Cardiovascular Medicine Book

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  • Stable Coronary Artery Disease

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Stable Coronary Artery Disease

Aka: Stable Coronary Artery Disease, Stable Ischemic Heart Disease, Coronary Artery Disease, Atherosclerotic Heart Disease
  1. See Also
    1. Acute Coronary Syndrome
    2. Acute Coronary Syndrome Immediate Management
    3. Acute Coronary Syndrome Adjunctive Therapy
    4. High Risk Acute Coronary Syndrome Management
    5. Moderate Risk Acute Coronary Syndrome Management
    6. Low Risk Acute Coronary Syndrome Management
    7. Myocardial Infarction Stabilization
    8. Vasospastic Angina
    9. Cocaine-Induced Coronary Vasospasm
    10. Angina
    11. Angina Diagnosis
    12. Unstable Angina
    13. Chest Pain
    14. Cardiac Risk Factors
    15. TIMI Risk Score
    16. Serum Cardiac Markers
    17. Electrocardiogram in Myocardial Infarction
    18. Echocardiogram in Myocardial Infarction
    19. Goldman Criteria for ICU Chest Pain Admission
  2. Definitions
    1. Stable Coronary Artery Disease
      1. Coronary Artery Disease (Angina, Myocardial Infarction, positive angiogram or CTA) AND
      2. Asymptomatic or controlled Angina
  3. Epidemiology
    1. Prevalence of Cardiovascular Disease: Over age 60 years (U.S.)
      1. Men: 25%
      2. Women: 16%
  4. Symptoms
    1. See Acute Coronary Syndrome
    2. See Angina
  5. Risk Factors
    1. See Cardiac Risk Factors
  6. Differential Diagnosis
    1. See Angina Diagnosis
    2. See Chest Pain
  7. Management
    1. See Cardiac Risk Management
    2. Tobacco Cessation
    3. Influenza Vaccine yearly
    4. Diabetes Mellitus Management
      1. Keep the Hemoglobin A1C less than 7% in Type I Diabetes and <8% in Type II Diabetes
    5. Exercise
      1. See Exercise Prescription
      2. Perform 30-60 min of moderate-intensity aerobic Exercise (e.g. quick walk) on 5-7 days/week
      3. Safe in Stable Coronary Artery Disease
        1. Stress testing is not needed before initiating low-moderate intensity Exercise
        2. Consider cardiac rehabitiliation setting for 8-12 weeks in higher risk patients
    6. Statins for Cholesterol lowering
      1. Specific LDL and HDL targets have been replaced with high-intensity Statin if 10 year CV risk >20%
      2. Non-Statins have provided minimal to no significant benefit in Cardiovascular Risk Reduction
        1. PCSK9 Inhibitors (e.g. Evolocumab) may be effective, but is cost prohibitive in 2018
      3. High intensity Statin (age <75 years with 10 year risk >20%)
        1. Atorvastatin 40-80 mg orally daily
        2. Rosuvastatin 20-40 mg orally daily
      4. Low intensity Statin (age >75 years, or Statin intolerant)
        1. Atorvastatin 10-20 mg orally daily
        2. Rosuvastatin 25-10 mg orally daily
        3. Simvastatin 20-40 mg orally daily
        4. Pravastatin 40-80 mg orally daily
        5. Lovastatin 40 mg orally daily
      5. References
