Kembara Xtra - Medicine - Coronary Artery Disease and Stable Angina

Kembara Xtra - Medicine - Coronary Artery Disease and Stable Angina 
​Introduction 
CAD is an abbreviation that stands for coronary artery disease.
a constriction of the epicardial coronary arteries due to atherosclerosis
arteries. It may first make itself known to you in the form of angina pectoris or
as an episode of acute coronary syndrome, abbreviated ACS.
Symptoms of stable angina include discomfort in the chest caused by myocardial
ischemia that can be reliably reproduced at a given threshold
as a result of physical labor or emotional strain.
Unstable angina (UA), non–ST-elevation myocardial infarction (NSTEMI), and non–ST-elevation coronar
ST elevation myocardial infarction (NSTEMI), as well as ST elevation myocardial infarction,
myocardial infarction of the elevation type (STEMI). Look at the chapters on
Please contact ACS for any additional information.
The Definitive Terms
- The traditional presentation of angina is characterized by the following three classical features: (i)
substernal chest tightness, also known as the feeling of weight or pressure that
may spread to the jaw, the back, or the limbs, and typically begins in the
ranges from two to fifteen minutes in length; 
(ii) happens at a given level
in relation to the demand for oxygen in the myocardium caused by physical activity,
tension or an elevated sympathetic nervous system tone; and 
(iii) eased
with rest or nitroglycerin administered sublingually - Atypical angina:
demonstrates the presence of two of the aforementioned typical qualities
- Chest pain that isn't caused by your heart: has at least one of the above usual symptoms
characteristics
- Anginal equivalent: Patients may present with no chest pain or discomfort.
discomfort, but with nonspecific symptoms such (and not limited to)
symptoms such as shortness of breath, heavy sweating, lethargy, nausea, and lightheadedness.
gastrointestinal distress caused by strenuous activity or
stress. Patients suffering from diabetes mellitus, women, and the elderly
It's possible that elderly patients will present with more unusual symptoms as they age.
in contrast to members of the broader population.
- Anginal symptoms that have recently appeared or are occurring more frequently,
characterized by an increase in severity or by a decline in degree
myocardial demand; although it is termed ACS, it does not actually cause the condition.
characterized by an increase in cardiac biomarker(s). (See "Acute
Syndromes of the Heart: NSTE-ACS (Unstable Angina and Acute Coronary Syndromes)
– Non-ST-elevation myocardial infarction (NSTEMI): increase of cardiac biomarker
(troponin) in the presence of anginal symptoms or an ischemia electrocardiogram
alterations that are not elevation-related, or both of these. (See "Acute
Among the coronary syndromes are NSTEACS, which stands for unstable angina and
NSTEMI)") - STEMI: manifests with classic symptoms such as chest pain, nausea, and dizziness.
mentioned previously with ST elevations having been observed on the ECG;
typically brought on by sudden plaque rupture and comprehensive
blockage of the responsible vessel, which may manifest itself before
laboratory confirmation of the presence of troponin. (See "Acute Coronary Syndrome"
Syndromes: STEMI.") 
● Canadian Cardiovascular
Scale for evaluating society:
- Class I: Angina does not prevent the patient from engaging in regular physical exercise.
only happening after lengthy or vigorous physical activity (7 exclusively)
to 8 metabolic equivalents [METs]).
- Class II: Angina results in a moderate but noticeable restriction of usual
activity. It happens when walking quickly, uphill, or more than 2 miles per hour.
blocks; ascending more than one flight of stairs; or dealing with emotional issues
tension (five to six METs).
- Class III: Angina results in a significant reduction in the patient's normal
engagement in sport or exercise. It can happen when walking one to two blocks or further.
three to four METs are equivalent to ascending one flight of stairs.
- Class IV: Angina can be brought on by any type of physical exertion and
may happen while the body is at rest (1 to 2 METs).

Considerations Regarding the Aged
It is possible for older patients to exhibit symptoms that are not usual.
Physiological constraints can potentially cause a delay in the diagnosis of angina until
It might happen with very little effort or while you are resting.
During the course of your investigation, you should keep a high level of suspicion.
a variety of nonspecific problems, including dyspnea.
Patients who are elderly may have heightened sensitivity to the drug's adverse effects.
consequences of taking drugs for the treatment of angina.

