Management of Coronary Artery Disease

Diterbitkan pada: 10/07/2025

Introduction

CVD remained the leading cause of death from the 1980s until today
In 2019, 15.0% of 109,164 medically certified deaths were caused by coronary artery disease (CAD)
2.5 times more than all cancer-related death combined

Definition

Imbalance between myocardial oxygen supply and demand, most commonly caused by the inability of atherosclerotic coronary arteries to perfuse the heart due to partial or total occlusion of the coronary arteries.
Chronic angina pectoris is stable, i.e., the severity and/or frequency of chest pain is not increasing or occurring at rest.
Unstable angina, myocardial infarction and sudden ischaemic death are also manifestations of chronic ischaemic heart disease, presenting as acute coronary syndromes.

Heart Anatomy

Risk Factors of CAD

Category	Risk Factors
Predisposing factors	Age, sex, family history, genes
Risk-modifying behaviors	Smoking, atherogenic diet, alcohol intake, physical activity
Metabolic risk factors	Dyslipidemias, hypertension, obesity, diabetes, metabolic syndrome
Disease markers	Calcium score, catheterization results, stress test results, left ventricular hypertrophy on echocardiogram, personal history of vascular disease (prior myocardial infarction or stroke, angina, peripheral vascular disease), inflammatory state

Pathophysiology

Myocardial ischaemia occurs when there is supply-demand mismatch.
Normally, coronary blood flow can increase 3-5x in response to exercise
Significant atherosclerotic plaquing (> 75% cross-sectional area) results in a drop in blood pressure across the stenotic lesion -> arterioles dilatation
Tt rest, most patients have no ischaemia and therefore no angina
During exercise, the capacity of coronary arterioles to dilate further is limited, and the oxygen demand soon outstrips the supply -> Ischaemia -> angina
Acute coronary syndromes : acute rupture of a intracoronary atheromatous plaque, with subsequent mobilisation of a sequence of inflammatory and thrombotic cascades culminating in the formation of thrombus

Myocardial Infarction

Symptoms

Chronic / stable

Dyscomfort,pressure sensation,heaviness
Provoked by exertion, emotion, cold weather
Lasts a few minutes
Relieved by nitrate

Acute

Unstable angina
Myocardial infarction (ST and non-ST elevation)
Severe pain
Increasing severity of angina
At rest
Last longer

Test/Screenings to Diagnose

Chronic

Basic blood screening
ECG – often normal
Echo – wall motion abnormalities
Stress test
CT angiogram
Coronary angiogram – not necessary in all

Acute

Blood test including cardiac enzymes
ECG
CXR
Echo – valve analysis, septum
Angiogram
MRI

Management & Treatment considerations (Factors)

Disease stability

STEMI, non-STEMI, stable angina

Procedural risks and patient comorbidities

Mainly mortality and stroke

Atherosclerotic burden and disease complexity

Heavy burden favours CABG

Management & Treatment considerations for Chronic vs Acute conditions

Chronic / stable
- Major goals to prevent MI and reduce symptoms
- Antianginal therapies
  - Medications
  - Revascularisation ; PCI, CABG
- Education and risk factor modifications
  - Lifestyle modifications
  - Medications
Acute
- Most except for low risk unstable angina need hospitalisation
- Goals; relieve pain and inhibit thrombosis/thrombolysis
- Correction of precipitating conditions; HPT, anaemia, hypoxia
- Medications including analgesia, anticoagulants, thrombolytics
- Management of complications ; inotropes, diuretics, balloon pump
- In-patient/primary coronary angiogram
- Revascularisation

This article was contributed by Associate Professor Dr. Ahmad Zuhdi Bin Mamat, Resident Consultant Cardiothoracic Surgeon at Pantai Hospital Ipoh. To know more about where and when to see Associate Professor Dr. Ahmad Zuhdi Bin Mamat at his clinic, click here .