Coronary heart disease: Difference between revisions

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'''Coronary heart disease''' (CHD), also called '''coronary artery disease''' (CAD), is a [[vascular disease]] caused by abnormalities the arteries that supply the heart with blood (called the [[coronary artery|coronary arteries]]). The usual cause of coronary heart disease is [[atherosclerosis]].
==Etiology/cause==
The cause and manifestation of coronary heart disease is multifactorial. About 3/4 of the risk of coronary heart disease is due to three risk factors: [[hypercholesterolemia]] (total cholesterol > 182 mg/dL [4.71 mmol/L]), [[hypertension]] (diastolic blood pressure > 90 mm Hg), and cigarette smoking.<ref name="pmid11732929">{{cite journal |author=Magnus P, Beaglehole R |title=The real contribution of the major risk factors to the coronary epidemics: time to end the "only-50%" myth |journal=Arch. Intern. Med. |volume=161 |issue=22 |pages=2657–60 |year=2001 |pmid=11732929 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=11732929 |issn=}}</ref>
===Atherosclerosis===
{{main|Atherosclerosis}}
Atherosclerosis is a degenerative disease of the arterial walls, in which the normal elastic walls of the arteries become thickened and replaced with deposits of fatty material, including [[cholesterol]]. As the walls of the affected arteries thicken, the hollow lumen at the center of each, that conduit through which oxygen enriched blood normally pulses, becomes narrower and, eventually, the flow of blood within it is decreased. With narrowing of the artery's lumen and reduced flow comes the risk of sudden occlusion of the artery, especially if the lining is abnormally roughened by deposits of irregular plaques of minerals and fats.
About 10% of patients with chronic [[angina]] have atherosclerosis of the left main [[coronary artery]].<ref name="pmid3141736">{{cite journal |author=Lee TH, Fukui T, Weinstein MC, Tosteson AN, Goldman L |title=Cost-effectiveness of screening strategies for left main coronary artery disease in patients with stable angina |journal=Med Decis Making |volume=8 |issue=4 |pages=268–78 |year=1988 |pmid=3141736 |doi= |url=http://mdm.sagepub.com/cgi/reprint/8/4/268 |issn=}}</ref><ref name="pmid7249303">{{cite journal |author=Chaitman BR, Bourassa MG, Davis K, ''et al'' |title=Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS) |journal=Circulation |volume=64 |issue=2 |pages=360–7 |year=1981 |month=August |pmid=7249303 |doi= |url=http://circ.ahajournals.org/cgi/reprint/64/2/360 |issn=}}</ref> In males over age 70 with definite angina, almost 50% have obstruction of the left main [[coronary artery]].<ref name="pmid7249303"/>
The extent of coronary obstructions can be quantified with the Duke Coronary Artery Disease Index.<ref name="pmid8181125">{{cite journal |author=Mark DB, Nelson CL, Califf RM, ''et al'' |title=Continuing evolution of therapy for coronary artery disease. Initial results from the era of coronary angioplasty |journal=Circulation |volume=89 |issue=5 |pages=2015–25 |year=1994 |month=May |pmid=8181125 |doi= |url= |issn=}}</ref>
====Plaque rupture and inflammation====
Rupture of [[atherosclerosis|atherosclerotic]] plaques may cause [[acute coronary syndrome]]. Inflammation may underlay the association between elevated [[C-reactive protein]] levels and coronary heart disease. [[Periodontal disease]] may contribute to this inflammation.<ref name="pmid18807098">{{cite journal |author=Humphrey LL, Fu R, Buckley DI, Freeman M, Helfand M |title=Periodontal disease and coronary heart disease incidence: a systematic review and meta-analysis |journal=J Gen Intern Med |volume=23 |issue=12 |pages=2079–86 |year=2008 |month=December |pmid=18807098 |doi=10.1007/s11606-008-0787-6 |url=http://dx.doi.org/10.1007/s11606-008-0787-6 |issn=}}</ref>
===Emotional stress===
The role of emotional stress was supported in a study of the incidence of coronary events in the [[Munich]] area during the 2006 World Cup Football ([[soccer]]) championship.<ref name="pmid18234752">{{cite journal |author=Wilbert-Lampen U, Leistner D, Greven S, ''et al'' |title=Cardiovascular events during World Cup soccer |journal=N. Engl. J. Med. |volume=358 |issue=5 |pages=475–83 |year=2008 |pmid=18234752 |doi=10.1056/NEJMoa0707427 |issn=}}</ref> The incidence of coronary events was higher during the match, especially for people who had pre-existing coronary disease. Stress, via increases in unhealthy behaviors, was also identified as more important than hypertension or [[C-reactive protein]] level in predicting coronary events.<ref name="pmid19095133">{{cite journal |author=Hamer M, Molloy GJ, Stamatakis E |title=Psychological distress as a risk factor for cardiovascular events pathophysiological and behavioral mechanisms |journal=J. Am. Coll. Cardiol. |volume=52 |issue=25 |pages=2156–62 |year=2008 |month=December |pmid=19095133 |doi=10.1016/j.jacc.2008.08.057 |url=http://content.onlinejacc.org/cgi/content/full/52/25/2156 |issn=}}</ref>
