Coronary Artery Disease

CAD is the leading cause of premature death in the developed world and is estimated to become, by
2020, the major cause of death worldwide. In the UK 1 in 3 men and 1 in 4 women die from CAD.
Disease in the coronary arteries is almost always due to atherosclerosis and its complications,
particularly thrombosis. Atherosclerosis is a progressive inflammatory disorder of the arterial wall,
characterised by focal lipid-rich deposits of atheroma that remain clinically silent until they become
large enough to impair arterial perfusion or until disruption of the lesion results in thrombotic
occlusion or embolization of the affected vessel. The pathogenesis of atherosclerosis is complex but
several risk factors have been identified:

- Age and sex age is the most powerful independent risk factor for atherosclerosis. Pre-
menopausal women have lower rates of disease than men thereafter risk is similar. HRT has
no role in prevention of atherosclerosis.
- Family history a positive family history is present when clinical problems occur in first-
degree relatives aged <50 yrs (male) or <55 yrs (female). Increased risk reflects a
combination of shared genetic and environmental (e.g. smoking, exercise, diet) factors.
- Hypertension the incidence of atherosclerosis increases as BP (systolic and diastolic) rises.
Antihypertensive therapy reduces CV mortality and stroke.
- Hypercholesterolaemia risk rises with plasma cholesterol concentration. Lowering low-
density lipoprotein and total cholesterol reduces the risk of CV events (death, MI, stroke)
- Diabetes mellitus this is a potent risk factor for all forms of atherosclerosis and is often
associated with diffuse disease. Insulin resistance (normal glucose homeostasis with high
levels of insulin) is also a risk factor of CAD
- Lifestyle factors there is a strong, dose linked relationship between cigarette smoking and
CAD. Alcohol is associated with reduced rates of coronary disease, but alcohol excess is
associated with hypertension and cerebrovascular disease. Physical inactivity and obesity
are independent risk factors for atherosclerosis; regular exercise appears to have a
protective effect. Diets deficient in fresh fruit, vegetables and polyunsaturated fatty acids
are associated with an increased risk of vascular disease.

Stable Angina

Angina pectoris is the symptom complex occurring when an imbalance between myocardial
oxygen supply and demand causes transient MI. coronary atheroma is by far the most common
cause of angina; however, the symptom may also be a manifestation of other forms of heart
disease, such as aortic valve disease, hypertrophic cardiomyopathy, or coronary vasospasm
(Prinzmetals angina). Occasionally, the coronary arteries are involved in other disorders, such as
polyarthritis and other connective tissue disease.

Clinical Features

History is by far the most important factor in making the diagnosis of stable angina. Stable
angina is characterised by central chest pain, discomfort or breathlessness that is precipitated by
exertion or other forms of stress, and is promptly relieved by rest. Physical examination is
frequently negative but may reveal evidence of:

- Aortic stenosis
- CAD risk factors (e.g. hypertension, diabetes, examine for retinopathy)
- LV dysfunction (e.g. cardiomegaly)
- Other arterial disease (e.g. carotid bruits, peripheral vascular disease)
 - Conditions that exacerbate angina (e.g. anaemia, thyrotoxicosis)

Investigations

- Resting ECG may show evidence of previous MI but is often normal even in patients with
severe CAD. The most convincing ECG evidence of MI is obtained by demonstrating
reversible ST segement depression or elevation, with or without T-wave inversion, during
symptoms.
- Exercise ECG patients ECG and BP are monitored during exercise using a standard treadmill
or bicycle ergometer protocol. Planar or down sloping ST segment depression of > 1mm is
indicative of ischaemia; up sloping ST depression is less specific. Exercise testing is also a
useful means of assessing the severity of coronary disease and identifying high risk
individuals. However, false negatives and positives do occur and the predictive accuracy if
exercise testing is lower in women than men.
- Myocardial perfusion scanning this is particularly helpful in patients who are unable to
exercise or who have an equivocal or uninterpretable exercise test. Scintiscans of the
myocardium are obtained at rest and during stress (exercise or pharmacological, e.g.
dobutamine) after IV administration of a radioactive isotope that is taken up by variable
perfused myocardium. A perfusion defect present during stress but not a rest indicates
reversible MI; a persistent defect suggests previous MI.
- Stress echocardiography this alternative to myocardial perfusion scanning has similar
predictive accuracy (superior to exercise ECG). Ischaemic segments of myocardium exhibit
reversible defects in contractility (on echocardiography) during exercise or pharmacological
stress; areas of infarction do not contract at rest or during stress. The technique is
particularly useful for identifying areas of viable hibernating myocardium in patients with
heart failure and CAD being considered for revascularisation
- Coronary arteriography provides detailed anatomical information about the extent and
nature of CAD. It may be indicated when non-invasive test have failed to elucidate the cause
of atypical chest pain but is usually performed with a view to revascularisation.