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Coronary artery disease
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==Diagnosis== [[File:Coro Man.jpg|thumb|Coronary angiogram of a male]] [[File:Coro Woman.jpg|thumb|Coronary angiogram of a female]] The diagnosis of CAD depends largely on the nature of the symptoms and imaging. The first investigation when CAD is suspected is an [[electrocardiogram]] (ECG/EKG), both for [[stable angina]] and acute coronary syndrome. An [[Chest X-ray|X-ray of the chest]], [[blood test]]s and resting [[echocardiography]] may be performed.<ref>{{Cite web |title=Coronary Artery Disease Diagnosis and Treatment |url=https://www.mayoclinic.org/diseases-conditions/coronary-artery-disease/diagnosis-treatment/drc-20350619 |website=[[Mayo Clinic]]}}</ref><ref name="Knuuti-2019">{{Cite journal |last1=Knuuti |first1=Juhani |last2=Wijns |first2=William |last3=Saraste |first3=Antti |last4=Capodanno |first4=Davide |last5=Barbato |first5=Emanuele |last6=Funck-Brentano |first6=Christian |last7=Prescott |first7=Eva |last8=Storey |first8=Robert F |last9=Deaton |first9=Christi |last10=Cuisset |first10=Thomas |last11=Agewall |first11=Stefan |last12=Dickstein |first12=Kenneth |last13=Edvardsen |first13=Thor |last14=Escaned |first14=Javier |last15=Gersh |first15=Bernard J |date=2019-08-31 |title=2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes |url=|journal=European Heart Journal |volume=41 |issue=3 |pages=407–77 |doi=10.1093/eurheartj/ehz425 |pmid=31504439 |issn=0195-668X|hdl=11379/537215 |hdl-access=free }}</ref> For stable symptomatic patients, several non-invasive tests can diagnose CAD depending on pre-assessment of the risk profile. Noninvasive imaging options include; [[Computed tomography angiography]] (CTA) (anatomical imaging, best test in patients with low-risk profile to "rule out" the disease), [[Positron emission tomography - computed tomography|positron emission tomography]] (PET), [[Myocardial perfusion imaging|single-photon emission computed tomography (SPECT)/nuclear stress test/myocardial scintigraphy]] and [[stress echocardiography]] (the three latter can be summarized as functional noninvasive methods and are typically better to "rule in"). [[Cardiac stress test|Exercise ECG]] or stress test is inferior to non-invasive imaging methods due to the risk of false negative and false positive test results. The use of non-invasive imaging is not recommended on individuals who are exhibiting no symptoms and are otherwise at low risk for developing coronary disease.<ref name="ASEfive">{{Cite journal |author1=American Society of Echocardiography |author1-link=American Society of Echocardiography |date=20 December 2012 |title=Five Things Physicians and Patients Should Question |url=http://www.choosingwisely.org/doctor-patient-lists/american-society-of-echocardiography |url-status=live |journal=Choosing Wisely: An Initiative of the ABIM Foundation |archive-url=https://web.archive.org/web/20130226052012/http://www.choosingwisely.org/doctor-patient-lists/american-society-of-echocardiography/ |archive-date=26 February 2013 |access-date=27 February 2013}}, citing * {{cite journal |author13=Society for Cardiovascular Angiography Interventions |author14=Society of Critical Care Medicine |author15=American Society of Echocardiography |display-authors=6 |vauthors=Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Ward RP, Weiner RB |date=March 2011 |title=ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians |journal=Journal of the American College of Cardiology |volume=57 |issue=9 |pages=1126–66 |doi=10.1016/j.jacc.2010.11.002 |pmid=21349406 |doi-access=free |author20=American Heart Association |author18=Society for Cardiovascular Magnetic Resonance |author16=American Society of Nuclear Cardiology |author17=Heart Failure Society of America |author19=Society of Cardiovascular Computed Tomography |author21=Heart Rhythm Society}}<!--|access-date=26 October 2015--> * {{cite journal |author15=American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina) |display-authors=6 |vauthors=Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB, Fihn SD, Fraker TD, Gardin JM, O'Rourke RA, Pasternak RC, Williams SV |date=January 2003 |title=ACC/AHA 2002 guideline update for the management of patients with chronic stable angina – summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina) |journal=Journal of the American College of Cardiology |volume=41 |issue=1 |pages=159–68 |doi=10.1016/S0735-1097(02)02848-6 |pmid=12570960 |doi-access=free}} * {{cite journal |display-authors=6 |vauthors=Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, Foster E, Hlatky MA, Hodgson JM, Kushner FG, Lauer MS, Shaw LJ, Smith SC, Taylor AJ, Weintraub WS, Wenger NK, Jacobs AK, Smith SC, Anderson JL, Albert N, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Nishimura R, Ohman EM, Page RL, Stevenson WG, Tarkington LG, Yancy CW |date=December 2010 |title=2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=Journal of the American College of