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Coronary artery disease

What's new

Updated 2024 ESC guidelines for the diagnosis and management of coronary artery disease .

Background

Overview

Definition
CAD, also known as chronic coronary disease, 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 5 key steps: endothelial dysfunction, formation of lipid layer or fatty streak within the intima, induction of innate inflammatory reaction with migration of leukocytes and smooth muscle cells into the vessel wall, foam cell formation from macrophages engulfing lipoprotein particles, and proliferation of extracellular matrix. Coronary collateral circulation may develop to provide an alternative blood supply to the myocardium.
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Epidemiology
The prevalence of CAD in adults aged ≥ 40 years in the US is estimated at 8.0%.
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Risk factors
Risk factors for CAD include male sex, advanced age, hypertension, obesity, metabolic syndrome, physical inactivity, diabetes, hypercholesterolemia, heavy drinking, and a family history of atherothrombotic CVDs. CKD, autoimmune diseases, cerebrovascular and vascular diseases have also been associated with an increased risk of CAD.
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Disease course
CAD is often asymptomatic early in the course, but can present with chronic, gradually worsening chest pain, stable angina, ischemic cardiomyopathy, or as ACSs (unstable angina and myocardial infarction) or SCD. Other symptoms may include dyspnea, exercise intolerance, fatigue, nausea, diaphoresis, or pain in the left arm, jaw, neck, upper back, or upper abdomen.
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Prognosis and risk of recurrence
Chronic coronary disease is the leading cause of death in the US and worldwide, with a mortality rate of 210.9 per 100,000 population in the US. The survival rates for CAD after PCI and CABG vary depending on patient characteristics and disease specifics. Generally, CABG shows a survival advantage, particularly in patients with multivessel disease or diabetes.
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Guidelines

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 Academy of Family Physicians (AAFP 2024), the American Heart Association (AHA/HRS/ACC/ACCP 2024), the Canadian Cardiovascular Society (CCS/CAIC 2024), the European Society of Cardiology (ESC 2024,2022), the European Society of Cardiology (ESC/EACTS 2024,2019), the Kidney Disease: ...
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Screening and diagnosis

Indications for screening: as per AAFP 2024 guidelines, do not obtain screening for CAD with exercise stress testing with ECG in asymptomatic individuals at low risk of cardiovascular events.
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Classification and risk stratification

Risk assessment, general principles: as per AAFP 2024 guidelines, use an appropriate clinical prediction tool for risk stratification in patients with acute chest discomfort (such as the HEART pathway) or stable chest discomfort (such as the CAD Consortium 2 calculator) to determine the need for further testing.
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  • Risk assessment (before revascularization)

  • Risk assessment (after revascularization)

  • Risk assessment (obstructive CAD)

Diagnostic investigations

Initial assessment
As per ESC 2024 guidelines:
Obtain a detailed assessment of cardiovascular risk factors, medical history, and symptom characteristics (including onset, duration, type, location, triggers, relieving factors, and time of day) in patients reporting symptoms of suspected myocardial ischemic origin.
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Decide on the choice of the initial noninvasive diagnostic test based on the pre-test likelihood of obstructive CAD, other patient characteristics that influence the performance of noninvasive tests, and local expertise and availability.
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  • ECG (resting)

  • ECG (exercise)

  • ECG (ambulatory monitoring)

  • TTE

  • Cardiac MRI

  • Noninvasive stress imaging

  • Coronary CTA

  • CAC scoring

  • CXR

  • Cardiac troponin

  • Other laboratory tests

  • Screening for PAD

Diagnostic procedures

Coronary angiography: as per ESC 2024 guidelines, prefer radial artery access when invasive coronary angiography is indicated.
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  • Coronary catheterization

  • Intravascular ultrasound

Medical management

General principles: as per ACC/ACCP/AHA/…/PCNA 2023 guidelines, optimize guideline-directed medical therapy to reduce major adverse cardiovascular events in patients with chronic coronary disease.
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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

  • PPIs

  • Management of HF

Nonpharmacologic interventions

Dietary modifications: as per ACC/ACCP/AHA/…/PCNA 2023 guidelines, 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.
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  • Physical activity

  • Smoking cessation

  • Alcohol restriction

  • Substance use cessation

  • Environmental exposures

  • Psychosocial support

  • Supplements

Therapeutic procedures

General principles: as per ESC 2024 guidelines, ensure the decision for revascularization and its modality is patient-centered, taking into account patient preferences, health literacy, cultural circumstances, and social support.
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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

Perioperative care

General principles
As per ACC/AHA/SCAI 2022 guidelines:
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.
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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 (for PCI)

  • Perioperative beta-blockers

  • Perioperative amiodarone

  • Intraoperative insulin infusion

Surgical interventions

Technical considerations for CABG: as per ACC/AHA/SCAI 2022 guidelines, calculate the STS risk score to help stratify patient risk in candidates for CABG.
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  • Off-pump surgery

Specific circumstances

Young patients: as per ACC/ACCP/AHA/…/PCNA 2023 guidelines, 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.
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  • Elderly patients

  • Pregnant patients

  • Postmenopausal patients

  • Patients with obesity

  • Patients with diabetes mellitus

  • Patients with nonobstructive CAD (evaluation)

  • Patients with nonobstructive CAD (management)

  • 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 CKD

  • Patients with cancer

  • Patients with autoimmune diseases

  • Patients with HIV

  • Patients with HF

  • Patients with AF

  • Patients with PAD

  • Patients undergoing valve surgery

  • Patients undergoing noncardiac surgery (preoprative evaluation)

  • Patients undergoing noncardiac surgery (preoperative beta-blockers)

  • Patients undergoing noncardiac surgery (management of antiplatelets)

  • Patients undergoing noncardiac surgery (coronary artery revascularization)

  • Patients undergoing noncardiac surgery (timing of surgery after PCI)

Patient education

General counseling
As per ESC 2024 guidelines:
Provide an informed discussion on CVD risk and treatment benefits tailored to individual patient needs.
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Offer multidisciplinary behavioral approaches to help patients achieve healthy lifestyles, in addition to appropriate pharmacological management.
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  • Preoperative counseling

Preventative measures

Antiplatelet therapy
As per CAIC/CCS 2024 guidelines:
Do not initiate aspirin routinely for primary prevention of ASCVD in patients without ASCVD, regardless of sex, age, or diabetes status.
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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

Follow-up and surveillance

Optimization of treatment adherence: as per ESC 2024 guidelines, offer mobile health interventions, such as using text messages, apps, wearable devices, to improve patient adherence to healthy lifestyles and medical therapy.
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  • Management of refractory disease

  • Post-revascularization care (cardiac rehabilitation)

  • Post-revascularization care (smoking cessation)

  • Post-revascularization care (psychological interventions)

  • Post-revascularization care (sexual health)

  • Postprocedural antithrombotic therapy

  • Clinical follow-up

  • Imaging follow-up

  • Repeat revascularization

  • Management of in-stent restenosis

Quality improvement

Healthcare system and hospital requirements: as per ACC/AHA/SCAI 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.
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  • Health equity