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