        1. Stone (2014) Circulation 129(25 suppl 2): S1-45 [PubMed]
    7. Hypertension Management
      1. Goal Blood Pressure
        1. CAD, CRF, DM: <130/80
          1. Exercise caution in older adults (allow <140-150/90)
        2. Other patients: <140/90
          1. Consider as goal for most patients after JNC 8
      2. Preferred antihypertensives
        1. Beta-Blockers (e.g. Metoprolol)
        2. ACE Inhibitors (e.g. Lisinopril) or Angiotensin Receptor Blockers (e.g. Losartan)
        3. Thiazide Diuretics (e.g. Chlorthalidone, Indapamide, Hydrochlorothiazide)
    8. Antplatelet therapy
      1. See Antiplatelet Therapy for Vascular Disease
      2. Aspirin
        1. Doses of 75-162 mg are as effective (and less GI Bleeding) as 325 mg daily
          1. Aspirin 81 mg is sufficient for most patients with stable cardiovascular disease
          2. Berger (2008) Am J Med 121(1): 43-9 [PubMed]
      3. Platelet ADP Receptor Antagonist (e.g. Clopidogrel, Ticagrelor, Prasugrel)
        1. See Platelet ADP Receptor Antagonist
        2. Indicated in known vascular disease if Aspirin contraindicated
        3. Marginally more effective than Aspirin in preventing CV events
          1. (1996) Lancet 348(9038): 1329-39 [PubMed]
        4. Aside from post-coronary stenting, avoid combining with Aspirin in stable cardiovascular disease
          1. Dual Antiplatelet Therapy is more effective CV prevention, but raises the major bleeding risk
          2. Bittl (2016) Circulation 134(10): e156-78 +PMID:27026019 [PubMed]
      4. Avoid NSAIDs (other than Aspirin)
        1. NSAIDs are associated with increased risk of cardiovascular events
        2. Naproxen may be associated with the least cardiovascular risk
        3. Even short-term NSAID use 5 years after coronary event increases CAD event risk
          1. Associated with 19 more events in 1000 patients with CAD
        4. References
          1. Antman (2007) Circulation 115(12):1634-42 [PubMed]
    9. Antianginal Management
      1. See Angina
      2. Step 1
        1. Aspirin 81 mg daily (or Platelet ADP Receptor Antagonist if Aspirin contraindicated)
        2. Sublingual Nitroglycerin prn and before Exercise
        3. Beta Blocker (e.g. Metoprolol)
      3. Step 2
        1. Increase Beta Blocker dose OR
        2. Consider Isosorbide monohydrate XR (once daily, least expensive long acting nitrate)
      4. Step 3
        1. Consider adding Dihydropyridine Calcium Channel Blocker (e.g. Amlodipine), if no Systolic Dysfunction
      5. Step 4: Refractory Angina
        1. Consider Stress test or angiography again if need >2 agents
        2. Revascularization may be needed
          1. PCI may improve symptoms but does not reduce mortality in stable coronary disease
          2. CABG is indicated in multi-vessel disease, Diabetes Mellitus, >50% left main Coronary Artery
  8. References
    1. Braun (2018) Am Fam Physician 97(6): 376-84 [PubMed]
    2. Fihn (2012) Circulation 126(25): 3097-137 [PubMed]