===Coronary vasospasm===
Approximately 15% of [[myocardial infarction|NSTEMI]] and 2% of [[myocardial infarction|STEMI]] patients have no obstruction of [[coronary artery|coronary arteries]] and in about half of these patients, spasm of a coronary artery can be induced.<ref name="pmid18687244">{{cite journal |author=Ong P, Athanasiadis A, Hill S, Vogelsberg H, Voehringer M, Sechtem U |title=Coronary artery spasm as a frequent cause of acute coronary syndrome: The CASPAR (Coronary Artery Spasm in Patients With Acute Coronary Syndrome) Study |journal=J. Am. Coll. Cardiol. |volume=52 |issue=7 |pages=523–7 |year=2008 |month=August |pmid=18687244 |doi=10.1016/j.jacc.2008.04.050 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(08)01872-X |issn=}}</ref>
===Syndrome X===
Cardiac syndrome X is the presence of typical [[angina]], abnormal exercise-test results, and normal coronary arteries (including no vasospasm).<ref name="pmid12075055">{{cite journal |author=Panting JR, Gatehouse PD, Yang GZ, ''et al'' |title=Abnormal subendocardial perfusion in cardiac syndrome X detected by cardiovascular magnetic resonance imaging |journal=N. Engl. J. Med. |volume=346 |issue=25 |pages=1948–53 |year=2002 |month=June |pmid=12075055 |doi=10.1056/NEJMoa012369 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=12075055&promo=ONFLNS19 |issn=}}</ref> Syndrome X may be caused by subendocardial hypoperfusion that can be demonstrated by cardiovascular [[magnetic resonance imaging]] during the administration of [[adenosine]].<ref name="pmid12075055"/>
===Hyperuricemia===
{{main|Hyperuricemia}}
[[Hyperuricemia]] has been proposed as contributing to coronary heart disease.
==Diagnosis==
===History, physical examination, and risk factors===
Angina pectoris, or simply angina, is the chest pain due to coronary heart disease; however, most patients do not report angina.<ref name="pmid18625923">{{cite journal |author=Gehi AK, Ali S, Na B, Schiller NB, Whooley MA |title=Inducible ischemia and the risk of recurrent cardiovascular events in outpatients with stable coronary heart disease: the heart and soul study |journal=Arch. Intern. Med. |volume=168 |issue=13 |pages=1423–8 |year=2008 |month=July |pmid=18625923 |doi=10.1001/archinte.168.13.1423 |url= |issn=}}</ref> The nature of the chest pain affects the probability of underlying coronary disease.<ref name="pmid16304077">{{cite journal |author=Swap CJ, Nagurney JT |title=Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes |journal=JAMA |volume=294 |issue=20 |pages=2623–9 |year=2005 |pmid=16304077 |doi=10.1001/jama.294.20.2623 |issn=}}</ref>
The [http://www.mssm.edu/medicine/general-medicine/ebm/CPR/CAD.html Pryor nomogram], a [[clinical prediction rule]], can help diagnose patients with suspected chest pain in a non emergent setting.<ref name="pmid8416322">{{cite journal |author=Pryor DB, Shaw L, McCants CB, ''et al'' |title=Value of the history and physical in identifying patients at increased risk for coronary artery disease |journal=Ann. Intern. Med. |volume=118 |issue=2 |pages=81–90 |year=1993 |pmid=8416322 |doi=|url=http://www.annals.org/cgi/content/full/118/2/81}} [http://www.mssm.edu/medicine/general-medicine/ebm/CPR/CAD.html Online calculator]</ref><ref name="pmid6638047">{{cite journal |author=Pryor DB, Harrell FE, Lee KL, Califf RM, Rosati RA |title=Estimating the likelihood of significant coronary artery disease |journal=Am. J. Med. |volume=75 |issue=5 |pages=771–80 |year=1983 |pmid=6638047 |doi= |url= |issn=}}</ref>
===Cardiac stress test===
{{main|Stress test}}
{| class="wikitable" align="right"
|+Sensitivity and specificity of cardiac stress tests<ref name="pmid10357690">{{cite journal |author=Garber AM, Solomon NA |title=Cost-effectiveness of alternative test strategies for the diagnosis of coronary artery disease |journal=Ann. Intern. Med. |volume=130 |issue=9 |pages=719–28 |year=1999 |month=May |pmid=10357690 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=10357690 |issn=}}</ref>
|-
! &nbsp;
! [[Sensitivity and specificity|Sensitivity]]
! [[Sensitivity and specificity|Specificity]]
|-
| Exercise electrocardiography
| 68%
| 77%
|-
| Stress echocardiography
| 76%
| 88%
|-
| Myocardial perfusion imaging<br/>thallium planar
| 79%
| 73%
|-
| Myocardial perfusion imaging<br/>single-photon emission computed tomography (SPECT)
