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Coronary artery disease

Definition
CAD is a disorder characterized by a reduction in blood flow to the myocardium caused by formation of atherosclerotic plaque in the coronary arteries.
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Pathophysiology
The process leading to the development of atherosclerotic plaques in the coronary arteries can be divided into five key steps, which are 1) endothelial dysfunction, 2) formation of lipid layer or fatty streak within the intima, 3) migration of leukocytes and smooth muscle cells into the vessel wall, 4) foam cell formation and 5) proliferation of extracellular matrix.
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Epidemiology
In the US, the prevalence of CAD in adults ≥ 40 years of age is estimated at 8.0%.
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Disease course
CAD can manifest as various clinical syndromes, which include stable angina, unstable angina, myocardial infarction, ischemic cardiomyopathy, and SCD.
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Prognosis and risk of recurrence
In patients with multivessel CAD undergoing revascularization with CABG or PCI, 5-year survival is 91.4-91.9%.
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Key sources
The following summarized guidelines for the evaluation and management of coronary artery disease are prepared by our editorial team based on guidelines from the American Heart Association (AHA/HRS/ACC/ACCP 2024), the National Lipid Association (NLA/PCNA/ASPC/ACC/AHA/ACCP 2023), the European Society of Hypertension (ESH 2023), the Canadian Cardiovascular Society (CCS/CAIC 2023), the Japanese Circulation Society (JCS 2022), the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the U.S. Preventive Services Task Force (USPSTF 2022), the European Society of Cardiology (ESC 2022), the European Society of Cardiology (ESC/EACTS 2021; 2019), the Canadian Cardiovascular Society (CCS/CHRS 2020), the European Society of Cardiology (ESC/ESVS 2018), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the Cardiac Society of Australia and New Zealand (CSANZ/NHFA 2018), the American College of Endocrinology (ACE/AACE 2016), and the American Heart Association (AHA/ACC 2014; 2010).
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Guidelines

1.Screening and diagnosis

Cardiovascular risk assessment: as per ACC 2014 guidelines, assess cardiovascular risk using global risk scores such as the Framingham Risk Score in asymptomatic adults without a clinical history of CAD.
B
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2.Classification and risk stratification

Risk assessment, general principles, PCNA/NLA/ASPC/ACCP/ACC/AHA: obtain risk stratification in patients with chronic coronary disease incorporating all available information, including noninvasive, invasive, or both cardiovascular diagnostic testing results, or use validated risk scores to classify patients as low (< 1%), intermediate (1-3%), or high (> 3%) yearly risk for cardiovascular death or non-fatal myocardial infarction.
B

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  • Risk assessment (before revascularization)

  • Risk assessment (after revascularization)

3.Diagnostic investigations

Noninvasive stress testing: as per AHA 2023 guidelines, obtain stress PET/SPECT myocardial perfusion imaging, or cardiac MRI to detect the presence and assess the extent of myocardial ischemia, estimate the risk of major adverse cardiovascular events, and guide therapeutic decision-making in patients with chronic coronary disease and a change in symptoms or functional capacity persisting despite guideline-directed medical therapy.
B
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  • Coronary CTA

  • CAC scoring

  • Screening for PAD

4.Diagnostic procedures

Coronary angiography: as per AHA 2023 guidelines, perform invasive coronary angiography for guiding therapeutic decision-making to improve anginal symptoms in patients with chronic coronary disease and a change in symptoms or functional capacity persisting despite guideline-directed medical therapy.
B
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  • Coronary catheterization

  • Intravascular ultrasound

5.Medical management

General principles: optimize guideline-directed medical therapy to reduce major adverse cardiovascular events in patients with chronic coronary disease.
A
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  • Shared-decision making

  • Beta-blockers

  • RAAS inhibitors

  • SGLT-2 inhibitors

  • GLP-1 receptor agonists

  • Colchicine

  • Antianginal therapy

  • Antihypertensive therapy

  • Lipid-lowering therapy

  • Antiplatelet therapy

  • Anticoagulant therapy

  • NSAIDs

6.Nonpharmacologic interventions

Dietary modifications: advise following a diet emphasizing vegetables, fruits, legumes, nuts, whole grains, and lean protein to reduce the risk of CVD events in patients with chronic coronary disease.
B
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  • Physical activity