Epidemiology (Incidence and Prevalence) 

Coronary heart disease is the main cause of death among adults in both the United States
United States of America and throughout the world.
The total cost of CAD in the United States was $555 billion in 2017.
2016, and it is anticipated that it will reach $1.1 trillion by the year 2035.
80% of coronary artery disease can be avoided by leading a healthy lifestyle.
Incidence
In the United States, a person who is 40 years old has a lifetime risk of
The risk of acquiring CAD is 49% for men, while the risk is only 32% for women.
Prevalence
There are 28.4 million persons in the United States who have been given a diagnosis of.
CAD, while 7.12 million people have been diagnosed with angina pectoris.

Pathophysiology 

Anginal sensations manifest themselves whenever there is myocardial
ischemia brought on by an imbalance between coronary blood flow and
perfusion as well as the oxygen demand of the myocardium.
Atherosclerotic plaque buildup in the coronary arteries is the cause of coronary artery disease.
most prevalent cause of angina, although it can also be caused by other conditions such as
people who have a significant amount of aortic stenosis, pulmonary hypertension, and
cardiovascular disease, hypertrophic cardiomyopathy, and hypertension
or an excessive amount of volume.
This is the point at which nerves carrying sensations from the heart enter the spinal cord.
levels C7–T4, which results in widespread referred pain and discomfort in the
the dermatomes that are connected with it.

Risk Factors 
Traditional risk factors, include hypertension, HDL, LDL, and triglycerides.
cigarette smoking, diabetes, and early-onset coronary artery disease in first degree
relatives (men less than 55 years old and women younger than 65 years old), age range
(more than 45 years for men, greater than 55 years for women) 
●
Nontraditional risk factors include being overweight and leading a sedentary lifestyle.
inflammation that has persisted for a long time, aberrant ankle-brachial indices, and
kidney disease

Preventative Steps and Precautions 

Stopping the habit of smoking

● Regular aerobic exercise program
• Weight reduction for people who are obese (target body mass index)
[BMI] <25 kg/m2). 
a diet focused on plants or that is similar to the Mediterranean
diet is recommended.
Management of blood pressure (BP) (target: less than 140/90 mm Hg;
Take a reading below 130/80 mm Hg if you have a 10-year risk of ASCVD.
risk ≥10%) (1)[C].

● Type 2 diabetes management: Consider more aggressive
target range for hemoglobin A1c (HbA1c) of between 6.5 and 7% in younger,
persons who have just lately been diagnosed.
Statin treatment of at least a moderate level for individuals who have
those with diabetes between the ages of 40 and 75, as well as those with a 10-year
risk of ASCVD between 7.5 and 20% (recommendations made by advice)
There are several different organizations, including the American College of
Calculator for cardiovascular disease and the American Heart Association
overestimates the risk in many cases by as much as fifty to one hundred percent.) 
●
It is no longer suggested that patients take low-dose aspirin for
primary prevention of myocardial infarction (MI) should be an everyday practice.
without any clear proof of coronary artery disease. Advantages and disadvantages
are finely balanced, and there is little convincing evidence supporting
reduction in mortality from all causes, but there is evidence for an increase in
decrease in the number of cardiovascular events at the expense of an increase in the
severe GI hemorrhage. A method based on collective decision-making.
may want to use aspirin as a key preventative measure for patients.
Between 40 to 59 years old, those who are at the highest risk for CAD, and those who are at the lowest risk
for GI hemorrhage. There is a slim chance that this will be beneficial. A dose of aspirin should
not be suggested for people who are over the age of sixty (USPSTF 2021).
"D" level recommendation). Those who have can benefit from using it.
high level of clinical suspicion in the period leading up to the stress
testing/catheterization.