| 88%
| 77%
|-
| [[Positron emission tomography]] (PET),
| 68%
| 77%
|}
The [[sensitivity and specificity]] of the various cardiac stress tests have been summarized.<ref name="pmid10357690">{{cite journal |author=Garber AM, Solomon NA |title=Cost-effectiveness of alternative test strategies for the diagnosis of coronary artery disease |journal=Ann. Intern. Med. |volume=130 |issue=9 |pages=719–28 |year=1999 |month=May |pmid=10357690 |doi= |url=http://www.annals.org/cgi/pmidlookup?view=long&pmid=10357690 |issn=}}</ref>
====Exercise treadmill test====
The [[exercise test|exercise treadmill test]] (ETT) can help diagnose and prognose patients with suspected CHD. The likelihood of a positive treadmill test depends on the severity of the underlying coronary disease.<ref name="pmid3141736">{{cite journal |author=Lee TH, Fukui T, Weinstein MC, Tosteson AN, Goldman L |title=Cost-effectiveness of screening strategies for left main coronary artery disease in patients with stable angina |journal=Med Decis Making |volume=8 |issue=4 |pages=268–78 |year=1988 |pmid=3141736 |doi= |url=http://mdm.sagepub.com/cgi/reprint/8/4/268 |issn=}}</ref> For example, 87% of patients with obstruction of the left main coronary artery will have a positive treatmill test, whereas only 57% of patients with  obstructions of one or two of the other coronaries will have a positive treadmill test. The treadmill can help predict the location of coronary stenoses.<ref name="pmid3789578">{{cite journal |author=Mark DB, Hlatky MA, Lee KL, Harrell FE, Califf RM, Pryor DB |title=Localizing coronary artery obstructions with the exercise treadmill test |journal=Ann. Intern. Med. |volume=106 |issue=1 |pages=53–5 |year=1987 |month=January |pmid=3789578 |doi= |url= |issn=}}</ref>
====Stress myocardial perfusion imaging====
====Stress echocardiography====
====Stress ventriculography====
===X-ray computed tomography===
There are two types of [[computed tomography]] used for noninvasive coronary arteriography.
====Electron beam computed tomography====
Electron beam computed tomography (EBCT) is also called ultrafast CT.
====Cardiac computed tomographic angiography====
====Cardiac computed tomographic angiography====
{{main|Computed tomographic cardiac angiography}}
{{main|Computed tomographic cardiac angiography}}
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* [[sensitivity (tests)|sensitivity]] = 85%
* [[sensitivity (tests)|sensitivity]] = 85%
* [[specificity (tests)|specificity]] = 90%
* [[specificity (tests)|specificity]] = 90%
====Coronary calcium score====
Both types of [[computed tomography]], electron beam computed tomography (EBCT) and multidetector [[spiral computed tomography]], can measure the amount of [[calcium]] in the walls of the [[coronary artery|coronary arteries]] in order to diagnose coronary heart diease.
==Treatment==
===Medications===
[[Ranolazine]] may increased exercise capacity and reduce symptoms<ref>Chaitman BR et al. Effects of ranolazine with atenolol, amlodipine, or diltiazem on exercise tolerance and angina frequency in patients with severe chronic angina: a randomized controlled trial. Combination Assessment of Ranolazine In Stable Angina (CARISA) Investigators. JAMA. 2004 Jan 21;291(3):309-16. PMID: 14734593</ref> but not reduce cardiac events.<ref>Morrow et al; MERLIN-TIMI 36 Trial Investigators. Effects of ranolazine on recurrent cardiovascular events in patients with non-ST-elevation acute coronary syndromes: the MERLIN-TIMI 36 randomized trial. JAMA. 2007 Apr 25;297(16):1775-83. PMID: 17456819</ref>
===Invasive treatments===
{{main|myocardial revascularization}}
Patient who have a [[left ventricular ejection fraction]] above 50%, no angina or their angina is controlled with medicines, do not benefit from either [[percutaneous transluminal coronary angioplasty]] (PCI)<ref name="pmid17387127">{{cite journal |author=Boden WE, O'Rourke RA, Teo KK, ''et al'' |title=Optimal medical therapy with or without PCI for stable coronary disease |journal=N. Engl. J. Med. |volume=356 |issue=15 |pages=1503–16 |year=2007 |month=April |pmid=17387127 |doi=10.1056/NEJMoa070829 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=17387127&promo=ONFLNS19 |issn=|quote=This is the COURAGE [[randomized controlled trial]].}}</ref> or from [[coronary artery bypass]] surgery<ref name="pmid6608052">{{cite journal |author= |title=Myocardial infarction and mortality in the coronary artery surgery study (CASS) randomized trial |journal=N. Engl. J. Med. |volume=310 |issue=12 |pages=750–8 |year=1984 |month=March |pmid=6608052 |doi= |url= |issn=|quote=This is the CASS [[randomized controlled trial]].}}</ref>.
