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Coronary Artery Disease  

Coronary artery disease, either with or without angina, includes patients with prior myocardial infarction, prior revascularization, angiographically proven coronary atherosclerosis, or noninvasive evidence of myocardial ischemia. The patient may report previous chest pressure, heaviness, and/or pain, with or without radiation of the pain.

Clinical evaluation

History taking and physical examination, including medication are important to confirm the diagnosis, assist in risk stratification, and develop a treatment plan. Important points include the

History of previous heart disease

Possible non-atheromatous causes of angina (eg, aortic stenosis)

Comorbid conditions affecting progression of CAD

Symptoms of systemic atherosclerosis

Severity and pattern of symptoms of angina

Physical examination should include a cardiovascular examination as well as evaluation for evidence of hyperlipidemia, hypertension, peripheral vascular disease, congestive heart failure, anemia, and thyroid disease.

Laboratory studies should include an electrocardiogram and a fasting lipid profile (total cholesterol, high-density lipoprotein, calculated low-density lipoprotein, and triglycerides). Further studies may include chest films, hemoglobin.

Modifiable risk factors, for coronary heart disease and comorbid factors should be addressed. Risk factors for coronary heart disease include smoking, inappropriate activity level, stress, hyperlipidemia, obesity, hypertension.

Exercise electrocardiography

Sensitivity of exercise electrocardiography (Master "2-step" exercise test, graded exercise [treadmill] test) may be

Noninvasive imaging. A noninvasive imaging study such as myocardial perfusion scintigraphy or stress echocardiography may be indicated in patients unable to complete exercise electrocardiography.

Medical therapy

One aspirin tablet daily is strongly recommended unless there are medical contraindications. In patients with mild, daily is strongly recommended unless there are medical contraindications.

A beta-blocker is indicated in asymptomatic patients with recent myocardial infarction.

Non-cardioselective beta-blockers

Propranolol sustained-release ( Inderal LA), 60-160-mg qd [60, 80, 120, 160 mg]., 60-160-mg qd [60, 80, 120, 160 mg].

Nadolol ( Corgard), 40-80 mg qd [20, 40, 80, 120, 160 mg]., 40-80 mg qd [20, 40, 80, 120, 160 mg].

Cardioselective beta-blockers

Metoprolol ( Lopressor), 100 mg bid [25, 50, 100 mg] or metoprolol XL (, 100 mg bid [25, 50, 100 mg] or metoprolol XL ( Toprol XL) 100-200 mg qd [50, 100, 200 mg tab ER].

Atenolol ( Tenormin), 100 mg qd [25, 50, 100 mg]., 100 mg qd [25, 50, 100 mg].

Bisoprolol ( Zebeta) 5-20 mg qd [5, 10 mg]. 5-20 mg qd [5, 10 mg].

Adverse Effects. Beta blockers are usually well tolerated. Symptomatic bradycardia, hypotension, fatigue, heart failure, dyspnea, cold extremities, and bronchospasm may occur. Impotence, constipation, and vivid dreams may occasionally occur.

Contraindications to beta-blockers

Raynaud's phenomenon, reactive airway disease, or resting leg or foot pain caused by peripheral vascular disease.

Beta blockers (including cardioselective agents) can cause severe bronchospasm in patients with reactive airway disease.

Long-acting nitrates. If beta blockers cannot be prescribed as first-line therapy, nitrates are the preferred alternative because of their efficacy. Sublingual nitroglycerin can be used prophylactically prior to activities that are likely to precipitate angina.

Immediate-release nitroglycerin

Nitroglycerin, sublingually or in spray form, is the only agent that is effective for rapid relief of an established angina attack.

Patients should carry nitroglycerin tablets or spray at all times and use it as needed.

Nitroglycerin SL (Nitrostat), 0.3-1.5 mg SL q5min prn pain [0.15, 0.3, 0.4, 0.6 mg].

Nitroglycerin oral spray (Nitrolingual) 1-2 sprays prn pain.

Nitroglycerin patches: Tolerance may be avoided by removing the patch at 2 p.m. for 8 hours each day. A minimum of

Isosorbide dinitrate

Isosorbide dinitrate slow-release, ( Dilatrate-SR, Isordil Tembids) one tab bid-tid.

Isosorbide dinitrate (Isordil, Titradose) 10-60 mg PO tid-qid [5, 10, 20, 30, 40 mg]; sustained release, 40-80 mg PO q8-12h [40 mg].

Isosorbide dinitrate immediate-release, 30 mg tid-qid.

Isosorbide mononitrate immediate release ( ISMO, Monoket), 10 to 20 mg bid in the morning and again 7 hours later [10, 20 mg]. 10 to 20 mg bid in the morning and again 7 hours later [10, 20 mg].

Isosorbide mononitrate extended-release ( Imdur): Start with 30 mg, and increase the dose to 120 mg once daily [30, 60,120 mg].: Start with 30 mg, and increase the dose to 120 mg once daily [30, 60,120 mg].

Adverse effects. Nitrates are well tolerated. The most common adverse effect is headache (30-60%). Symptomatic postural hypotension may sometimes occur. Syncope may rarely occur.

Calcium channel blockers. For patients who are unable to take beta blockers or long-acting nitrates, the use of

Combination therapy may be necessary in selected patients. A combination of beta blockers and long-acting nitrates is preferred because of efficacy and reduced potential for adverse side effects.

Percutaneous transluminal coronary angiography and artery bypass grafting.