Conditions That Often Occur Together 
Hyperlipidemia, peripheral vascular disease,
diseases of the brain and blood vessels, high blood pressure, obesity, and diabetes

Providing an Account of History 

It is essential to take a thorough history in order to elicit symptoms.
One way to illustrate pain is to place a closed fist over the area.
(the Levine sign) in the middle of the chest.
Typically, one's level of discomfort is unaffected by either their position or how deep
inspiration.
Symptoms of angina tend to present themselves in the same way each time.
as well as at the same physical area as the other episodes.
It's possible that the recent decline in your level of physical activity is linked to
to an increase in the severity of anginal symptoms.
Dyspnea on exertion may be the only symptom that the patient experiences.
Those who are female, old, or African-American are more prone to exhibit atypical symptoms.
and people suffering from diabetes.
May manifest with symptoms that are analogous to those of gastrointestinal (GI)
distressing symptoms (nausea, diaphoresis, indigestion)

The Patient's Clinical Examination 
● Normal cardiac exam does not exclude the diagnosis of
angina or CAD.
An examination of the heart might uncover arrhythmias or cardiac murmurs.
symptoms of valve illness, gallops, or indications of valvular disease
heart failure that is congestive.
Decreased signs of peripheral vascular disease (which had previously been present)
pulses, bruits, and abdominal aortic aneurysm (also known as AAA) may or may not be present.
might not be noted at all.

Differential Diagnosis 
Disorders of the blood vessels, include aortic dissection, pericarditis, myocarditis, MI, and
vasospasm
Pleuritis, pulmonary embolism, and pneumothorax are examples of pulmonary conditions.
Gastroesophageal: include gastroesophageal reflux disease (GERD), esophageal spasm, and
peptic ulcer
Disorders of the musculoskeletal system, include costochondritis, arthritis, and muscular strain
rib fracture 
Other: panic disorder, psychosomatic symptoms, and cocaine use
abuse

Results From the Laboratory 

Initial Tests (lab, imaging)
Serial measurements of cardiac troponins for patients who come with an acute condition
symptoms
HbA1c, complete blood count, and lipid profile for risk assessment
stratification
A metabolic panel of the most fundamental kind to rule out electrolyte imbalances
and evaluate the function of the kidneys 
● ECG
- Should be obtained unless there is a reason of that is not related to the heart.
the ache in the chest
- Typically unremarkable in the time in between anginal bouts;
may exhibit symptoms of myocardial ischemia at any point during the
recurrence of symptoms, signs of a previous MI - left bundle
Interpretation can be complicated by branch block or ventricular pacing.
unreliable for ischemia treatment.
An x-ray of the chest can help rule out other potential reasons of the pain.

Additional Examinations, as well as Other Important Factors
The objective is to identify coronary lesions that pose a high risk.
Taking action would result in a reduction in overall mortality or
reduce the severity of the anginal symptoms.
Patients who are at intermediate risk are the ones who benefit the most from stress testing.
cardiovascular disease (CAD) danger.
- Physical activity examination for people who are able to exercise physically
(≥5 METs)
Exercise electrocardiogram, standard for persons who have normal baseline
ECG (meaning there is no blockage of the left bundle branch or
pacing of the ventricles) Exercise stress assessment with echocardiography
Alternatively, perfusion imaging may be performed on patients who have aberrant baseline
Electrocardiogram, or in premenopausal women – In patients who have a history of
cannot tolerate exercise, consider pharmacologic
putting under pressure.
• Patients diagnosed with a should have an echocardiogram performed.
new or loud murmur (III/VI), evidence of myocardial infarction, and symptoms of myocardial infarction
cardiac insufficiency, apprehension regarding hypertrophic cardiomyopathy, or
pericardial effusion, as well as in patients who had newly developed arrhythmias. A
normal echocardiography can not rule out CAD.
Patients who have chest pain should carefully consider having an echocardiogram.
hypertension or diabetes, as well as an irregular electrocardiogram.
Computed tomography coronary angiograms or magnetic resonance imaging of the heart
regarded as a potential complement to or replacement for stress testing
people who continued to exhibit symptoms despite having negative
testing under pressure, inconclusive testing under pressure, or the requirement for
improved anatomical understanding of the condition.