{| class="wikitable" align="right"
|+ Coronary artery bypass versus percutaneous transluminal coronary angioplasty
! rowspan="2"|&nbsp;!! colspan="2"|Outcomes at 5 years||rowspan="2"| Procedural related [[stroke]]
|-
! Relief of angina!!Repeat revascularization
|-
| CABG||align="center"| 84%||align="center"|10%||align="center"|1.2%
|-
| PTCA||align="center"|79%||align="center"|With stents 40% <br/>Without stents 46%||align="center"|0.6%
|-
| colspan="4"|Abbreviations:<br/>CABG. [[Coronary artery bypass]] grafting<br/>PTCA. [[Percutaneous transluminal coronary angioplasty]]
|}
Regarding patients who must undergo invasive treatment, a [[systematic review]] comparing [[percutaneous transluminal coronary angioplasty]] and [[coronary artery bypass]] grafting (CABG) surgery found that CABG was more effective but was more likely to be complicated by [[stroke]].<ref name="pmid-17938385">{{cite journal |author=Bravata DM, Gienger AL, McDonald KM, ''et al'' |title=Systematic Review: The Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Surgery |journal=Ann Intern Med |volume= |issue= |pages= |year=2007 |pmid=17938385 |doi=|url=http://www.annals.org/cgi/content/full/147/10/703}}</ref>
====Percutaneous cardiac intervention====
{{main|Percutaneous transluminal coronary angioplasty}}
Patient who have a stable angina and [[left ventricular ejection fraction]] above 35% do not reduce mortality from [[percutaneous transluminal coronary angioplasty]] (PCI)<ref name="pmid17387127">{{cite journal |author=Boden WE, O'Rourke RA, Teo KK, ''et al'' |title=Optimal medical therapy with or without PCI for stable coronary disease |journal=N. Engl. J. Med. |volume=356 |issue=15 |pages=1503–16 |year=2007 |month=April |pmid=17387127 |doi=10.1056/NEJMoa070829 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=17387127&promo=ONFLNS19 |issn=|quote=This is the COURAGE [[randomized controlled trial]].}}</ref> although there is some reduction in angina for the first three years after procedure<ref name="pmid18703470">{{cite journal |author=Weintraub WS, Spertus JA, Kolm P, ''et al'' |title=Effect of PCI on quality of life in patients with stable coronary disease |journal=N. Engl. J. Med. |volume=359 |issue=7 |pages=677–87 |year=2008 |month=August |pmid=18703470 |doi=10.1056/NEJMoa072771 |url=http://content.nejm.org/cgi/content/full/359/7/677 |issn=}} (see [http://content.nejm.org/cgi/content/full/359/7/677/T3 Table 3] in the article)</ref>.
Patients are more likely to benefit from PCI when [[clinical practice guideline]]s are followed.<ref name="pmid16267252">{{cite journal |author=Anderson HV, Shaw RE, Brindis RG, ''et al'' |title=Relationship between procedure indications and outcomes of percutaneous coronary interventions by American College of Cardiology/American Heart Association Task Force Guidelines |journal=Circulation |volume=112 |issue=18 |pages=2786–91 |year=2005 |month=November |pmid=16267252 |doi=10.1161/CIRCULATIONAHA.105.553727 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16267252 |issn=}}</ref>
:Stents
[[Meta-analysis|Meta-anlayses]] have found that the rate of late thrombosis was <2% between years 1 and 4.<ref name="pmid17296821">{{cite journal |author=Mauri L, Hsieh WH, Massaro JM, Ho KK, D'Agostino R, Cutlip DE |title=Stent thrombosis in randomized clinical trials of drug-eluting stents |journal=N. Engl. J. Med. |volume=356 |issue=10 |pages=1020–9 |year=2007 |month=March |pmid=17296821 |doi=10.1056/NEJMoa067731 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=17296821&promo=ONFLNS19 |issn=}}</ref><ref name="pmid17296824">{{cite journal |author=Stone GW, Moses JW, Ellis SG, ''et al'' |title=Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents |journal=N. Engl. J. Med. |volume=356 |issue=10 |pages=998–1008 |year=2007 |month=March |pmid=17296824 |doi=10.1056/NEJMoa067193 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=17296824&promo=ONFLNS19 |issn=}}</ref><ref name="pmid17296823">{{cite journal |author=Kastrati A, Mehilli J, Pache J, ''et al'' |title=Analysis of 14 trials comparing sirolimus-eluting stents with bare-metal stents |journal=N. Engl. J. Med. |volume=356 |issue=10 |pages=1030–9 |year=2007 |month=March |pmid=17296823 |doi=10.1056/NEJMoa067484 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=17296823&promo=ONFLNS19 |issn=}}</ref>
====Coronary artery bypass====
{{main|Coronary artery bypass}}
Patient who have a [[left ventricular ejection fraction]] between 35 and 49 percent benefit from [[coronary artery bypass]] if they have disease of three [[coronary artery|coronary arteries]].<ref name="pmid6608052">{{cite journal |author= |title=Myocardial infarction and mortality in the coronary artery surgery study (CASS) randomized trial |journal=N. Engl. J. Med. |volume=310 |issue=12 |pages=750–8 |year=1984 |month=March |pmid=6608052 |doi= |url= |issn=|quote=This is the CASS [[randomized controlled trial]].}}</ref>.
