Chronic Coronary Disease

CCD

• discharged after ACS or coronary revascularization

• LV systolic dysfunction with known/suspected CAD or those with established ischemic cardiomyopathy

• angina symptoms medically managed without positive results of imaging test

• diagnosis based on screening study (stress test) and concluded to have coronary disease

CAD

• coronary artery disease

• build up of plaque coronary arteries that may lead to ischemia

Ischemia

• lack of oxygen and decreased/no blood flow in myocardium

• mismatch between O2 supply/demand

Ischemic heart disease (IHD)

• primarily caused by atherosclerosis → coronary heart disease

• process begins early in life, manifests in middle years

Angina pectoris

chest pain due to decreased oxygen supply to myocardial tissue

Stable CAD

• microvascular angina

• stable angina pectoris

• vasospastic angina

Pathophys of decreased myocardial O2 supply

• coronary flow (perfusion pressure, resistance)

• arterial O2 content

• myocardial O2 content

Pathophys of increased myocardial O2 demand

• heart rate

• contractility

• wall tension

Clinical presentation of CCD

• may be silent

• angina → chronic or variant

• acute coronary syndrome= unstable angina, nstemi, stemi

• other manifestations: HF, arrhythmias, stroke, PAD/PVD

Chest Pain

• one of most common reasons people seek medical care

• 50% have non-cardiac cause

• important to determine if chest pain is related to myocardial ischemia

High probability of ischemic chest pain

• central

• pressure

• squeezing/gripping/heaviness/tightness

• extertional/stress-related

• restrosternal

• left-sided

• dull, aching

Low probability of ischemic chest pain

• sharp

• fleeting, shifting

• pleuritic

• positional

• right-sided

• tearing/ripping

• burning

Acute chest pain

new onset or involves change in pattern, intensity, or duration

Stable chest pain

symptoms are chronic and associated with consistent precipitants

Chest Pain Initial Eval

• PQRST

• Precipitating factors

• Palliative measures (relieved by rest w/wo SL nitro)

• Quality of pain (squeezing, heaviness, tightness)

• region (substernal)

• radiation

• severity

• temporal pattern (pain less than 20 min, usually relived in 5-10)

CCD in Women

• less likely to have timely/appropriate care

• present with different sx: nausea, fatigue, SOB

CCD in geriatrics

• > 75

• can have SOB, syncope, or acute delirium

• possibly unexplained fall

Clinical Chest pain eval

• substernal chest discomfort with characteristic quality/duration

• provoked by exertion or emotional stress

• relieved by rest or nitroglycerin

• cardiac → meets all 3

• possible → meets 2

• noncardiac → meets 1 or less

Cardiac Testing

• ECG (all)

• Stress testing (if symptoms)

• Echo (TTE, TEE)

• Coronary angiography (gold standard)

ECG

• oldest diagnostic tool used

• map of electrical activity across heart

• critical step in eval

• may be normal in CCD

Exercise Stress Testing

• resting ECG may be normal for CCD pts

• physical excertion → increased HR, contractility, and BP →increased myocardial O2 demand → abnormalities on ECG

• treadmill with bruce protocol (continuous ECG, BP every 3 min, assess chest pain sx)

• must achieve 85% of age-predicted max HR to be diagnostic

Pharmacological Stress Testing

• alt for pts unable to exercise or cannot achieve target HR

• 2 methods:

  • agent that increases myocardial O2 deman (dobutamine ± atropine)

  • agent that dilates coronary arteries → regional perfusion abnormalities (adenosine, dipyridamole, regadenoson)

ECHO

• most common modality for cardiac function and presence of CVD

• use of emission of ultrasound waves to construct image

Coronary angiography

• may be preformed with cardiac catherization

• use of contrast and imaging to determine blood flow through coronary arteries

• does not provide info on arterial walls or implication of lesion

Cardiac catherization

• catheter inserted into large blood vessel and advanced to heart

• may be used to perform therapeutic interventions

• may be left or right sided depending on insertion site/info needed

  • left more common

  • right → acute decompensated HF, PAH, surveillance, shock

General management of CCD

• risk factor modification

• angina management

Modifiable risk factors of CCD

• smoking

• HTN

• dyslipidemia

• obesity

• sedentary lifestyle

• psychosocial factors

• certain drugs

General Tx approach

• team-based

• individualized education on sx management, lifestyle, SDOH, med adherence

• routine assessment for SDOH

• diet emphasizes veggies, fruit, legumes, nuts

• exercise 150+ min/week of moderate intensity

Smoking approach CCD

• tobacco use assessed at every health care visit

• advise quitting every visit

• behavioral interventions with pharmacotherapy

• routinely asked and counseled about substance use to reduce ASCVD events

Lipid approach to CCD

• high intensity statin

• goa: 50+% reduction in LDL

• adherence measured by fasting lipids in 4-12 weeks after initiation/adjustment, ever 3-12 mo after

