Elsevier

Mayo Clinic Proceedings

Volume 84, Issue 12, December 2009, Pages 1130-1146
Mayo Clinic Proceedings

SYMPOSIUM ON CARDIOVASCULAR DISEASES
Chronic Coronary Artery Disease: Diagnosis and Management

https://doi.org/10.4065/mcp.2009.0391Get rights and content

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.

Section snippets

DIAGNOSIS OF CHRONIC CAD

Chronic stable angina, the initial manifestation of CAD in approximately 50% of all patients,6 is usually caused by the obstruction of at least 1 large epicardial coronary artery by atheromatous plaque. Angina is due to the mismatch between myocardial oxygen demand and supply, resulting in myocardial ischemia. Angina pectoris is characterized by substernal discomfort, heaviness, or a pressure-like feeling, which may radiate to the jaw, shoulder, back, or arm and which typically lasts several

MANAGEMENT OF CHRONIC CAD

Management of CAD has 2 main goals: to reduce symptoms and ischemia and to prevent MI and death. These are modulated by different mechanisms: symptoms and ischemia, by the insufficient oxygen supply/demand ratio(usually due to coronary atherosclerosis); and MI and death, usually by unstable coronary artery plaque rupture. Medical management is pivotal in all patients with CAD. The first step is to identify and treat any associated diseases that can precipitate angina by increasing myocardial

CONCLUSION

All patients with stable CAD require comprehensive and aggressive control of risk factors. An initial trial of medical therapy alone is appropriate in most patients with chronic stable angina and is the cornerstone of treatment for chronic CAD. Persistent symptoms, the magnitude of the ischemic burden, or drug intolerance should drive decision making regarding subsequent revascularization. Ischemia should be established with a noninvasive stress test before angiography. In patients undergoing

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    Dr Gersh is an advisory board member with Boston Scientific and a stock shareholder for CV Therapeutics.

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