==Complications==
* [[Sudden cardiac death]]
===Acute coronary syndrome===
{{main|Acute coronary syndrome}}
* [[Unstable angina]]
* [[Myocardial infarction]]
==Prognosis==
: See also: [[Vascular disease#Prognosis]]
===Coronary calcium score===
{| class="wikitable" align="right"
|+Coronary calcium score for predicting [[myocardial infarction]] or death from coronary heart disease amond 6814 persons without known cardiovascular disease<ref name="pmid18367736">{{cite journal |author=Detrano R, Guerci AD, Carr JJ, ''et al'' |title=Coronary calcium as a predictor of coronary events in four racial or ethnic groups |journal=N. Engl. J. Med. |volume=358 |issue=13 |pages=1336–45 |year=2008 |month=March |pmid=18367736 |doi=10.1056/NEJMoa072100 |url=http://content.nejm.org/cgi/content/full/358/13/1336 |issn=}}</ref>
|-
! Score
! Number of patients
! Hazard ratio
|-
| 0
| 8/3409
| 1.0
|-
| 1-100
| 25/1728
| 3.9
|-
| 101-300
| 24/752
| 7.1
|-
| > 300
| 32/833
| 6.8
|}
Both types of [[computed tomography]], electron beam computed tomography (EBCT) and multidetector [[spiral computed tomography]], can measure the amount of [[calcium]] in the walls of the [[coronary artery|coronary arteries]] in order to estimate prognosis. The calcium score improves upon using clinical risk factors for prognosticating. <ref name="pmid18367736">{{cite journal |author=Detrano R, Guerci AD, Carr JJ, ''et al'' |title=Coronary calcium as a predictor of coronary events in four racial or ethnic groups |journal=N. Engl. J. Med. |volume=358 |issue=13 |pages=1336–45 |year=2008 |month=March |pmid=18367736 |doi=10.1056/NEJMoa072100 |url=http://content.nejm.org/cgi/content/full/358/13/1336 |issn=}}</ref> Using clinical risk factors alone, the area under the [[receiver operating-characteristic curve]] (AUC) was 0.79 while the AUC rose to 0.83 when the calcium score was added. The clinical importance of this rise is not clear.<ref name="pmid18367744">{{cite journal |author=Weintraub WS, Diamond GA |title=Predicting cardiovascular events with coronary calcium scoring |journal=N. Engl. J. Med. |volume=358 |issue=13 |pages=1394–6 |year=2008 |month=March |pmid=18367744 |doi=10.1056/NEJMe0800676 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=18367744&promo=ONFLNS19 |issn=}}</ref>
===Cardiac stress test===
Various cardiac [[stress test]]s are available.
