Coronary Artery Disease (CAD)

Notes
  • This is a disease that involves impairment of blood flow through the coronary arteries. It is mainly caused by atheromas, to lesser extent coronary artery spasm and rarely aneurysm, coronary artery embolism, dissection, and vasculitis.
  • An atheroma is an accumulation of cholesterol and fatty acids, macrophage cells and calcium as well as the formation of fibrous connective tissue in the inner layer of arterial walls (tunica intima).
  • Statistics: It accounts for about 33% of deaths in the developed countries; it is the 6th cause of deaths in Kenya.

##Pathogenesis of CAD include;

  • The growth of atheromatous plaque and consequent narrowing of the arterial lumen that lead to ischemia.
  • Rupture of atheromatous plaque that exposes thrombogenic materials (including collagen) leading the formation of thrombus that results to thrombogenic ischaemia
  • Coronary artery spasm that is caused by the atheroma.
  • Coronary artery spasm that is caused by vasoconstricting drugs (such as nicotine) and emotional stress
  • Coronary artery spasm of unknown etiology that can directly cause ischaemia or indirectly cause the formation of thrombus and consequent thrombogenic ischaemia

##Risk factors for CAD:

  • High blood levels of low-density lipoprotein (LDL) cholesterol, lipoprotein A, apoprotein B and C-reactive protein (CRP).
  • Low blood levels of high-density lipoprotein (HDL) cholesterol
  • Smoking
  • Obesity
  • Diabetes mellitus
  • Lack of body exercise
Symptoms

##Symptoms and signs of the following conditions / diseases are manifested:

  • Silent ischemia
  • Angina pectoris
  • Unstable angina
  • Myocardial infarction
  • Cardiac arrest

##Symptoms and signs include the following:

  • Chest pain (angina) that is usually in the middle or left side of the chest
  • Shortness of breath or fatigue with exertion
  • Sweating
  • Rapid and shallow breathing
  • Reduced mental alertness.
  • Arterial hypotension
  • Ventricular fibrillation
  • Absence of heart, carotid, and femoral sounds
  • Apnoea and cyanosis
  • Asystole
  • Collapse and death may happen without prior warning.
  • Seizure may occur before collapse
Diagnosis
  • Clinical review
  • ECG
  • Stress testing
  • Coronary angiography
Differential
  • Acute Pericarditis
  • Angina Pectoris
  • Diabetes
  • Dilated Cardiomyopathy
  • Hypertension
  • Hypertensive Heart Disease
  • Myocardial Ischemia
  • Myocarditis
  • Pulmonary Embolism
  • Thromboangiitis Obliterans
Prevention

##Treatment of underlying conditions or risk factors such as:

  • Hypercholesterolemia
  • Hypertension
  • Lack of exercise
  • Obesity
  • Smoking
Management

## Statins (HMG-CoA reductase inhibitor) to lower LDL cholesterol levels

  • Atorvastatin
  • Simvastatin
  • Fluvastatin
  • Pravastatin
  • Rosuvastatin

##Antiplatelets

  • Aspirin 
  • Clopidogrel
  • Dipyridamole
  • Ticlopidine

##Beta-blockers to reduce symptoms of angina (by reducing heart rate and contractility and consequently oxygen demand):

  • Acebutolol
  • Atenolol
  • Bisoprolol
  • Carvedilol
  • Labetalol
  • Metoprolol
  • Pindolol
  • propranolol

##Calcium channel blockers(mostly used together with Beta-blockers):

  • Nifedipine
  • Nicardipine
  • Felodipine
  • Amlodipine
  • Verapamil 
  • Diltiazem

##Nitrates (dilate coronary arteries reducing venous return and cardiac load thus relieving angina)

  • Sublingual nitroglycerin
  • Isosorbide dinitrate
  • Isosorbide-5-mononitrate
  • Transdermal nitroglycerin

##ACE inhibitors and angiotensin II receptor blockers (useful in CAD patients with left ventricle dysfunction)

  • Captopril
  • Enalapril
  • Fosinopril
  • Lisinopril
  • Perindopril
  • Ramipril
  • Trandolapril
  • Candesartan
  • Irbesartan
  • Losartan
  • Telmisartan
  • Valsartan

##Other measures

  • Heparin
  • Oxygen in serious cases
  • Angioplasty Stent
  • Coronary artery bypass grafting (CABG)
  • Proper diet
  • Reduction of salt intake
  • Body exercises
  • Management of underlying illness like diabetes and hypertension

Treatment of obesity

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