolenic acid
  • Barley
  • Cocoa
  • Coenzyme Q10
  • Fiber, including blond psyllium and oat bran (found in oatmeal and whole oats)
  • Garlic
  • Plant stanols and sterols (found in supplements and some margarine, such as Promise, Smart Balance, and Benecol)

Always talk to your doctor before adding a new over-the-counter medication or supplement to your treatment plan. Some drugs and supplements can interfere with other medications and cause side effects or make them less effective.

Risk factors

Risk factors for coronary artery disease include:

  • Age – Getting older increases your risk of damaged and narrowed arteries.
  • Sex – Men are generally at greater risk of coronary artery disease. However, the risk for women increases after menopause.
  • Family history – A family history of heart disease is associated with a higher risk of coronary artery disease, especially if a close relative developed heart disease at an early age. Your risk is highest if your father or a brother was diagnosed with heart disease before age 55 or if your mother or a sister developed it before age 65.
  • Smoking – People who smoke have a significantly increased risk of heart disease. Breathing in secondhand smoke also increases a person’s risk of coronary artery disease.
  • High blood pressure – Uncontrolled high blood pressure can result in hardening and thickening of your arteries, narrowing the channel through which blood can flow.
  • High blood cholesterol levels – High levels of cholesterol in your blood can increase the risk of the formation of plaque and atherosclerosis. High cholesterol can be caused by a high level of low-density lipoprotein (LDL) cholesterol, known as the “bad” cholesterol. A low level of high-density lipoprotein (HDL) cholesterol, known as the “good” cholesterol, can also contribute to the development of atherosclerosis.
  • Diabetes – Diabetes is associated with an increased risk of coronary artery disease. Type 2 diabetes and coronary artery disease share similar risk factors, such as obesity and high blood pressure.
  • Overweight or obesity – Excess weight typically worsens other risk factors.
  • Physical inactivity – Lack of exercise also is associated with coronary artery disease and some of its risk factors, as well.
  • High stress – Unrelieved stress in your life may damage your arteries as well as worsen other risk factors for coronary artery disease.
  • Unhealthy diet – Eating too much food that has high amounts of saturated fat, trans fat, salt, and sugar can increase your risk of coronary artery disease.
  • Sleep apnea – This disorder causes you to repeatedly stop and start breathing while you’re sleeping. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system, possibly leading to coronary artery disease.
  • High-sensitivity C-reactive protein (hs-CRP) – This protein appears in higher-than-normal amounts when there’s inflammation somewhere in your body. High hs-CRP levels may be a risk factor for heart disease. It’s thought that as coronary arteries narrow, you’ll have more hs-CRP in your blood.
  • High triglycerides – This is a type of fat (lipid) in your blood. High levels may raise the risk of coronary artery disease, especially for women.
  • Homocysteine – Homocysteine is an amino acid your body uses to make protein and to build and maintain tissue. But high levels of homocysteine may increase your risk of coronary artery disease.
  • Preeclampsia – This condition that can develop in women during pregnancy causes high blood pressure and a higher amount of protein in the urine. It can lead to a higher risk of heart disease later in life.
  • Alcohol use – Heavy alcohol use can lead to heart muscle damage. It can also worsen other risk factors of coronary artery disease.
  • Autoimmune diseases – People who have conditions such as rheumatoid arthritis and lupus (and other inflammatory conditions) have an increased risk of atherosclerosis.
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Prevention

References

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