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4
IschemicHeartDisease
NoahN.Williford,MarcA.Sintek
CoronaryHeartDiseaseandStableAngina
GENERALPRINCIPLES
Definition
Coronaryarterydisease (CAD)refers tothe luminal narrowingof a coronaryartery, usuallydue to atherosclerosis.CADistheleadingcontributortoischemicheartdisease(IHD).IHDincludesangina pectoris,myocardialinfarction(MI),andsilentmyocardialischemia. Cardiovascular disease (CVD) includes IHD, cardiomyopathy, heart failure (HF), arrhythmia, hypertension, cerebrovascular accident (CVA), diseases of the aorta, peripheral vascular disease (PVD),valvularheartdisease,andcongenitalheartdisease. Stable anginais definedas anginasymptoms or angina equivalent symptoms that are reproducedby consistentlevelsofactivityandrelievedbyrest. AmericanHeartAssociation/AmericanCollegeofCardiology(AHA/ACC)guidelinesprovideamore thoroughoverviewofstableIHD.
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Epidemiology
ThelifetimeriskofIHDatage40isoneintwoformenandoneinthreeforwomen. Therearemorethan15millionAmericanswithIHD,50%ofwhomhavechronicangina. CVDhasbecomeanimportantcauseofdeathworldwide,accountingfornearly30%ofalldeathsand hasbecomeincreasinglysignificantindevelopingnations.
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Etiology
CADmostcommonlyresultsfromluminalaccumulationofatheromatousplaque. Other causes of obstructive CAD include congenital coronary anomalies, myocardial bridging, vasculitis,andpriorradiationtherapy.
Pathophysiology
Stable angina results from progressive luminal obstruction of angiographically visible epicardial coronaryarteriesor,lesscommonly,obstructionofthemicrovasculature,whichresultsinamismatch betweenmyocardialoxygensupplyanddemand. Atherosclerosis is aninflammatory process, initiatedbylipid depositioninthe arterial intima layer followedbyrecruitmentofinflammatorycellsandproliferationofarterialsmoothmusclecellstoform anatheroma.
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The coronary lesionsresponsible for stable angina differ from the vulnerable plaques associated with acute MI. The stable angina lesion is fixed and is less prone to fissuring, hence producing symptomsthataremorepredictable.
4
Allcoronarylesionsareeccentricanddonotuniformlyaltertheinnercircumferenceoftheartery. Epicardialcoronarylesionscausinglessthan40%luminalnarrowinggenerallydonotsignificantly impaircoronaryflow. Moderateangiographiclesions(40%–70% obstruction) mayinterfere withflow andare routinely underestimatedoncoronaryangiogramsgiventheeccentricityofCAD.
RiskFactors
OfIHDevents,>90%canbeattributedtoelevationsinatleastonemajorriskfactor.
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AssessmentoftraditionalCVDriskfactorsincludes:
Age Bloodpressure(BP) Bloodglucose(Note:DiabetesisconsideredanIHDriskequivalent.) Lipidprofile(low-densitylipoprotein[LDL],high-densitylipoprotein[HDL],triglycerides);direct LDLfornonfastingsamplesorveryhightriglycerides Tobacco use (Note: Smoking cessation restores the risk of IHD to that of a nonsmoker within approximately15years.)
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Familyhistory of premature CAD: Defined as first-degree male relative with IHD before age55 yearsorfemalerelativebeforeage65years Measures forobesity,particularlycentralobesity;bodymassindexgoalisbetween18.5 and24.9
kg/m2;waistcircumferencegoalis<40informenand<35inforwomen As of 2013, AHA/ACC guidelines recommend assessing 10-year atherosclerotic cardiovascular disease(ASCVD)riskforpatientsaged40–79 years usingnewrace andage-specific pooledcohort equations.
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The ASCVD risk calculator is available online (http://tools.cardiosource.org/ASCVD-Risk-
Estimator/).
If there remains uncertainty about lower risk estimates, high-sensitivity C-reactive protein (≥2
mg/dL),coronaryarterycalciumscore(≥300Agatstonunitsor≥75thpercentile),orankle-brachial
index(<0.9)maybeobtainedtoreviseriskestimatesupward.
Traditionalriskfactorsnotedaboveshouldbeassessedinpatientsyoungerthan40yearsandevery
4–6 years after 40;10-yearASCVDriskshouldbe calculated every 4–6 years in patients 40–79
yearsofage.
LifetimeriskcanbeassessedusingtheASCVDriskcalculatorandmaybehelpfulinthesettingof
counselingpatientsaboutlifestylemodifications.
Prevention
Primaryprevention:SeeChapter3,PreventiveCardiology.
ClinicalPresentation
HISTORY
Typical angina has three features: (1) substernal chest discomfort with a characteristic qualityand durationthatis(2)provokedbystressorexertionand(3)relievedbyrestornitroglycerin.
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Atypicalanginahastwoofthesethreecharacteristics.
Noncardiacchestpainmeetsoneornoneofthesecharacteristics.