Cardiology |volume=56 |issue=25 |pages=e50–103 |doi=10.1016/j.jacc.2010.09.001 |pmid=21144964 |doi-access=free}}</ref><ref name="ACCPandATSfive">{{Citation|author1=American College of Cardiology|author1-link=American College of Cardiology|date=September 2013|title=Five Things Physicians and Patients Should Question|publisher=American College of Cardiology|work=[[Choosing Wisely]]: an initiative of the [[ABIM Foundation]]|url=http://www.choosingwisely.org/doctor-patient-lists/american-college-of-cardiology|access-date=10 February 2014|url-status=live|archive-url=https://web.archive.org/web/20131217231756/http://www.choosingwisely.org/doctor-patient-lists/american-college-of-cardiology/|archive-date=17 December 2013}}</ref> Invasive testing with [[coronary angiography]] (ICA) can be used when non-invasive testing is inconclusive or show a high event risk.<ref name="Knuuti-2019" /> The diagnosis of [[microvascular angina]] (previously known as ''cardiac syndrome X'' – the rare coronary artery disease that is more common in females, as mentioned, is a diagnosis of exclusion. Therefore, usually, the same tests are used as in any person suspected of having coronary artery disease:<ref>{{cite journal | vauthors = Agrawal S, Mehta PK, Bairey Merz CN | title = Cardiac Syndrome X: update 2014 | journal = Cardiology Clinics | volume = 32 | issue = 3 | pages = 463–78 | date = August 2014 | pmid = 25091971 | pmc = 4122947 | doi = 10.1016/j.ccl.2014.04.006 }}</ref> * [[Intravascular ultrasound]] * [[Magnetic resonance imaging]] (MRI) ===Stable angina=== {{main|Angina#Stable angina}} [[Stable angina]] is the most common manifestation of ischemic heart disease, and is associated with reduced quality of life and increased mortality. It is caused by epicardial coronary stenosis which results in reduced blood flow and oxygen supply to the myocardium.<ref>{{cite web |title=Angina – Symptoms and causes |url=https://www.mayoclinic.org/diseases-conditions/angina/symptoms-causes/syc-20369373 |website=Mayo Clinic |language=en}}</ref> Stable angina is short-term chest pain during physical exertion caused by an imbalance between myocardial oxygen supply and metabolic oxygen demand. Various forms of [[cardiac stress test]]s may be used to induce both symptoms and detect changes by way of electrocardiography (using an ECG), [[echocardiography]] (using [[medical ultrasonography|ultrasound]] of the heart) or [[scintigraphy]] (using uptake of [[radionuclide]] by the heart muscle). If part of the heart seems to receive an insufficient blood supply, [[Coronary catheterization|coronary angiography]] may be used to identify [[stenosis]] of the coronary arteries and suitability for [[angioplasty]] or [[Coronary artery bypass surgery|bypass surgery]].<ref>{{cite web|title=Coronary Angiography|url=https://www.nhlbi.nih.gov/health/health-topics/topics/ca|website=National Heart, Blood, and Lung Institute|access-date=10 December 2017}}</ref> In minor to moderate cases, nitroglycerine may be used to alleviate acute symptoms of stable angina or may be used immediately before exertion to prevent the onset of angina. Sublingual nitroglycerine is most commonly used to provide rapid relief for acute angina attacks and as a complement to anti-anginal treatments in patients with refractory and recurrent angina.<ref>{{cite journal |last1=Tarkin |first1=Jason M |last2=Kaski |first2=Juan Carlos |title=Pharmacological treatment of chronic stable angina pectoris |journal=Clinical Medicine |pages=63–70 |doi=10.7861/clinmedicine.13-1-63 |date=February 2013|volume=13 |issue=1 |pmid=23472498 |pmc=5873712 }}</ref> When nitroglycerine enters the bloodstream, it forms free radical nitric oxide, or NO, which activates guanylate cyclase and in turn stimulates the release of cyclic GMP. This molecular signaling stimulates smooth muscle relaxation, resulting in vasodilation and consequently improved blood flow to heart regions affected by atherosclerotic plaque.<ref>{{cite web |url=https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021134s004lbl.pdf |archive-url=https://web.archive.org/web/20140419045424/http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021134s004lbl.pdf |archive-date=2014-04-19 |url-status=live |title=Nitrostat® (Nitroglycerin Sublingual Tablets, USP) |publisher=United States Food and Drug Administration}}</ref> Stable coronary artery disease (SCAD) is also often called stable ischemic heart disease (SIHD).<ref name="Li 2015 Overview of ischemic heart disease">{{cite book | vauthors = Li YR |chapter=Overview of ischemic heart disease, stable angina, and drug therapy |pages=245–53 |chapter-url=https://books.google.com/books?id=rXy0BgAAQBAJ&pg=PA245 |title=Cardiovascular Diseases: From Molecular Pharmacology to Evidence-Based Therapeutics |date=2015 |publisher=John Wiley & Sons |isbn=978-0-470-91537-0 }}</ref> A 2015 monograph explains that "Regardless of the nomenclature, stable angina is the chief manifestation of SIHD or SCAD."