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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 and/or shortness of breath.
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 coronary artery disease, heart disease, heart attack, coronary heart disease, angina
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
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, and tests for
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, and diabetes mellitus.
Exercise electrocardiography
Sensitivity of exercise electrocardiography (Master "2-step" exercise test, graded exercise [treadmill] test) may be reduced for
Noninvasive imaging. A noninvasive imaging study such as myocardial perfusion scintigraphy or stress echocardiography may be indicated in patients unable to complete exercise electrocardiography. Exercise electrocardiography and prognostic imaging studies may yield results that indicate high, intermediate, or low risk of adverse clinical events. High-risk patients should
Medical therapy
One aspirin tablet daily is strongly recommended unless there are medical contraindications. In patients with mild, stable CAD, drug therapy may be limited to short-acting sublingual nitrates on an as-needed basis or prophylactically in situations
A beta-blocker is indicated in asymptomatic patients with recent myocardial infarction. The use of angiotensin-converting enzyme inhibitors has been demonstrated to be beneficial in patients with left ventricular systolic dysfunction, including that
Non-cardioselective beta-blockers
Propranolol sustained-release ( Inderal LA), 60-160-mg qd [60, 80, 120, 160 mg].
Nadolol ( Corgard), 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 ( Toprol XL) 100-200 mg qd [50, 100, 200 mg tab ER].
Atenolol ( Tenormin), 100 mg qd [25, 50, 100 mg].
Bisoprolol ( Zebeta) 5-20 mg qd [5, 10 mg].
Contraindications to beta-blockers
Long-acting nitrates. If beta blockers cannot be prescribed as first-line therapy, nitrates are the
Immediate-release nitroglycerin
Nitroglycerin, sublingually or in spray form, is the only agent that is effective for rapid relief of an established angina attack.
Nitroglycerin patches: Tolerance may be avoided by removing the patch at 2 p.m. for 8 hours each day. A minimum of 15 mg of nitroglycerin per 24-hr period is necessary for effect. Nitroglycerin patch (Transderm -Nitro) 0.6-0.8 mg/h applied for
Isosorbide dinitrate
Isosorbide dinitrate slow-release, ( Dilatrate-SR, Isordil Tembids) one tab bid-tid.
Calcium channel blockers. For patients who are unable to take beta blockers or long-acting nitrates, the
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. The relative survival benefit of CABG, compared with medical therapy, is enhanced by an increase in the absolute number of