Coronary artery disease

Investigations

• Fasting lipids and HbA1c, to assess cardiovascular risk and guide risk reduction treatment
• Stress test: exercise or persantine/dobutamine; ECG or echo or nuclear (mibi); see below
  • Nuclear perfusion scan (mibi) or stress echo, for risk stratification and identification of reversible perfusion defects
• Angiography, for direct coronary visualization and diagnosis, and possible angioplasty
  • Done for high risk features on stress testing

Choice of stress test

graph LR;
LBBB_etc[LBBB or V-paced] --yes--> mibi[persantine mibi]
LBBB_etc --no--> exercise[can exercise?]
exercise --yes--> normal_ecg[ECG normal]
exercise --no--> either[persantine mibi or dobutamine echo]
normal_ecg --yes--> exercise_ecg[exercise ECG]
normal_ecg --no--> exercise_either[exercise mibi or echo]

Management

• Medical management
  • Prevention
    • Antiplatelet
      • ASA
      • Add PPi if GI bleed
      • If ASA allergy: clopidogrel
    • BP control
    • Statin for cholesterol
  • Anti-anginal
    • Beta blockers
    • Calcium channel blockers
    • Nitrates
  • ACEi if heart failure
• Cardiac rehab
• Procedures
  • Angioplasty (percutaneous intervention [PCI])
    • Requires dual antiplatelet therapy (DAPT) for up to 1 year (for drug-eluting stents)
  • Coronary artery bypass surgery (CABG)
    • Better for multivessel disease, diabetics

ABCDE

• Antiplatelets and ACEi/ARB
• Beta blockers and BP
• Cholesterol, cigarettes, and cease hormone-replacement therapy
• Diet and diabetes
• Exercise and education