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ICTROMI IOP Publishing
IOP Conf. Series: Earth and Environmental Science1234567890
125 (2018) 012125 doi:10.1088/1755-1315/125/1/012125

Management of coronary artery disease

Z Safri

Department of Internal Medicine, Faculty of Medicine, Universitas Sumatera Utara,

Jl. Cardiac Center No.2, Medan, Indonesia
*
Corresponding author: [email protected]

Abstract. Coronary Artery Disease (CAD) is associated with significant morbidity and
mortality, therefore it’s important to early and accurate detection and appropriate management.
Diagnosis of CAD include clinical examination, noninvasive techniques such as biochemical
testing, a resting ECG, possibly ambulatory ECG monitoring, resting echocardiography, chest
X-ray in selected patients; and catheterization. Managements of CAD patients include lifestyle
modification, control of CAD risk factors, pharmacologic therapy, and patient education.
Revascularization consists of percutaneous coronary angioplasty and coronary artery bypass
grafting. Cardiac rehabilitation should be considered in all patients with CAD. This
comprehensive review highlights strategies of management in patients with CAD.

1. Introduction
Coronary artery disease is the most common cause of death in cardiovascular disease. The rate of
morbidity and mortality is high, the costs incurred for the treatment process are also very high, thus
giving a bad impact on the welfare and quality of life both in patients, families, and health costs borne
by the state. The proper management can reduce the number of losses. Therefore, here will be
discussed about the appropriate treatment steps to deal with this coronary artery disease.

2. Definition
Stable coronary artery disease (SCAD) is generally characterized by episodesof reversible myocardial
demand/supply mismatch, related to ischemia or hypoxia, which are usually inducible by exercise,
emotion or other stress and reproducible but, which may also be occurring spontaneously.[1] Coronary
artery disease most commonly caused by the inability of atherosclerotic coronary arteries to perfuse
the heart due to partial or total occlusion of the coronary arteries.[2] SCAD also includes the
stabilized, often asymptomatic, phases that follow an ACS.
SCAD has various clinical presentations that are associated with different underlying mechanisms
that mainly include: plaque-related obstruction of epicardial arteries, focal or diffuse spasm of normal
or plaque-diseased arteries, microvascular dysfunction and left ventricular dysfunction caused by prior
acute myocardial necrosis and/or hibernation.[1]

3. Epidemiology
Angina pectoris is more prevalent in middle-aged women than men, probably due to the high
prevalence of functional coronary artery disease such as microvascular angina in women. In contrast,
angina pectoris is more prevalent in elderly men.[3,4]

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ICTROMI IOP Publishing
IOP Conf. Series: Earth and Environmental Science1234567890
125 (2018) 012125 doi:10.1088/1755-1315/125/1/012125

4. Natural History and Prognosis

Conventional risk factors for the development of CAD are hypertension, hypercholesterolemia,
diabetes, sedentary lifestyle, obesity, smoking, and family history have an adverse influence on
prognosis in those with established disease.[1]
Prognostic assessment is an important part of the management of patients with SCAD. On the one
hand, it is important to reliably identify those patients with more severe forms of disease, who may
have an improvement in outcome with more aggressive investigation and maybe intervention,
including revascularization. On the other hand, it is also important to identify those patients with a less
severe form of disease and a good prognosis, thereby avoiding unnecessary invasive and non-invasive
tests and revascularization procedures. The prognosis in patients with SCAD is relatively benign with
estimates of annual mortality rates in mixed population ranging from 1.2-2.4% with an annual
incidence of cardiac death between 0.6 and 1.4%.[5-10]

5. Pathophysiology
Myocardial ischemia occurs when myocardial oxygen delivery cannot meet metabolic myocardial
demand. Although this term is too simple, myocardial oxygen delivery largely determined by the
carrying capacity of blood oxygen and coronary flow. In normal coronary arteries, coronary blood
flow can increase three to five fold. This increase, termed coronary flow reserve, occurs mostly
through decreased resistance in coronary microcirculation. Significant atherosclerotic plaquing in the
epicardial coronary artery (> 75% cross-sectional region) results in a decrease in blood pressure
throughout the stenotic lesions. Coronary arterioles dilate to compensate for the decrease in distal
perfusion pressure, keeping coronary blood flow normal. Consequently, during exercise, however,
coronary capacity the arterioles to widen further are finite, and the demand for myocardial oxygen
immediately exceeds supply, resulting in ischemia, followed usually by angina.

