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Coronary Artery Disease and Stable Angina

Basics

  • CAD is atherosclerotic narrowing of epicardial coronary arteries causing ischemia.
  • Stable angina: chest discomfort predictable with exertion or stress; relieved by rest or nitroglycerin.
  • ACS spectrum: unstable angina (UA), NSTEMI, STEMI.
  • Typical angina: substernal chest pressure lasting 2-15 minutes, triggered by exertion, relieved by rest or nitrates.
  • Atypical angina: two of typical features.
  • Anginal equivalents: dyspnea, fatigue, nausea, lightheadedness during exertion.
  • Elderly often present atypically.

Epidemiology

  • Leading cause of death in US and worldwide.
  • Estimated lifetime risk at age 40: 49% men, 32% women.
  • ~5% US adults have CAD.
  • 80% preventable with healthy lifestyle.

Etiology and Pathophysiology

  • Ischemia from mismatch between myocardial oxygen supply and demand.
  • Most commonly caused by atherosclerosis.
  • Other causes: aortic stenosis, pulmonary hypertension, hypertrophic cardiomyopathy, coronary spasm, volume overload.

Risk Factors

  • Traditional: hypertension, high LDL, smoking, diabetes, premature family history, older age, low HDL.
  • Nontraditional: obesity, sedentary lifestyle, chronic inflammation, abnormal ankle-brachial index, renal disease.

Prevention

  • Smoking cessation.
  • Regular aerobic exercise; weight loss to BMI <25.
  • Plant-based or Mediterranean diet.
  • BP goal <140/90 mm Hg (consider <130/80 mm Hg if ASCVD risk β‰₯10%).
  • Intensive diabetes management (HbA1c 6.5-7% for younger/early disease).
  • High-intensity statins for CAD patients regardless of lipid levels.
  • Avoid aspirin for routine primary prevention unless high clinical suspicion.

Common Associated Conditions

  • Hyperlipidemia, peripheral vascular disease, cerebrovascular disease, hypertension, obesity, diabetes.

Diagnosis

History

  • Chest pain: typical (Levine sign), atypical, or anginal equivalents.
  • Dyspnea on exertion may be sole symptom.
  • Symptoms mimicking GI upset possible.
  • Atypical presentations more common in women, elderly, diabetics.

Physical Exam

  • May be normal.
  • Possible murmurs, dysrhythmias, gallops, signs of heart failure.

Differential Diagnosis

  • Vascular: aortic dissection, pericarditis, myocarditis, MI, vasospasm.
  • Pulmonary: pleuritis, PE, pneumothorax.
  • GI: reflux, esophageal spasm, ulcer.
  • Musculoskeletal: costochondritis, arthritis, muscle strain.
  • Others: anxiety, cocaine abuse.

Diagnostic Tests

  • Serial troponins for acute presentations.
  • CBC, lipid profile, HbA1c, metabolic panel.
  • ECG: may be normal or show ischemia; LBBB or pacing complicates interpretation.
  • Chest X-ray for alternative diagnoses.
  • Stress testing (exercise or pharmacologic) for intermediate risk.
  • CT coronary angiography or cardiac MRI if inconclusive or continued symptoms.
  • Cardiac catheterization with angiography is gold standard for diagnosis and guiding intervention.

Treatment

General Measures

  • BP control goal <130/80 mm Hg.
  • Complete smoking cessation.
  • Moderate aerobic exercise: 30-60 minutes, 5-7 days/week.

Medication

  • Ξ²-Blockers: first-line; reduce HR, BP, contractility; improve angina and mortality post-MI/HF.
  • Calcium channel blockers: dihydropyridines (amlodipine, nifedipine) and nondihydropyridines (diltiazem, verapamil); avoid in EF <40% (negative inotropy).
  • Nitrates: sublingual nitroglycerin for acute angina; long-acting nitrates for prophylaxis.
  • Lipid-lowering agents: high-intensity statins (atorvastatin, rosuvastatin); ezetimibe or PCSK9 inhibitors if needed.
  • Antiplatelets: aspirin first line; clopidogrel if aspirin contraindicated; dual therapy post-MI or PCI.
  • ACE inhibitors/ARBs: especially with LV dysfunction or diabetes.
  • Ranolazine: second-line adjunct, no effect on HR/BP.
  • Low-dose colchicine may improve outcomes in established CAD.

Surgery/Procedures

  • Revascularization (CABG preferred in left main, multivessel disease).
  • PCI for significant lesions refractory to medical therapy.
  • PCI first line in UA/NSTEMI/STEMI.

Ongoing Care

  • Aggressive lifestyle counseling at every visit.
  • Diet: plant-based or Mediterranean recommended; fatty fish preferred over omega-3 supplements.

Prognosis

  • Depends on extent of disease, symptom severity, LV function.

Complications

  • Acute coronary syndrome, arrhythmias, heart failure, cardiac arrest.

ICD10: - I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris - I25.118 Atherosclerotic heart disease of native coronary artery with other angina pectoris - I20.9 Angina pectoris, unspecified

Clinical Pearls: - Maximize antianginal therapy with Ξ²-blockers, calcium channel blockers, and nitrates. - Use high-intensity statins and antiplatelet therapy. - PCI is reserved for stable angina refractory to medical therapy and first-line for ACS.