Chronicstable anginais reproduciblyprecipitatedina predictable manner byexertion or emotional stressandrelievedwithin5–10minutesbysublingualnitroglycerinorrest. The severity of angina may be quantified using the Canadian Cardiovascular Society (CCS) classificationsystem(Table4-1).
TABLE4-1
CANADIANCARDIOVASCULARSOCIETY(CCS)CLASSIFICATIONSYSTEM
Class Definition
CCS1Anginawithstrenuousorprolongedactivity
CCS2Anginawithmoderateactivity(walkinggreaterthantwolevelblocksoroneflightof
stairs)
CCS3Anginawithmildactivity(walkinglessthantwolevelblocksoroneflightofstairs)
CCS4Anginathatoccurswithanyactivityoratrest
Anginalsymptomsmayincludetypicalchestdiscomfortoranginalequivalents. DatafromSangareddiV,AnandC,GnanaveluG,etal.CanadianCardiovascularSocietyclassificationofeffortangina:an
angiographiccorrelation.CoronArteryDis.2004;15(2):111-114.
Associatedsymptomsmayincludedyspnea,diaphoresis,nausea,vomiting,dizziness,jawpain,andleft armpain. Female patients and those with diabetes or chronic kidney disease may have minimal or atypical symptomsthatserveasanginalequivalents.Suchsymptomsincludedyspnea(mostcommon),epigastric pain,andnausea. The clinician’s assessment of the pretest probability of IHD is the important driver for further diagnostictesting inpatientswithoutknownCADandis largelyascertainedfromtheclinicalhistory (Table4-2).Patientswithalowpretestprobability(<5%)ofCADareunlikelytobenefitfromfurther diagnostictestingaimedatdetectingCAD.
TABLE4-2
PRETESTPROBABILITYOFCORONARYARTERYDISEASEBYAGE,GENDER,AND SYMPTOMS
Age(y) Asymptomatic Nonanginal
ChestPain
Atypical/Probable AnginaPectoris
Typical/Definite AnginaPectoris
Gender Women Men Women Men Women Men Women Men
30–39 <5 <5 2 4 12 34 26 76
40–49 <5 <10 3 13 22 51 55 87
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50–59 <5 <10 7 20 31 65 73 93
60–69 <5 <5 14 27 51 72 86 94
Verylow<5% Low<10% Intermediate10%–80% High>80%
DatafromGibbonsRJ,BaladyGJ,BrickerJT,etal.(CommitteeMembers).ACC/AHA2002guidelineupdateforexercisetesting– summaryarticle:areportoftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForceonPracticeGuidelines (CommitteetoUpdatethe1997ExerciseTestingGuidelines).Circulation.2002;106(14):1883-1892.
DifferentialDiagnosis
A wide range ofdisorders maymanifestwithchestdiscomfortandmay include both cardiovascular andnoncardiovascularetiologies(Table4-3).
TABLE4-3
DIFFERENTIALDIAGNOSISOFCHESTPAINEXCLUDINGEPICARDIAL ATHEROSCLEROSIS
Diagnosis Comments
Cardiovascular
Aorticstenosis Anginalepisodescanoccurwithsevereaorticstenosis.
HCM Subendocardialischemiamayoccurwithexerciseand/orexertion.
Prinzmetal angina
Coronaryvasospasmthatmaybeelicitedbyexertionoremotionalstress.
Pericarditis Pleuriticchestpainassociatedwithpericardialinflammationfrominfectious
orautoimmunedisease.
Aortic dissection
Maymimicanginalpainand/orinvolvethecoronaryarteries.
Cocaineuse Resultsincoronaryvasospasmand/orthrombusformation.
Other
Anemia MarkedanemiacanresultinamyocardialO2supply–demandmismatch.
Thyrotoxicosis IncreaseinmyocardialdemandmayresultinanO2supply–demand
mismatch.
Esophageal disease
GERDandesophagealspasmcanmimicangina(responsivetoNTG).
Biliarycolic Gallstonescanusuallybevisualizedonabdominalsonography.
Respiratory diseases
Pneumoniawithpleuriticpain,pulmonaryembolism,pulmonaryhypertension.
Musculoskeletal Costochondritis,cervicalradiculopathy.
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GERD,gastroesophagealrefluxdisease;HCM,hypertrophiccardiomyopathy;NTG,nitroglycerin.
A careful history focused on cardiac risk factors, physical exam, and initial laboratory evaluation usuallynarrowsthedifferentialdiagnosis. InpatientswithestablishedIHD,alwayslookforexacerbatingfactorsthatcontributetoischemia. Any process that reduces myocardial oxygen supply or increases demand can cause or exacerbate angina(Table4-4).
