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Coronary artery disease
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==Treatment== There are a number of treatment options for coronary artery disease:<ref>{{cite book|vauthors=Jameson JN, Kasper DL, Harrison TR, Braunwald E, Fauci AS, Hauser SL, Longo DL|title=Harrison's principles of internal medicine|publisher=McGraw-Hill Medical Publishing Division|location=New York|year=2005|edition=16th|isbn=978-0-07-140235-4|url=http://highered.mcgraw-hill.com/sites/0071402357/information_center_view0|oclc=54501403|access-date=26 October 2015|url-status=dead|archive-url=https://web.archive.org/web/20140219090440/http://highered.mcgraw-hill.com/sites/0071402357/information_center_view0/|archive-date=19 February 2014}}</ref> * Lifestyle changes * Medical treatment – [[commonly prescribed drugs]] (e.g., [[Antihyperlipidemic|cholesterol lowering medications]], [[beta-blocker]]s, [[nitroglycerin]], [[calcium channel blocker]]s, etc.); * Coronary interventions as [[angioplasty]] and [[coronary stent]]; * [[Coronary artery bypass grafting]] (CABG) ===Medications=== * [[Statin]]s, which reduce cholesterol, reduce the risk of coronary artery disease<ref>{{cite journal | vauthors = Gutierrez J, Ramirez G, Rundek T, Sacco RL | title = Statin therapy in the prevention of recurrent cardiovascular events: a sex-based meta-analysis | journal = Archives of Internal Medicine | volume = 172 | issue = 12 | pages = 909–19 | date = June 2012 | pmid = 22732744 | doi = 10.1001/archinternmed.2012.2145 | doi-access = free }}<!--|access-date=26 October 2015--></ref> * [[Medical use of nitroglycerin|Nitroglycerin]]<ref name="medline">{{MedlinePlusEncyclopedia|a601086|Nitroglycerin Sublingual}}</ref> * Calcium channel blockers and/or beta-blockers<ref name="Ohman2016">{{cite journal | vauthors = Ohman EM | title = Clinical Practice: Chronic Stable Angina | journal = The New England Journal of Medicine | volume = 374 | issue = 12 | pages = 1167–76 | date = March 2016 | pmid = 27007960 | doi = 10.1056/NEJMcp1502240 }}</ref> * [[Antiplatelet drug]]s such as [[aspirin]]<ref name="Ohman2016"/><ref name="Grove2015">{{cite journal | vauthors = Grove EL, Würtz M, Thomas MR, Kristensen SD | title = Antiplatelet therapy in acute coronary syndromes | journal = Expert Opinion on Pharmacotherapy | volume = 16 | issue = 14 | pages = 2133–47 | date = 2015 | pmid = 26293612 | doi = 10.1517/14656566.2015.1079619 | type = Review | s2cid = 9841653 }}</ref> It is recommended that blood pressure typically be reduced to less than 140/90 mmHg.<ref name=Ros2015/> The diastolic blood pressure should not be below 60 mmHg. Beta-blockers are recommended first line for this use.<ref name="Ros2015">{{cite journal | vauthors = Rosendorff C, Lackland DT, Allison M, Aronow WS, Black HR, Blumenthal RS, Cannon CP, de Lemos JA, Elliott WJ, Findeiss L, Gersh BJ, Gore JM, Levy D, Long JB, O'Connor CM, O'Gara PT, Ogedegbe G, Oparil S, White WB | display-authors = 6 | title = Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension | journal = Circulation | volume = 131 | issue = 19 | pages = e435–70 | date = May 2015 | pmid = 25829340 | doi = 10.1161/cir.0000000000000207 | pmc = 8365343 | doi-access = free }}<!--|access-date=26 October 2015--></ref> ====Aspirin==== In those with no previous history of heart disease, aspirin decreases the risk of a myocardial infarction but does not change the overall risk of death.<ref>{{cite journal | vauthors = Guirguis-Blake JM, Evans CV, Senger CA, O'Connor EA, Whitlock EP | title = Aspirin for the Primary Prevention of Cardiovascular Events: A Systematic Evidence Review for the U.S. Preventive Services Task Force | journal = Annals of Internal Medicine | volume = 164 | issue = 12 | pages = 804–13 | date = June 2016 | pmid = 27064410 | doi = 10.7326/M15-2113 | type = Systematic Review and Meta-Analysis | doi-access = free }}</ref> Aspirin therapy to prevent heart disease is thus recommended only in adults who are at increased risk for cardiovascular events, which may include [[postmenopausal]] females, males above 40, and younger people with risk factors for coronary heart disease, including [[high blood pressure]], a family history of heart disease, or [[diabetes]]. The benefits outweigh the harms most favorably in people at high risk for a cardiovascular event, where high risk is defined as at least a 3% chance over five years, but others with lower risk may still find the potential benefits worth the associated risks.<ref name="pmid11790071">{{cite journal | author = U.S. Preventive Services Task Force | title = Aspirin for the primary prevention of cardiovascular events: recommendation and rationale | journal = Annals of Internal Medicine | volume = 136 | issue = 2 | pages = 157–60 | date = January 2002 | pmid = 11790071 | doi = 10.7326/0003-4819-136-2-200201150-00015 | doi-access = free }}</ref> ====Anti-platelet therapy==== [[Clopidogrel]] plus aspirin (dual anti-platelet therapy) reduces cardiovascular events more than aspirin alone in those with a [[STEMI]]. In others at high risk but not having an acute event, the evidence is weak.