Diagnostic Methods and Other Procedures
The diagnostic procedure of choice is cardiac catheterization combined with coronary angiography.
the highest standard for confirming and outlining coronary artery disease
disease as well as the intended course of interventional therapy or surgical treatment.
It is recommended in the event when noninvasive testing reveals a high risk.
a lesion, or if the patient does not respond appropriately to adequate medical treatment
management.
The term "significant CAD" refers to a left coronary artery narrowing of at least 50%.
main coronary artery or stenosis of at least 70 percent in another major
angiography to examine the coronary arteries.

Management 

The suggested blood pressure control goal for the majority of people by the AHA and ACC
with substantial CAD: less than 130/80 millimeters of mercury. Individualize
goal based on the preferences of the patient.
● Smoking cessation goal: full quit, no exposure
to passive smoking or the use of electronic cigarettes 
Engaging in athletic endeavors
30–60 minutes per day of moderate aerobic activity should be the goal.
at least five days per week, ideally seven 
● Weight management
target range for body mass index: 18.5 to 24.9 kg/m2; waist circumference: less than 35
inches for women or less than 40 inches for men. 
● Individualize
aims for glycemic control in diabetics include avoiding hypoglycemia states.
episodes.

Medication 

First Line
-Blockers reduce the amount of oxygen that the myocardium needs to function by
decreases in heart rate, blood pressure, and the ability to contract
mortality in patients who have had a heart attack or are suffering from heart failure and should be
utilized in the beginning stages of treatment
- May reduce the severity of angina symptoms
- Metoprolol (25 to 400 mg daily [succinate] or divided
carvedilol (3.125 to 25.000 mg BID) or tartrate (BID).
Doses should be adjusted based on the patient's clinical response. Maintain
heart rate during rest between 50 and 60 beats per minute.
- Adverse effects include slow heart rate, tiredness, and sexual dysfunction.
malfunction most commonly observed in males
Calcium channel blockers, often known as CCBs, are known to produce arterial
vasodilation, a decrease in the oxygen demand of the myocardium, and
increased blood flow to the coronary arteries. Effectiveness comparable to that of -
blockers; they can be utilized in place of or in addition to -.
blockers. Only CCBs with a lengthy half-life should be used: –
Dihydropyridine CCBs: Nifedipine (30 to 90 mg/day),
amlodipine (5 to 10 mg/day), or felodipine (2.5 to 10
mg each day) focus primarily on relaxing the vascular vasculature and
can result in an increase in coronary blood flow.
- Nondihydropyridine CCBs, including diltiazem (120 to 480 micrograms per
mg/day) or verapamil (120 to 480 mg/day) also had
effects that are inotropically detrimental and should not be employed in
those having an ejection fracture that is less than forty percent because they may
precipitate heart failure. Among the side effects are:
a lack of bowel movement and peripheral swelling.
Nitrates are known to widen veins and arteries throughout the body, including the heart.
coronary arteries) and result in a reduction in preload. At greater levels, the
dosages, they have the effect of lowering blood pressure.
- Nitroglycerin sublingual administration (0.4 mg every 5 minutes for as long as
up to three doses) for the treatment of acute anginal events
– Nitrates with a prolonged half-life, such as isosorbide mononitrate (30
to 240 mg daily (in the form of an extended-release formulation) may be recommended for
angina prophylaxis.
- Headaches and low blood pressure are only two of the potential side effects.
to become more effective with continued use.
- Not recommended in the presence of concurrent phosphodiesterase
type 5 inhibitor use (e.g., sildenafil)
Agents that reduce lipid levels:
— High-intensity statin therapy is recommended for each and every patient
having coronary arteriopathy despite their cholesterol levels.
- Treatment with statins should also be given serious consideration for
those who have a significant likelihood of developing CAD. (Lifetime ASCVD risk ≥7.5–
10%, between the ages of 75 and 80. There is limited evidence that this treatment is beneficial for.
after 75 years, statins are recommended for primary prevention, and many
If patients are of this age or older, it is recommended that statins not be prescribed.
a medication that is not used for treatment) – Atorvastatin (40 to 80 mg daily)
mg per day) and rosuvastatin (between 20 and 40 mg per day) are considered to be high-intensity
statins.
Statins lower the risk of myocardial infarction and the requirement for revascularization.
Myalgias, transaminitis, and rhabdomyolysis are some of the adverse consequences.
rhabdomyolysis, which is extremely uncommon, as well as reduced glucose tolerance.
- Ezetimibe may be added to statin treatment in the event that LDL is not adequately reduced.
at target, following the highest dose of statin that may be safely tolerated,
particularly in regard to secondary prevention.
- Inhibitors of the proprotein convertase subtilisin/kexin type 9 complex
Combining these two treatments results in an even greater decrease in LDL levels.
with statins for those who have a high risk and to lower the
cardiovascular events in highly chosen patients, however these patients are not at higher risk overall
incredibly high in cost.
Antiplatelets have been shown to reduce the risk of thrombosis.
- Taking aspirin (75 to 162 milligrams per day) lowers the risk of having a first heart attack and
decreases the risk of dangerous cardiovascular events in patients
stable angina.
- Clopidogrel at a dosage of 75 milligrams per day may be prescribed to patients who have
conditions that should not be treated with aspirin.
- A Dual Antiplatelet Treatment Consisting of Clopidogrel and Aspirin,
prasugrel or ticagrelor may be prescribed in the event of a MI or
PCI stands for percutaneous coronary intervention. Prasugrel should be used during this procedure.
only after PCI, and never in patients with a previous history of CVA).
Angiotensin-converting enzyme inhibitors, sometimes known as ACEIs, are drugs that work through
lowering blood pressure through the renin-angiotensin-aldosterone pathway.
as well as afterload. In addition to this, they have an impact on cardiac
renovation after MI.
ACEIs, including lisinopril (at doses ranging from 5 to 40 mg per day) and enalapril
(2.5 to 20.0 mg BID) have been observed to decrease either or both of the following:
cardiac mortality and myocardial infarction in people with coronary artery disease and
disruption of the systolic function of the left ventricle.
- Angiotensin receptor blockers such as candesartan, which can lower blood pressure by four to
32 mg on a daily basis) is an option for those who cannot tolerate
ACEIs.
ACEIs are most likely to cause a cough, which is one of the side effects.
hyperkalemia, and angioedema.
Two-Thirds Line
Ranolazine (500 to 1,000 mg BID) lowers calcium
overload in myocytes, hence exhibiting antianginal and antiischemic properties
agent.
It has no effect on the heart rate or blood pressure, and it can be utilized as an
adjuvant therapy is used in cases where symptoms continue to exist despite
doses of various antianginals that are optimal. Nausea and vomiting are among the adverse effects.
constipation, disorientation, QT prolongation, headache