Coronary Arteriosclerosis (C0010054)

Definition (MSH) Thickening and loss of elasticity of the CORONARY ARTERIES, leading to progressive arterial insufficiency (CORONARY DISEASE).
Concepts Disease or Syndrome (T047)
MSH D003324
ICD9 414.0
ICD10 I25.1, K76.1, I25.10
SnomedCT 53741008, 266231003, 41702007, 155316000, 194841001, 266290000, 194795001, 155315001
LNC MTHU020784
English Arterioscleroses, Coronary, Arteriosclerosis, Coronary, Coronary Arterioscleroses, Coronary Arteriosclerosis, CORONARY ARTERIOSCLEROSIS, CORONARY SCLEROSIS, ARTERIOSCLEROTIC HEART DISEASE, Atherosclerotic heart disease, Coronary atheroma, coronary arteriosclerosis (diagnosis), coronary arteriosclerosis, ASHD - Atherosclerotic heart disease, Cardiac sclerosis, Coronary (artery) atherosclerosis, Coronary (artery) sclerosis, cardiac ischemia, myocardial ischemia, Disease;atherosclerotic;heart, arteriosclerotic heart disease, cardiac ischaemia, coronary atheroma, coronary sclerosis, ischaemic heart disease, coronary heart disease, myocardial ischaemia, coronary artery atherosclerosis, coronary artery diseases, coronary artery disease, coronary atherosclerosis, Atherosclerotic heart disease NOS, Coronary atherosclerosis (disorder), cardiac; sclerosis, coronary; arteriosclerosis, coronary; sclerosis, disease (or disorder); arteriosclerotic, coronary (artery), disease (or disorder); arteriosclerotic, heart, heart; arteriosclerosis, sclerosis; cardiac, sclerosis; coronary, arteriosclerosis; coronary (artery), arteriosclerosis; coronary, arteriosclerosis; heart, Atheroscleroses, Coronary, Atherosclerosis, Coronary, Coronary Atheroscleroses, Coronary Atherosclerosis, Arteriosclerotic heart disease, Coronary arteriosclerosis, Coronary sclerosis, Coronary arteriosclerosis (disorder), ASHD, Coronary artery arteriosclerosis, atherosclerotic heart disease, Coronary atherosclerosis, Arteriosclerosis coronary artery, Coronary artery atherosclerosis, Coronary artery sclerosis
German KORONARSKLEROSE, Arteriosklerose der Koronararterie, Koronararterie Sklerose, arteriosklerotische Herzkrankheit, Koronarsklerose, Koronararteriosklerose, Atherosklerotische Herzkrankheit, Koronararteriensklerose, Sklerose, Koronar-
Dutch kransslagaderateriosclerose, kransslagaderatherosclerose, kransslagadersclerose, arteriosclerotische hartaandoening, aandoening; arteriosclerotisch, coronair{arterie}, aandoening; arteriosclerotisch, hart, arteriosclerose; aandoening, coronair{arterie}, arteriosclerose; aandoening, hart, arteriosclerose; coronair, cardiaal; sclerose, coronair; arteriosclerose, coronair; sclerose, hart; arteriosclerose, sclerose; cardiaal, sclerose; coronair, Arteriosclerose, coronaire, Atherosclerose, coronaire, Atherosclerotische hartziekte, Coronaire arteriosclerose, Coronaire atherosclerose, Coronaire hartziekte, Coronairziekte
French Artériosclérose de l'artère coronaire, Sclérose de l'artère coronaire, Athérosclérose artérielle coronaire, Athérosclérose coronaire, Sclérose coronaire, Maladie cardiaque artérioscléreuse, SCLEROSE CORONAIRE, Artériosclérose coronaire, Artériosclérose coronarienne, Athérosclérose coronarienne, Artériosclérose des artères coronaires, Artériosclérose des coronaires, Athérosclérose des artères coronaires, Athérosclérose des coronaires
Italian Arteriosclerosi dell'arteria coronaria, Sclerosi coronarica, Stenosi dell'arteria coronaria, Aterosclerosi coronarica, Aterosclerosi dell'arteria coronaria, Cardiopatia arteriosclerotica, Arteriosclerosi coronarica
Portuguese Arteriosclerose das coronárias, Esclerose coronária, Aterosclerose das artérias coronárias, Esclerose das artérias coronárias, Aterosclerose coronária, Cardiopatia arteriosclerótica, ESCLEROSE CORONARIA, Arteriosclerose Coronária, Aterosclerose Coronária
Spanish Arterioesclerosis de la arteria coronaria, Ateroesclerosis de la arteria coronaria, Esclerosis coronaria, Esclerosis de la arteria coronaria, Ateroesclerosis coronaria, CORONARIA, ESCLEROSIS, Arteriosclerosis Coronaria, arteriosclerosis coronaria (trastorno), arteriosclerosis coronaria, arterioesclerosis coronaria, Enfermedad arterioesclerotica cardiaca, ateroesclerosis coronaria (trastorno), esclerosis coronaria, ateroesclerosis coronaria, enfermedad ateroesclerótica cardíaca, enfermedad aterosclerótica cardíaca, Aterosclerosis Coronaria
Japanese 冠血管硬化症, 冠状動脈粥状硬化症, 冠動脈粥状硬化症, 動脈硬化性心疾患, カンジョウドウミャクジュクジョウコウカショウ, カンドウミャクコウカショウ, カンケッカンコウカショウ, カンドウミャクジュクジョウコウカショウ, ドウミャクコウカセイシンシッカン, アテローム硬化症-冠状, 冠状動脈硬化, 冠状アテローム硬化症, 冠状動脈アテローム硬化, 冠状動脈硬化症, 冠動脈アテローム硬化, 冠動脈硬化症, 動脈硬化症-冠状動脈, 冠動脈アテローム性硬化, 冠状動脈アテローム性硬化症, 冠動脈硬化, 冠状動脈アテローム性硬化
Czech koronární arterioskleróza, Arterioskleróza koronárních tepen, Koronární skleróza, Arteriosklerotické onemocnění srdce, Ateroskleróza koronárních arterií, Skleróza koronární arterie, Koronární ateroskleróza
Korean 죽상경화성 심장병
Croatian KORONARNA ARTERIOSKLEROZA
Hungarian Coronaria atherosclerosis, Arteria cor onaria arteriosclerosis, Coronariasclerosis, Arteria coronaria atherosclerosis, Szív arterioscleroticus betegsége, Arteria coronaria sclerosis
Norwegian Koronar arteriosklerose
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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