<ref>{{cite journal | vauthors = Squizzato A, Bellesini M, Takeda A, Middeldorp S, Donadini MP | title = Clopidogrel plus aspirin versus aspirin alone for preventing cardiovascular events | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | pages = CD005158 | date = December 2017 | issue = 12 | pmid = 29240976 | pmc = 6486024 | doi = 10.1002/14651858.CD005158.pub4 }}</ref> Specifically, its use does not change the risk of death in this group.<ref>{{cite web|title=FDA Drug Safety Communication: FDA review finds long-term treatment with blood-thinning medicine Plavix (clopidogrel) does not change risk of death|url=https://www.fda.gov/Drugs/DrugSafety/ucm471286.htm|website=FDA|access-date=25 January 2016|date=6 November 2015|url-status=live|archive-url=https://web.archive.org/web/20160204011823/https://www.fda.gov/Drugs/DrugSafety/ucm471286.htm|archive-date=4 February 2016}}</ref> In those who have had a stent, more than 12 months of clopidogrel plus aspirin does not affect the risk of death.<ref>{{cite journal | vauthors = Elmariah S, Mauri L, Doros G, Galper BZ, O'Neill KE, Steg PG, Kereiakes DJ, Yeh RW | display-authors = 6 | title = Extended duration dual antiplatelet therapy and mortality: a systematic review and meta-analysis | journal = Lancet | volume = 385 | issue = 9970 | pages = 792–98 | date = February 2015 | pmid = 25467565 | pmc = 4386690 | doi = 10.1016/S0140-6736(14)62052-3 }}<!--|access-date=26 October 2015--></ref> ===Surgery=== Revascularization for [[acute coronary syndrome]] has a mortality benefit.<ref>{{cite journal | vauthors = Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE, Steward DE, Theroux P, Gibbons RJ, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Smith SC | display-authors = 6 | title = ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction—2002: 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 Unstable Angina) | journal = Circulation | volume = 106 | issue = 14 | pages = 1893–900 | date = October 2002 | pmid = 12356647 | doi = 10.1161/01.CIR.0000037106.76139.53 | doi-access = free }}</ref> Percutaneous revascularization for ''stable'' ischaemic heart disease does not appear to have benefits over medical therapy alone.<ref name="pmid24296791">{{cite journal | vauthors = Stergiopoulos K, Boden WE, Hartigan P, Möbius-Winkler S, Hambrecht R, Hueb W, Hardison RM, Abbott JD, Brown DL | display-authors = 6 | title = Percutaneous coronary intervention outcomes in patients with stable obstructive coronary artery disease and myocardial ischemia: a collaborative meta-analysis of contemporary randomized clinical trials | journal = JAMA Internal Medicine | volume = 174 | issue = 2 | pages = 232–40 | date = February 2014 | pmid = 24296791 | doi = 10.1001/jamainternmed.2013.12855 | doi-access = free }}<!--|access-date=26 October 2015--></ref> In those with disease in more than one artery, [[coronary artery bypass graft]]s appear better than [[percutaneous coronary intervention]]s.<ref name="pmid24296767">{{cite journal | vauthors = Sipahi I, Akay MH, Dagdelen S, Blitz A, Alhan C | title = Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease: meta-analysis of randomized clinical trials of the arterial grafting and stenting era | journal = JAMA Internal Medicine | volume = 174 | issue = 2 | pages = 223–30 | date = February 2014 | pmid = 24296767 | doi = 10.1001/jamainternmed.2013.12844 | doi-access = free }}</ref> Newer "anaortic" or no-touch off-pump coronary artery revascularization techniques have shown reduced postoperative stroke rates comparable to percutaneous coronary intervention.<ref>{{cite journal | vauthors = Zhao DF, Edelman JJ, Seco M, Bannon PG, Wilson MK, Byrom MJ, Thourani V, Lamy A, Taggart DP, Puskas JD, Vallely MP | display-authors = 6 | title = Coronary Artery Bypass Grafting With and Without Manipulation of the Ascending Aorta: A Network Meta-Analysis | journal = Journal of the American College of Cardiology | volume = 69 | issue = 8 | pages = 924–36 | date = February 2017 | pmid = 28231944 | doi = 10.1016/j.jacc.2016.11.071 | doi-access = free }}</ref> Hybrid coronary revascularization has also been shown to be a safe and feasible procedure that may offer some advantages over conventional CABG though it is more expensive.<ref>{{cite journal | vauthors = Reynolds AC, King N | title = Hybrid coronary revascularization versus conventional coronary artery bypass grafting: Systematic review and meta-analysis | journal = Medicine | volume = 97 | issue = 33 | pages = e11941 | date = August 2018 | pmid = 30113498 | pmc = 6112891 | doi = 10.1097/MD.0000000000011941 }}</ref>
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