Surgical Methods and Operations 

Revascularization ought to be contemplated in the event that appropriate medical
The therapy does not effectively control the symptoms.

Percutaneous coronary intervention with balloon angioplasty and/or stent implantation (with or without)
drug-eluting or bare-metal stent) is performed for
major lesions. Additional treatments involve laser
treatment as well as atherectomy.
It does not appear that PCI lowers the risk of MI or the death rate.
compared to rigorous medical management for patients who have
stable angina.
Percutaneous coronary intervention (PCI) is not as effective as coronary artery bypass grafting (CABG).
people who have significant stenosis of the left major coronary artery
lesions that are considerable in at least three of the major coronary arteries, and for
lesions not susceptible to PCI.

Extra Treatments and Medications 

Treatment for angina that focuses on relaxation and stress reduction

In addition, we have some recommendations for you. 

Modifications to one's way of life ought to be forcefully emphasized at
each and every visit.
Monitoring of the Patient
Regular check-ins following the original occurrence: once every four to six months in the
after the first year, once or twice per year thereafter
It is recommended that you follow a diet similar to the Mediterranean or one centered on plants.
It has been demonstrated to reduce mortality from all causes in comparison to
standard diet. It is recommended that you consume fatty seafood such as salmon.
(but not omega-3 supplements) 
Observance of prescribed eating habits
alterations made to account for coexisting illnesses (such as diabetes and heart disease)
failure, hypertension)

Prognosis 
Variable; it depends on the intensity of the symptoms, the degree of CAD, and other factors.
Regarding the operation of the left ventricle

Complications 
heart failure, arrhythmia, cardiac arrest, and acute coronary syndrome