====Exercise treadmill test====
The [[exercise test|exercise treadmill test]] (ETT) can help diagnose and prognose patients with suspected CHD. [[Clinical prediction rule]]s are available to help interpret the results of the ETT. These rules are the [http://www.cardiology.org/tools/medcalc/duke/ Duke Treadmill score]<ref name="pmid1875969">{{cite journal |author=Mark DB, Shaw L, Harrell FE, ''et al'' |title=Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease |journal=N. Engl. J. Med. |volume=325 |issue=12 |pages=849–53 |year=1991 |pmid=1875969 |doi=}}</ref> and the newer [http://www.bio.ri.ccf.org/html/riskcal.html Cleveland Clinic model]<ref name="pmid18087052">{{cite journal |author=Lauer MS, Pothier CE, Magid DJ, Smith SS, Kattan MW |title=An externally validated model for predicting long-term survival after exercise treadmill testing in patients with suspected coronary artery disease and a normal electrocardiogram |journal=Ann. Intern. Med. |volume=147 |issue=12 |pages=821–8 |year=2007 |pmid=18087052 |doi=}}</ref>. The Duke score has been more extensively studied; however, in a direct comparison by the authors of the Cleveland Clinic model, the latter performed better.<ref name="pmid18087052"/>
The ETT adds to clinical risk factors in prediction complications. The area under the receiver-operator-characteristics-curve (AUC) for clinical data alone is 0.798 and rises to 0.857 when the ETT is added.<ref name="pmid1875969">{{cite journal |author=Mark DB, Shaw L, Harrell FE, ''et al'' |title=Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease |journal=N. Engl. J. Med. |volume=325 |issue=12 |pages=849–53 |year=1991 |month=September |pmid=1875969 |doi= |url= |issn=}}</ref>
The ETT also adds to the cardiac catheterization in prognosticating<ref name="pmid6229569">{{cite journal |author=Weiner DA, Ryan TJ, McCabe CH, ''et al'' |title=Prognostic importance of a clinical profile and exercise test in medically treated patients with coronary artery disease |journal=J. Am. Coll. Cardiol. |volume=3 |issue=3 |pages=772–9 |year=1984 |month=March |pmid=6229569 |doi= |url= |issn=}}</ref><ref name="pmid3579066">{{cite journal |author=Mark DB, Hlatky MA, Harrell FE, Lee KL, Califf RM, Pryor DB |title=Exercise treadmill score for predicting prognosis in coronary artery disease |journal=Ann. Intern. Med. |volume=106 |issue=6 |pages=793–800 |year=1987 |month=June |pmid=3579066 |doi= |url= |issn=}}</ref><ref name="pmid8498316">{{cite journal |author=Morris CK, Morrow K, Froelicher VF, ''et al'' |title=Prediction of cardiovascular death by means of clinical and exercise test variables in patients selected for cardiac catheterization |journal=Am. Heart J. |volume=125 |issue=6 |pages=1717–26 |year=1993 |month=June |pmid=8498316 |doi= |url= |issn=}}</ref> although some researchers have questioned the extent of information provided by the treadmill test<ref name="pmid449990">{{cite journal |author=Weiner DA, Ryan TJ, McCabe CH, ''et al'' |title=Exercise stress testing. Correlations among history of angina, ST-segment response and prevalence of coronary-artery disease in the Coronary Artery Surgery Study (CASS) |journal=N. Engl. J. Med. |volume=301 |issue=5 |pages=230–5 |year=1979 |month=August |pmid=449990 |doi= |url= |issn=}}</ref>. However, in one study among information available from cardiac catheterization, only the left ventricular ejection fraction contributed to the ETT in predicting complications<ref name="pmid8498316">{{cite journal |author=Morris CK, Morrow K, Froelicher VF, ''et al'' |title=Prediction of cardiovascular death by means of clinical and exercise test variables in patients selected for cardiac catheterization |journal=Am. Heart J. |volume=125 |issue=6 |pages=1717–26 |year=1993 |month=June |pmid=8498316 |doi= |url= |issn=}}</ref> whereas in another study, both the left ventricular ejection fraction and the number of stenoses aided prediction<ref name="pmid6229569">{{cite journal |author=Weiner DA, Ryan TJ, McCabe CH, ''et al'' |title=Prognostic importance of a clinical profile and exercise test in medically treated patients with coronary artery disease |journal=J. Am. Coll. Cardiol. |volume=3 |issue=3 |pages=772–9 |year=1984 |month=March |pmid=6229569 |doi= |url= |issn=}}</ref>.
===Cardiac catheterization===
{| class="wikitable" align="right"
|+Rates of occlusion after 4-5 years<ref name="pmid8409054">{{cite journal |author=Alderman EL, Corley SD, Fisher LD, ''et al'' |title=Five-year angiographic follow-up of factors associated with progression of coronary artery disease in the Coronary Artery Surgery Study (CASS). CASS Participating Investigators and Staff |journal=J. Am. Coll. Cardiol. |volume=22 |issue=4 |pages=1141–54 |year=1993 |month=October |pmid=8409054 |doi= |url= |issn=}}</ref>
|-
! Severity of original stenosis
! Rate of subsequent occlusion
|-
| No stenosis
| 0.7%
|-
| 5% to 49%
| 2.3%
|-
| 50% to 80%
| 10.1%
|-
| 81% to 95%
| 23.6%
|}
Much research has addressed the association between severity of coronary obstructions and subsequent complications such as [[myocardial infarction]]s. Coronary obstructions are more likely to progress or occlude within 4-5 years if the obstructions are severe according to the CASS investigation.<ref name="pmid8409054">{{cite journal |author=Alderman EL, Corley SD, Fisher LD, ''et al'' |title=Five-year angiographic follow-up of factors associated with progression of coronary artery disease in the Coronary Artery Surgery Study (CASS). CASS Participating Investigators and Staff |journal=J. Am. Coll. Cardiol. |volume=22 |issue=4 |pages=1141–54 |year=1993 |month=October |pmid=8409054 |doi= |url= |issn=}}</ref> 23% of subsequent occlusions were associated with a [[myocardial infarction]]. The [[cholesterol]] level or the [[exercise test]] did not improve the ability to prediction occlusion in the CASS investigation.