<ref name="Li 2015 Overview of ischemic heart disease"/> There are U.S. and European [[medical guideline|clinical practice guidelines]] for SIHD/SCAD.<ref name="pmid_25070666">{{cite journal | vauthors = Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, Fonarow GC, Lange RA, Levine GN, Maddox TM, Naidu SS, Ohman EM, Smith PK | display-authors = 6 | title = 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons | journal = Circulation | volume = 130 | issue = 19 | pages = 1749–67 | date = November 2014 | pmid = 25070666 | doi = 10.1161/CIR.0000000000000095 | doi-access = free }}</ref><ref name="ESC">{{cite web |title=ESC Guidelines on Chronic Coronary Syndromes (Previously titled Stable Coronary Artery Disease) |url=https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Chronic-Coronary-Syndromes |website=European Society of Cardiology }}</ref><ref name="Knuuti-2019" /> In patients with non-severe asymptomatic [[Aortic stenosis|aortic valve stenosis]] and no overt coronary artery disease, the increased [[troponin T]] (above 14 pg/mL) was found associated with an increased 5-year event rate of [[Coronary ischemia|ischemic cardiac events]] ([[myocardial infarction]], [[percutaneous coronary intervention]], or [[coronary artery bypass surgery]]).<ref>{{Cite journal |last1=Hadziselimovic |first1=Edina |last2=Greve |first2=Anders M. |last3=Sajadieh |first3=Ahmad |last4=Olsen |first4=Michael H. |last5=Kesäniemi |first5=Y. Antero |last6=Nienaber |first6=Christoph A. |last7=Ray |first7=Simon G. |last8=Rossebø |first8=Anne B. |last9=Wachtell |first9=Kristian |last10=Nielsen |first10=Olav W. |date=April 2023 |title=Association of high-sensitivity troponin T with outcomes in asymptomatic non-severe aortic stenosis: a post-hoc substudy of the SEAS trial |url=|journal=eClinicalMedicine |volume=58 |pages=101875 |doi=10.1016/j.eclinm.2023.101875 |issn=2589-5370 |pmc=10006443 |pmid=36915288}}</ref> ===Acute coronary syndrome=== {{main|Acute coronary syndrome}} Diagnosis of [[acute coronary syndrome]] generally takes place in the [[emergency department]], where ECGs may be performed sequentially to identify "evolving changes" (indicating ongoing damage to the heart muscle). Diagnosis is clear-cut if ECGs show elevation of the "[[Electrocardiogram#ST segment|ST segment]]", which in the context of severe typical chest pain is strongly indicative of an acute [[myocardial infarction]] (MI); this is termed a STEMI (ST-elevation MI) and is treated as an emergency with either urgent [[Coronary catheterization|coronary angiography]] and [[percutaneous coronary intervention]] (angioplasty with or without [[stent]] insertion) or with [[thrombolysis]] ("clot buster" medication), whichever is available. In the absence of ST-segment elevation, heart damage is detected by [[cardiac marker]]s (blood tests that identify heart muscle damage). If there is evidence of damage ([[infarction]]), the chest pain is attributed to a "non-ST elevation MI" (NSTEMI). If there is no evidence of damage, the term "unstable angina" is used. This process usually necessitates hospital admission and close observation on a [[coronary care unit]] for possible complications (such as [[cardiac arrhythmia]]s – irregularities in the heart rate). Depending on the risk assessment, stress testing or angiography may be used to identify and treat coronary artery disease in patients who have had an NSTEMI or unstable angina.{{Citation needed|date=January 2021}} ===Risk assessment=== There are various risk assessment systems for determining the risk of coronary artery disease, with various emphasis on the different variables above. A notable example is [[Framingham Score]], used in the [[Framingham Heart Study]]. It is mainly based on age, gender, diabetes, total cholesterol, HDL cholesterol, tobacco smoking, and systolic blood pressure. When predicting risk in younger adults (18–39 years old), the Framingham Risk Score remains below 10–12% for all deciles of baseline-predicted risk.<ref>{{cite journal | vauthors = Berry JD, Lloyd-Jones DM, Garside DB, Greenland P | title = Framingham risk score and prediction of coronary heart disease death in young men | journal = American Heart Journal | volume = 154 | issue = 1 | pages = 80–86 | date = July 2007 | pmid = 17584558 | pmc = 2279177 | doi = 10.1016/j.ahj.2007.03.042 }}</ref> [[Polygenic score]] is another way of risk assessment. In one study the relative risk of incident coronary events was 91% higher among participants at high genetic risk than among those at low genetic risk.<ref>{{cite journal | vauthors = Khera AV, Emdin CA, Drake I, Natarajan P, Bick AG, Cook NR, Chasman DI, Baber U, Mehran R, Rader DJ, Fuster V, Boerwinkle E, Melander O, Orho-Melander M, Ridker PM, Kathiresan S | display-authors = 6 | title = Genetic Risk, Adherence to a Healthy Lifestyle, and Coronary Disease | journal = The New England Journal of Medicine | volume = 375 | issue = 24 | pages = 2349–58 | date = December 2016 | pmid = 27959714 | pmc = 5338864 | doi = 10.1056/NEJMoa1605086 }}</ref>
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