Coronary Artery Disease (CAD)

Background

• CAD refers to atherosclerotic narrowing of coronary arteries that is often asymptomatic early in the course of the disease but may lead to stable or unstable angina, and/or myocardial infarction with the progressive thickening or plaque rupture of the wall of the coronary arteries.
• Common risk factors for CAD include dyslipidemia, tobacco abuse, hypertension, family history of CAD, diabetes mellitus, and obesity.
• Complications include acute coronary syndromes (ACS), ST-elevation myocardial infarction (STEMI), acute heart failure, arrhythmias, and sudden death. There is general agreement about approaches to secondary prevention of CAD and its complications.
• CAD remains the number one cause of death in the United States; see risk scores to assess risk of cardiovascular mortality.

Evaluation

• Obtain an electrocardiogram (ECG) in all patients with chest pain (Strong recommendation).
  • For patients with acute chest pain and suspicion of unstable angina or acute myocardial infarction (AMI), see Acute coronary syndromes or ST-elevation myocardial infarction (STEMI).
• In stable patients with known or suspected CAD, perform a history and physical and consider selected blood tests.
• Order ECG stress testing in stable patients with at least intermediate pretest probability of CAD based on cardiovascular risk prediction who are able to exercise with interpretable ECG and order nuclear myocardial perfusion imaging (MPI) or echocardiography if the ECG is uninterpretable or the patient is unable to exercise (Strong recommendation).
• Cardiac stress testing is not recommended for routine screening of asymptomatic men or women (Strong recommendation).
• Perform coronary angiography in stable patients suspected of having CAD if:
  • there is high likelihood of severe CAD based on clinical characteristics and noninvasive testing if benefits may outweigh risks (Strong recommendation)
  • there is presumed stable CAD, unacceptable ischemia on guideline-directed medical therapy, and candidacy for revascularization (Strong recommendation)
• Consider coronary angiography in stable patients suspected of having CAD if:
  • clinical characteristics and noninvasive testing indicate a high likelihood of severe ischemic heart disease in candidates for revascularization (Weak recommendation)
  • stress testing is contraindicated or results of stress testing are inconclusive and there is a high likelihood that coronary angiography results will inform therapeutic options (Weak recommendation)
  • stress testing results are of unacceptable quality but are negative despite high clinical suspicion of CAD and there is a high likelihood that coronary angiography results will inform therapeutic options (Weak recommendation)
• Do not perform coronary angiography in patients without known CAD who are:
  • at low risk based on clinical characteristics without any prior noninvasive testing (Strong recommendation)
  • asymptomatic with no ischemia on noninvasive testing (Strong recommendation)

Management

• Institute the following lifestyle modifications for all patients with CAD:
  • Limit daily intake of saturated fats (< 7%-10%) and trans-fatty acids (< 1%) (Strong recommendation).
  • Increase daily consumption of fresh fruits and vegetables (Strong recommendation).
  • Encourage regular aerobic physical activity with durations ranging from 20 minutes to 60 minutes/day and recommended frequency ranging from ≥ 3 times/week to 7 days/week (Strong recommendation).
  • Weight management is recommended to achieve and maintain both of:
    • body mass index (BMI) 18.5-24.9 kg/meter²
    • waist circumference < 40 inches (102 cm) for men, < 35 inches (89 cm) for women
  • Advise smoking cessation at every visit and assist with smoking cessation support (counseling, pharmacotherapy, and/or smoking cessation services) (Strong recommendation).
• Administer the following medications to all patients with CAD:
  • high-intensity statins if aged 21-75 years (Strong recommendation), and consider if > 75 years old (Weak recommendation)
  • antiplatelet agents:
    • aspirin 75-162 mg/day orally unless contraindicated (Strong recommendation)
    • clopidogrel 75 mg orally once daily as alternative for patients intolerant of or allergic to aspirin (Strong recommendation)
    • dual antiplatelet therapy (P2Y12 inhibitor plus aspirin) for patients who undergo percutaneous coronary intervention (PCI) with stent placement (Strong recommendation)
  • angiotensin-converting enzyme (ACE) inhibitors indefinitely, unless contraindicated, with left ventricular ejection fraction ≤ 40%, hypertension, diabetes, or chronic kidney disease (Strong recommendation)
• Prescribe medications for the treatment of acute and chronic management of angina as needed (Strong recommendation).
• Do not give hormone replacement therapy, antioxidant vitamins, or folic acid for secondary prevention in patients with CAD (Strong recommendation).
• Routine follow-up for patients with stable ischemic heart disease:
  • should include annual review of risk factors, assessment of symptoms, and adherence to lifestyle modifications and medications (Strong recommendation)
  • may include a 12-lead electrocardiogram, screening for diabetes mellitus, depression, and chronic kidney disease (Weak recommendation)
• See Management of stable angina topic for medical and interventional treatment of symptomatic CAD.
• See the Revascularization for coronary artery disease (CAD) topic for the indications for revascularization in patients with CAD.