BP management in CCD

• non-pharm first-line in elevated BP

• Target < 130/80

• GDMT ACEi/ARB/BB firstline for compelling indications with additional anti-HTN meds added as needed

SGLT2 inhibitors and GLP-1 agonists

• CCD + T2DM → use with proven CV benefit is recommended to reudduce risk of MACE

• CCD and HFrEF → reduce CV death and HF hospitalization and improve QOL

• SGLT2 inhibtiros don’t appear to primarily reduce atherosclerosis vs HR

• GLP-1 inhibitors appear to primary reduce risk of atheroscleotic (some inconstanstinsy)

CCD with no inidcation for oral anticoag

low dose aspirin 81 mg

CCD treated with PCI

• DAPT with aspirin and clopidogrel → 6 months post

• SAPT initated at 6 months to reduce MACE and bleeding

CCD with no PCI or ACS in 1 year

aspirin indefinitely

Prior ACS with/without PCI

DAPT for 1 year

post PCI with low bleeding risk

• DES DAPT for 6 months

• SAPT after 1 year

past PCI with high bleed risk

• DES DAPT 1-3 mo

• P2Y12 3-12 mo

• SAPT after 1 year

PCI with low bleed risk

• DOAC/clopidogrel/aspirin for 1 month

• DOAC and clopidogrel 6 months

• DOAC alone for around 6 months

OAC use without PCI

doac alone

Beta Blockers

• CCD and LVEF 40% or less → reduce MACE

• < 50% → metoprolol succinate, carvedilol, or bisoprolol with tiration to target doses

Renin-Angiotensin-Aldosterone inhibitors

ARBS/ACEi recommended to reduce CV events in CCD+ HTN or DM

Medical therapy for angina relief

• BB, CCB, or long-acting nitrate

• pts who remain symptomatic after initial can add 2nd antianginal

• ranolazine → for pts who remain symptomatic symptomatic

• SL/spray NTG rec for immediate short term believe

Agents that decrease myocardial O2 deman

• decrease contractility, HR, or both

• beta blockers (1st line, pref for LV dysfunction)

• non-DHPs 

  • can depress LV function, do not use with signifcant LV dysfunction

Agents that increase myocardial O2 supply

• nitrates

• DHP CCBs

Long acting nitrates

• isosornbide mononitrate and isosorbide dinitreate

• for sx uncontrolled with BB or CCD

Short acting nitrate

• SL NTG, NTG spray, buccal tablets

• for anginal attacks or prophylaxis

Nitrate counseling points

• 10-12 hour nitrate free interval to avoid tolerance

• keep in original container

• replace every 3-6 months

• store away from heat, light, moisture

• sit down during use

• do not use with PDE-5 inhibits due to risk of hypotension

• can take 3 doses in 15 min or 5-10 min prior to activites that may provoke angina

Nitroglycerin ointment counseling

• apply ½ inch upon rising and another ½ inch 6 H later

• max freq is 2 doses/day

• include nitrate free interval

Nitroglycerin patch

• 0.2-/0.4 mg/hour; increase as needed

• max 0,8 mg/hour

• patch on for 12-14 H/day, then patch off period

• notify or remove before MRI

Ranolazine

• MOA: reduce Ca overload in ischemic myoctes through selective inhibition of late sodium current

• do not depend on reductions in HR/BP

• indicated in chronic angina for pts who remian symptomatic despite maximally tolerated stnadard antiangial therapy

• risk of QTx prolongation

PCI

• use of balloon angioplasty with stent placement

• catheter guided through femoral or radial access into coronary arteries

• deflated balloon slide along guidewire and infalted at site of plaque

Coronaray Artery Bypass Graft

• CABG

• sternotomy

• vascular conduits harvested

• used to bypass plaque