Surprisingly, while patients with more severe stenoses are more likely to develop occlusions predicting the exact site of furture occlusions is very difficult. Most subsequent occlusions occur in arteries that originally did not have severe stenoses and were originally not the most severely stenotic arteries in a patient.<ref name="pmid3180375">{{cite journal |author=Little WC, Constantinescu M, Applegate RJ, ''et al'' |title=Can coronary angiography predict the site of a subsequent myocardial infarction in patients with mild-to-moderate coronary artery disease? |journal=Circulation |volume=78 |issue=5 Pt 1 |pages=1157–66 |year=1988 |month=November |pmid=3180375 |doi= |url= |issn=}}</ref><ref name="pmid1546645">{{cite journal |author=Giroud D, Li JM, Urban P, Meier B, Rutishauer W |title=Relation of the site of acute myocardial infarction to the most severe coronary arterial stenosis at prior angiography |journal=Am. J. Cardiol. |volume=69 |issue=8 |pages=729–32 |year=1992 |month=March |pmid=1546645 |doi= |url= |issn=}}</ref><ref name="pmid15623544">{{cite journal |author=Glaser R, Selzer F, Faxon DP, ''et al'' |title=Clinical progression of incidental, asymptomatic lesions discovered during culprit vessel coronary intervention |journal=Circulation |volume=111 |issue=2 |pages=143–9 |year=2005 |month=January |pmid=15623544 |doi=10.1161/01.CIR.0000150335.01285.12 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15623544 |issn=}}</ref><ref name="pmid3379219">{{cite journal |author=Ambrose JA, Tannenbaum MA, Alexopoulos D, ''et al'' |title=Angiographic progression of coronary artery disease and the development of myocardial infarction |journal=J. Am. Coll. Cardiol. |volume=12 |issue=1 |pages=56–62 |year=1988 |month=July |pmid=3379219 |doi= |url= |issn=}}</ref>
In addition, when occlusions develop in severely stenotic vessels, these occlusions may be less likely to cause a [[myocardial infarction]].<ref name="pmid3379219">{{cite journal |author=Ambrose JA, Tannenbaum MA, Alexopoulos D, ''et al'' |title=Angiographic progression of coronary artery disease and the development of myocardial infarction |journal=J. Am. Coll. Cardiol. |volume=12 |issue=1 |pages=56–62 |year=1988 |month=July |pmid=3379219 |doi= |url= |issn=}}</ref>
In summary, the concept of which coronary stenoses are ''vulnerable'' to subsequent plaque rupture and occlusion many be more important that the degree of stenosis of a vessel.<ref name="pmid14530185">{{cite journal |author=Naghavi M, Libby P, Falk E, ''et al'' |title=From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part I |journal=Circulation |volume=108 |issue=14 |pages=1664–72 |year=2003 |month=October |pmid=14530185 |doi=10.1161/01.CIR.0000087480.94275.97 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=14530185 |issn=}}</ref>
==Prevention==
{{main|Vascular disease#Prevention}}
Coronary heart disease is the most common form of heart disease in the Western world. Prevention centers on the modifiable risk factors, which include decreasing [[cholesterol]] levels, addressing [[obesity]] and [[hypertension]], avoiding a [[sedentary lifestyle]], making healthy dietary choices, and [[smoking cessation|stopping smoking]]. There is some evidence that lowering [[uric acid]] and [[homocysteine]] levels may contribute. In [[diabetes mellitus]], there is little evidence that [[blood sugar]] control actually improves cardiac risk. Some recommend a diet rich in omega-3 fatty acids and [[vitamin C]]. The World Health Organization (WHO) recommends "low to moderate alcohol intake" to reduce risk of coronary heart disease.<ref>http://www.who.int/nutrition/topics/5_population_nutrient/en/index12.html</ref>
An increasingly growing number of other [[physiological]] markers and [[homeostatic]] mechanisms are currently under scientific investigation.  Among these markers are [[low density lipoprotein]] and [[asymmetric dimethylarginine]].  Patients with CHD and those trying to prevent CHD are advised to avoid fats that are readily oxidized (e.g., saturated fats and trans-fats), limit carbohydrates and processed sugars to reduce production of [[Low density lipoprotein]]s while increasing [[High density lipoprotein]]s, keeping [[blood pressure]] normal, exercise and stop smoking.  These measures limit the progression of the disease.  Recent studies have shown that dramatic reduction in LDL levels can cause mild regression of coronary heart disease.