  • Smoking cessation

  • Alcohol restriction

  • Substance use cessation

  • Environmental exposures

  • Psychosocial support

  • Supplements

7.Therapeutic procedures

General principles: offer a 'heart team' approach including representatives from interventional cardiology and cardiac surgery to improve patient outcomes in patients with chronic coronary disease with complex 3-vessel disease or if the optimal treatment strategy is unclear.
B

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  • Indications for revascularization

  • Choice of revascularization (PCI)

  • Choice of revascularization (CABG)

  • Choice of revascularization (hybrid)

  • Technical considerations for PCI (arterial approach)

  • Technical considerations for PCI (choice of stent)

  • Technical considerations for PCI (intravascular imaging)

  • Technical considerations for PCI (calcified lesions)

  • Technical considerations for PCI (bifurcation lesions)

  • Technical considerations for PCI (chronic total occlusion)

  • Technical considerations for PCI (hemodynamic support device)

  • Enhanced external counterpulsation

8.Perioperative care

General principles
Establish multidisciplinary, evidence-based perioperative management programs to optimize analgesia, minimize opioid exposure, prevent complications and to reduce time to extubation, length of stay, and healthcare costs in patients undergoing CABG.
B
Ensure a comprehensive approach to reduce sternal wound infection in patients undergoing CABG.
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  • Periprocedural antiplatelet therapy (for PCI)

  • Periprocedural antiplatelet therapy (for CABG)

  • Periprocedural anticoagulant therapy

  • Perioperative beta-blockers

  • Perioperative amiodarone

  • Intraoperative insulin infusion

  • Postprocedural antiplatelet therapy

9.Surgical interventions

Technical considerations for coronary artery bypass graft: as per SCAI 2022 guidelines, calculate the STS risk score to help stratify patient risk in candidates for CABG.
B
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  • Off-pump surgery

10.Specific circumstances

Young patients: consider offering a comprehensive evaluation and treatment of nontraditional cardiovascular risk factors (after optimization of traditional cardiovascular risk factors) to reduce the risk of cardiovascular events in young adult patients with chronic coronary disease.
C

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  • Elderly patients

  • Pregnant patients

  • Postmenopausal patients

  • Patients with obesity

  • Patients with nonobstructive CAD

  • Patients with spontaneous coronary artery dissection

  • Patients with previous CABG (repeat revascularization)

  • Patients with previous CABG (saphenous vein graft disease)

  • Patients with cardiac allograft vasculopathy

  • Patients with ventricular arrhythmia

  • Patients with diabetes mellitus

  • Patients with CKD

  • Patients with cancer

  • Patients with autoimmune diseases

  • Patients with HIV

  • Patients with AF

  • Patients with PAD

  • Patients undergoing valve surgery

  • Patients undergoing non-cardiac surgery

11.Patient education

General counseling: as per AHA 2023 guidelines, provide ongoing individualized education on symptom management, lifestyle changes, social determinants of health risk factors, and medication adherence to improve knowledge and facilitate behavior change in patients with chronic coronary disease.
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12.Preventative measures

Antiplatelet therapy
As per CCS 2023 guidelines:
Do not initiate aspirin routinely for primary prevention of ASCVD in patients without ASCVD, regardless of sex, age, or diabetes status.
D
Consider initiating aspirin for primary prevention of ASCVD in certain patients deemed at high risk of ASCVD but with low bleeding risk in the context of a patient-centered and informed shared decision-making process.
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  • Routine immunizations

13.Follow-up and surveillance

Post-revascularization care, cardiac rehabilitation, PCNA/NLA/ASPC/ACCP/ACC/AHA: offer a cardiac rehabilitation program to improve outcomes in all patients with chronic coronary disease with appropriate indications.
A

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  • Post-revascularization care (smoking cessation)

  • Post-revascularization care (psychological interventions)

  • Post-revascularization care (sexual health)

  • Serial clinical assessment

  • Serial imaging assessment

  • Repeat revascularization

  • Management of in-stent restenosis

14.Quality improvement

Healthcare system and hospital requirements: as per ACC 2022 guidelines, ensure that cardiac surgery and PCI programs participate in state, regional, or national clinical data registries and receive periodic reports of their risk-adjusted outcomes as a quality assessment and improvement strategy with the goal of improving patient outcomes.
B
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