6. Diagnosis and Assessment

Diagnosis and assesment for SCAD includes clinical evaluation and identification for risk factor and
additional investigation such as stress testing or coronary imaging to confirm the diagnosis of SCAD.
Angina Pectoris can be classified into typical and atypical angina pectoris which definitions are
summarized in table 1 below.

Table 1. Traditional clinical classification of chest pain[1].

The Canadian Cardiovascular Society classification which is widely used as a grading system for
stable angina are divided into 4 class, angina pain at rest may occur in all grades of this classification
as a manifestation of associated and superimposed coronary vasospasm. The class assigned is
indicative of the maximum limitation while the patient may do better when the patient is healthy.
Non-invasive cardiac investigation include standard laboratory biochemical testing, a resting ECG,
possibly ambulatory ECG monitoring, resting echocardiography and in selected patients a chest X-ray.

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ICTROMI IOP Publishing
IOP Conf. Series: Earth and Environmental Science1234567890
125 (2018) 012125 doi:10.1088/1755-1315/125/1/012125

Figure 1. Initial diagnostic management of patients with suspected SCAD [1].

7. Lifestyle and Pharmacological Management

The aim of the management of SCAD is to reduce symptoms and improve prognosis. The
management of CAD patients encompasses lifestyle modification, control of CAD risk factors,
evidence-based pharmacological therapy and patient education.[11,12] Lifestyle recommendations
include smoking cessation, a healthy diet, regular physical activity, weight and lipid management, also
blood pressure and glucose control.[1]
Smoking is a strong and independent risk factor for CVD and all smoking must be avoided,
smoking cessationis associated with a reduction in mortality of 36% after MI.[13,14] Healthy diet
reduces CVD risk with The target of BMI is <25 kg/m2, recommended dieat intake list in table 2
below.
Regular physical activity is associated with a decrease in CV morbidity and mortality in patients
with established CAD. Patients with previous acute MI, CABG, percutaneous coronary intervention
(PCI), stable angina pectoris or stable chronic heart failure should undergo moderate-to-vigorous
intensity aerobic exercise training ≥3 times a week and for 30 min per session.[1]

3
ICTROMI IOP Publishing
IOP Conf. Series: Earth and Environmental Science1234567890
125 (2018) 012125 doi:10.1088/1755-1315/125/1/012125

Table 2. Recommended diet intake [1].

Dyslipidemia should be managed according to lipid guidelines with pharmacological and lifestyle
intervention. The goals of treatment are LDL-C below 1.8 mmol/L (<70 mg/dL) or <50% LDL-C
reduction when target level cannot be reached.[1]
Diabetes mellitus is a strong risk factor for CV complications, increases the risk of progression of
coronary disease and should be managed carefully, with good control of glycated hemoglobin
(HbA1c) to <7.0% (53 mmol/mol) generally and <6.5%–6.9% (48–52 mmol/mol) on an individual
basis.[1]
There is sufficient evidence to recommend that systolic BP (SBP) be lowered to<140 mmHg and
diastolic BP (DBP) to<90 mmHg in SCAD patients with hypertension. Based on current data, it may
be prudent to recommend lowering SBP/DBP to values within therange 130–139/80–85 mmHg. BP
targets in diabetes are recommended to be <140/85 mmHg.[1]

8. Pharmacological Management
The two aims of pharmacological management of stable CAD patients are to obtain relief of
symptoms and to prevent CV events.[1]

Figure 2. Medical management of patients with stable coronary artery disease. ACEI (angiotensin
converting enzyme inhibitor); CABG (coronary artery bypass graft); CCB (calcium channel blockers);
CCS (Canadian Cardiovascular Society); DHP (dihydropyridine); PCI (percutaneous coronary
intervention). aData for diabetics. bif intolerance, consider clopidogrel [12].