==References==
<references/>
==Sell also==
* [[Acute coronary syndrome]]
* [[Myocardial infarction]]
* [[Percutaneous transluminal coronary angioplasty]]
* [[Thrombolysis in Myocardial Infarction (TIMI) risk score]]

Revision as of 16:26, 26 May 2009

Cardiac computed tomographic angiography

For more information, see: Computed tomographic cardiac angiography.

Computed tomographic cardiac angiography (CT cardiac angiography) uses multidetector spiral computed tomography.[1][2][3] The physiologic significance of obstructions estimated to be 60% to 80% is difficult to predict.[4]


Accuracy using 64-row CT for detecting stenoses of 50%[5][6][7]
  Patients Per patient Per segment
Sensitivity Specificity Sensitivity Specificity
CORE 64 study.[5]
2008		 291 patients with suspected coronary heart disease and calcium scores ≤ 600 85% 90% 75% 93%
Meijboom et al.[6]
2008		 360 symptomatic patients 99% 64% 88% 90%
ACCURACY study.[7]
2008		 230 symptomatic patients 95% 83% 84% 90%


The accuracy using 64-row CT for detecting stenoses of 50% is:[8]

  1. ↑ Stein PD, Yaekoub AY, Matta F, Sostman HD (August 2008). "64-slice CT for diagnosis of coronary artery disease: a systematic review". The American journal of medicine 121 (8): 715–25. DOI:10.1016/j.amjmed.2008.02.039. PMID 18691486. Research Blogging.
  2. ↑ Mowatt G, Cook JA, Hillis GS, et al (July 2008). "64-slice computed tomography angiography in the diagnosis and assessment of coronary artery disease: systematic review and meta-analysis". Heart. DOI:10.1136/hrt.2008.145292. PMID 18669550. Research Blogging.
  3. ↑ Rubinshtein R, Halon DA, Gaspar T, et al (November 2007). "Impact of 64-slice cardiac computed tomographic angiography on clinical decision-making in emergency department patients with chest pain of possible myocardial ischemic origin". Am. J. Cardiol. 100 (10): 1522–6. DOI:10.1016/j.amjcard.2007.06.052. PMID 17996512. Research Blogging.
  4. ↑ Sato A, Hiroe M, Tamura M, et al (April 2008). "Quantitative measures of coronary stenosis severity by 64-Slice CT angiography and relation to physiologic significance of perfusion in nonobese patients: comparison with stress myocardial perfusion imaging". J. Nucl. Med. 49 (4): 564–72. DOI:10.2967/jnumed.107.042481. PMID 18344444. Research Blogging.
  5. ↑ 5.0 5.1 Miller, Julie M.; Carlos E. Rochitte, Marc Dewey, Armin Arbab-Zadeh, Hiroyuki Niinuma, Ilan Gottlieb, Narinder Paul, Melvin E. Clouse, Edward P. Shapiro, John Hoe, Albert C. Lardo, David E. Bush, Albert de Roos, Christopher Cox, Jeffery Brinker, Joao A.C. Lima (2008-11-27). "Diagnostic Performance of Coronary Angiography by 64-Row CT". N Engl J Med 359 (22): 2324-2336. DOI:10.1056/NEJMoa0806576. PMID 19038879. Retrieved on 2008-11-27. Research Blogging.
  6. ↑ 6.0 6.1 Meijboom WB, Meijs MF, Schuijf JD, et al. (December 2008). "Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study". J. Am. Coll. Cardiol. 52 (25): 2135–44. DOI:10.1016/j.jacc.2008.08.058. PMID 19095130. Research Blogging.
  7. ↑ 7.0 7.1 Budoff MJ, Dowe D, Jollis JG, et al. (November 2008). "Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial". J. Am. Coll. Cardiol. 52 (21): 1724–32. DOI:10.1016/j.jacc.2008.07.031. PMID 19007693. Research Blogging.
  8. ↑ Miller, Julie M.; Carlos E. Rochitte, Marc Dewey, Armin Arbab-Zadeh, Hiroyuki Niinuma, Ilan Gottlieb, Narinder Paul, Melvin E. Clouse, Edward P. Shapiro, John Hoe, Albert C. Lardo, David E. Bush, Albert de Roos, Christopher Cox, Jeffery Brinker, Joao A.C. Lima (2008-11-27). "Diagnostic Performance of Coronary Angiography by 64-Row CT". N Engl J Med 359 (22): 2324-2336. DOI:10.1056/NEJMoa0806576. Retrieved on 2008-11-27. Research Blogging.
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