Chronic coronary artery disease: diagnosis and management

Abstract

Coronary artery disease (CAD) is the single most common cause of death in the developed world, responsible for about 1 in every 5 deaths. The morbidity, mortality, and socioeconomic importance of this disease make timely accurate diagnosis and cost-effective management of CAD of the utmost importance. This comprehensive review of the literature highlights key elements in the diagnosis, risk stratification, and management strategies of patients with chronic CAD. Relevant articles were identified by searching the PubMed database for the following terms: chronic coronary artery disease or stable angina. Novel imaging modalities, pharmacological treatment, and invasive (percutaneous and surgical) interventions have revolutionized the current treatment of patients with chronic CAD. Medical treatment remains the cornerstone of management, but revascularization continues to play an important role. In the current economic climate and with health care reform very much on the horizon, the issue of appropriate use of revascularization is important, and the indications for revascularization, in addition to the relative benefits and risks of a percutaneous vs a surgical approach, are discussed.

FIGURE 1.

Composite graph estimating the probability of severe coronary artery disease on the basis of a 5-point risk score that awards 1 point for each of the following variables: male sex, typical angina, history or electrocardiographic evidence of myocardial infarction, diabetes, and use of insulin. Each curve shows the probability of severe disease as a function of age for a given risk score. From Arch Intern Med, with permission. Copyright ©1992 American Medical Association. All rights reserved.

FIGURE 2.

Survival of medically treated patients with coronary artery disease according to ejection fraction (EF) and number of diseased vessels. A, Patients with 1-, 2-, or 3-vessel disease by EF; B, patients with 1-vessel disease by EF; C, patients with 2-vessel disease by EF; and D, patients with 3-vessel disease by EF. From Circulation, with permission from Wolters Kluwer Health.

FIGURE 3.

Five-year survival rate in patients according to severity and proximity of coronary artery lesions and adjusted hazard ratios for coronary artery bypass grafting (CABG) vs medical treatment. 95% = 95% coronary artery stenosis; LAD = left anterior descending artery; VD = number of diseased vessels. From J Thorac Cardiovasc Surg, with permission from Elsevier.

FIGURE 4.

Revascularization vs medical therapy as a function of percentage of ischemic myocardium. From Circulation, with permission from Wolters Kluwer Health.

FIGURE 5.

Patient outcomes in the SYNTAX (Synergy Between PCI With TAXUS and Cardiac Surgery) trial according to treatment group and SYNTAX score. A, Death from any cause, stroke, or myocardial infarction; B, follow-up revascularization; C, major adverse cardiac or cerebrovascular event (MACCE); D, low SYNTAX score; E, intermediate SYNTAX score; and F, high SYNTAX score. CABG = coronary artery bypass grafting; PCI = percutaneous coronary intervention. From N Engl J Med, with permission. Copyright ©2009 Massachusetts Medical Society. All rights reserved.

FIGURE 6.

Revascularization of future culprit lesions with coronary artery bypass grafting (CABG). PCI = percutaneous coronary intervention. From Lancet, with permission from Elsevier. Copyright ©2006.