9. Revascularization
Advance in techniques, equipment, stent and adjuvant therapy have established PCI as a routine and
safe procedure in patients with SCAD and suitable coronary anatomy. The decision to revascularize a

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ICTROMI IOP Publishing
IOP Conf. Series: Earth and Environmental Science1234567890
125 (2018) 012125 doi:10.1088/1755-1315/125/1/012125

patient should be based on the presence of significant obstructive coronary artery stenosis, the amount
of related ischaemia, and the expected benefit on prognosis and/ or symptom. Revascularization can
also be considered as first-line treatment in the following situation: post-myocardial infarction
angina/ischaemia, left ventricular dysfunction, multivessel disease and/or large ischaemic territory,
left main stenosis.
The indications for PCI and CABG in SCAD patients have clearly been defined by the recent
recommendations on myocardial revascularization. Following figures show algorithms to help
simplify the decision making process.
After revascularization, therapy and secondary prevention should be initiated during
hospitalization, all revascularized patients receive a secondary prevention and be scheduled for
follow-up visit, antiplatelet therapy that must be given is aspirin, for BMS DAPT is indicated at least 1
month, and 6 to 12 months after 2nd generation DES. In symptomatic patients, stress imaging is
indicated rather than stress ECG, if low risk (<5% ischemic myocardium) optimal medical therapy is
recommended, but if high risk (>10%) coronary angiography is recommended. Systematic control
angiography, early or late after PCI is not recommended.

Table 3. Indications for revascularization of stable coronary artery disease patients on

optimal medical therapy (adapted from ESC/EACTS 2010 Guidelines) [12].

Figure 3. Percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG)
in stable coronary artery disease without left main coronary artery involvement [12].

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ICTROMI IOP Publishing
IOP Conf. Series: Earth and Environmental Science1234567890
125 (2018) 012125 doi:10.1088/1755-1315/125/1/012125

10. Cardiac rehabilitation

A comprehensive risk reduction regimen integrated into comprehensive cardiac rehabilitation is
recommended for patients with CAD.[1] Cardiac rehabilitation should be considered in all patients
with CAD, including those with chronic angina. Cardiac-based rehabilitation exercises are effective in
reducing total mortality and CV and hospital admissions. The evidence also shows beneficial benefits
on health-related quality of life (QoL). In the selected subgroup, cardiac center-based rehabilitation
may be substituted for home-based rehabilitation, which is not inferior. The participation of patients in
cardiac rehabilitation remains too low, especially in women, elderly and socioeconomic loss, and may
benefit from systematic referral.[13]

References
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The task force on the management of stable coronary artery disease of the european society
of cardiology Eur. Heart J. 34 2949-3003
[2] Morrow D A and Boden W E 2012 Stable ischemic heart disease Braunwald’s heart disease: a
textbook of cardiovascular 9th edition (Philadelphia: Elsevier) pp 1087-98
[3] Reis S E, et al. 2001 Coronary microvascular dysfunction is highly prevalentin women with
chest pain in the absence of coronary artery disease: result from the NHLBI WISE study Am.
Heart J. 141 735–41
[4] Han S H, Bae J H, Holmes D R Jr, et al. 2008 Sex differences in atheroma burden and
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[5] Boden W E, et al. 2007 Optimal medical therapy with or without PCI for stable coronary
disease N. Engl. J. Med. 356 1503–16
[6] Chung S C, et al. 2011 The effect of age on clinical outcomesand health status BARI 2D
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[7] Frye R L, et al. 2009 A randomized trial of therapies for type 2 diabetes and coronary artery
disease N. Engl. J. Med. 360 2503–15
[8] Henderson R A, Pocock S J, Clayton T C, et al. 2003 Seven-year outcome in the RITA-2 trial:
coronary angioplastyversus medical therapy J. Am. Coll. Cardiol. 42 1161–70
[9] Poole-Wilson P A, et al. 2004 Effect of long-acting nifedipine on mortality and cardiovascular
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[10] Steg P G, Greenlaw N, Tardif J C, et al. 2012 Women and men with stable coronary artery
disease have similar clinical outcomes: insights from the international prospective
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[11] Perk J, et al. 2012 European guidelines on cardiovascular disease prevention in clinical practice
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societies on cardiovascular disease prevention Eur. Heart J. 33 1635–701
[12] Reiner Z, et al. 2011 ESC/EAS Guidelines for the management of dyslipidemias: the task force
for the management of dyslipidaemias of the european society of cardiology (ESC) and the
european atherosclerosis society (EAS) Eur. Heart J. 32 1769–818
[13] Piepoli M F, et al. 2010 Secondary prevention through cardiac rehabilitation: from knowledge
to implementation A position paper from the cardiac rehabilitation section of the european
association of cardiovascular prevention and rehabilitation Eur. J. Cardiovasc. Prev.
Rehabil. 17 1–17