TABLE4-4
CONDITIONSTHATMAYPROVOKEOREXACERBATEISCHEMIA/ANGINA INDEPENDENTOFWORSENINGATHEROSCLEROSIS
IncreasedOxygenDemand DecreasedOxygenSupply
Noncardiac
Hyperthermia Hyperthyroidism Sympathomimetic toxicity (i.e.,
cocaineuse) Hypertension Anxiety
Anemia Sicklecelldisease Hypoxemia
Pneumonia Asthmaexacerbation Chronicobstructivepulmonarydisease Pulmonaryhypertension Pulmonaryfibrosis Obstructivesleepapnea
Pulmonaryembolus Sympathomimetic toxicity (i.e., cocaine use,
pheochromocytoma) Hyperviscosity Polycythemia
Leukemia Thrombocytosis Hypergammaglobulinemia
Cardiac
Hypertrophiccardiomyopathy Aorticstenosis Dilatedcardiomyopathy Tachycardia
Ventricular Supraventricular
Aorticstenosis Elevatedleftventricularend-diastolicpressure Hypertrophiccardiomyopathy Microvasculardisease
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ModifiedfromFihnSD,GardinJM,AbramsJ,etal.2012ACCF/AHA/ACP/AATS/PCNA/SCAI/STSGuidelineforthediagnosisand managementofpatientswithstableischemicheartdisease:areportoftheAmericanCollegeofCardiologyFoundation/American HeartAssociationTaskForceonPracticeGuidelines,andtheAmericanCollegeofPhysicians,AmericanAssociationfor ThoracicSurgery,PreventiveCardiovascularNursesAssociation,SocietyforCardiovascularAngiographyandInterventions,and SocietyofThoracicSurgeons.JAmCollCardiol.2012;60(24):e44-e164.Copyright©2012AmericanCollegeofCardiology FoundationandtheAmericanHeartAssociation,Inc.Withpermission.
DiagnosticTesting
Generaldiagnostictesting
A resting ECGcanbe helpful in determining the presence of prior infarcts or conductionsystem
diseaseandmayalertthecliniciantothepossibilityofCADinpatientswithchestpain.
Atransthoracicechocardiogram(TTE)canbeusefulindeterminingpresenceofleftventricular(LV)
dysfunctionorvalvularheartdiseasethatmayaffectthemanagementanddiagnosisofIHD.TTEcan
alsobeusedtoassessforrestingwallmotionabnormalitiesthatmaybetheresultofpriorMI.
Evidenceofvascular diseaseor prior MI onthe diagnostic testingmodalities notedabove should
raisethepretestprobabilityofIHDinpatientspresentingwithchestpain.
Stresstestingoverview
Allstress testingrequires (1)acardiovascularstressand(2) a wayofevaluatingcardiac changes
consistentwithischemia. Thelatteris alwaysdonewith continuousECG;however,itcanbedone
eitherwithorwithoutanimagingmodality.
Many stress testing modalities provide not only detection of ischemia/CAD but also prognostic
informationbasedontheburdenofischemia.
Table 4-5 provides an overview of the sensitivity and specificity for each stress and imaging
modalityalongwithadvantagesanddisadvantagesforthecliniciantoconsider.
TABLE4-5
DIAGNOSTICACCURACYOFCOMMONSTRESSTESTINGMODALITIESINPATIENTS WITHOUTKNOWNISCHEMICHEARTDISEASE
TestType Sensitivity Specificity Advantages Disadvantages
ECG
Exercise 61% 70%–77%
Easytoperform Inexpensive
Less diagnostic accuracy, especially in women
No viability assessment
Pharmacologic — —
Echocardiography
Exercise 70%–85% 77%–89%
Gather other important information on diastolic function, valvular disorders, and pulmonarypressures
Limited by imagequality
Diagnostic accuracy reduced with
Pharmacologic (dobutamine)
85%–90% 79%–90%
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Can assess viability with pharmacologicstress
resting wall motion abnormalities
NuclearPerfusionImaging
Exercise 82%–88% 70%–88%
More sensitive for small areasofischemia/infarct
Very accurate ejection fractionassessment
Easy to compare to priorstudies
Significant radiation
May underestimate severe balanced ischemia
No other valve or other structural information
Viability may require separate testing
Pharmacologic (adenosine, regadenoson,or dobutamine)
82%–91% 75%–90%
CardiacMRI
Exercise — —
Excellent assessment of viability
Anatomic detail of heart and great vessels superb
Expensive Requires
closedMRI Exercise option
not typically available
Pharmacologic
a
91% 81%
Alldiagnosticaccuraciesunadjustedforreferralbias.
1,2
a
Vasodilatorstressonly;dobutaminehassensitivityof83%andspecificityof86%.
Stresstestingindications
SeetheACCF2013MultimodalityAppropriateUseCriteriafortheDetectionandRiskAssessment
ofStableIschemicHeartDisease10foracomprehensivelistoftheindicationsforstresstesting.
Thefollowingaresomeofthemorecommonindications:
PatientswithoutknownCAD:
□ Patientswithanginalsymptomswhoareintermediaterisk □ Asymptomaticintermediate-riskpatientswhoplanonbeginningavigorousexerciseprogramor
workinginahigh-riskoccupation(e.g.,airlinepilot)
□ Atypical symptoms in patients with a high risk of IHD (i.e., diabetes or vascular disease
patients)
PatientswithknownCAD:
□ Post-MIriskstratification(seesectiononST-segmentelevationMI) □ Preoperativeriskassessmentifitwillchangemanagementpriortosurgery □ Recurrentanginalsymptomsdespitemedicaltherapyorrevascularization
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