Diagnosis and Management of Chronic Coronary Artery Disease

Abstract

Coronary artery disease (CAD) usually coexists with atherosclerosis of other arterial trees and is accelerated by several risk factors. It may remain asymptomatic for a long period affecting the vessel wall with no lumen encroachment. However, its course may change dramatically when complicated by thrombosis arising from ruptured atherosclerotic plaques leading to myocardial infarction or sudden death, which are often the first manifestations. Alternatively, thrombosis may remain clinically silent yet contributing to the natural history of plaque progression and ultimately luminal stenosis resulting in symptomatic or asymptomatic myocardial ischemia. Thus, chronic CAD may be classified as: 1) Asymptomatic/non-ischemic (subclinical) including asymptomatic patients without stress-induced myocardial ischemia and one or more of the following: a) non-coronary forms of atherosclerotic disease, b) diabetes, c) high Framingham Risk Score (FRS) or European Heart Score (EHS), and d) intermediate FRS or EHS and either a coronary artery calcium score 100 or a carotid intima-media thickness score 1mm; 2) Asymptomatic/ischemic, including asymptomatic patients with a positive stress-test and one or more of the following: a) non-coronary forms of atherosclerosis, b) diabetes, and c) intermediate or high FRS or EHS; 3) Symptomatic/ ischemic, including patients with effort angina and stress test-induced myocardial ischemia. Lifestyle modification, aspirin, and lipid lowering with statins, are the mainstay of treatment in all patients with chronic CAD. Antiischemic pharmacotherapy should be considered in patients with evidence of myocardial ischemia and reperfusion treatment in selected patients with obstructive lesions in coronary angiography.