Coronary Artery Disease (CAD)

flowchart TD
    A[CAD] --> B[CCD/SIHD<br>'stable angina']
    A --> C[ACS]
    C --> D[USA]
    C --> E[MI]
    E --> F[NSTEMI]
    E --> G[STEMI]

• Risk Calculation for patients without known CAD

  • ASCVD Risk Calculator
  • PREVENT Risk Calculator
  • MESA Risk Score

• Stress Testing

• Pharmacotherapy

  • Aspirin
  • Hyperlipidemia

• Lifestyle Modifications

  • Diet
    • Mediterranean Diet
    • DASH Diet

• The coronary arterial system consists of epicardial coronary arteries, prearterioles, and arterioles with different sizes, distinct functions, and uninterrupted borders. ¹

  • Myocardial ischemia from the mismatch of demand and supply of coronary artery blood flow to the myocardium can originate from any part of this coronary arterial system
  • 

Figure source: ² - In addition to the ‘classic mechanisms’ (i.e. atherosclerotic disease and vasospastic disease) that lead to myocardial ischaemia, coronary microvascular dysfunction (CMD) has recently emerged as a ‘third’ potential mechanism of myocardial ischaemia. As in the case of the other two mechanisms, coronary microvascular dysfunction (alone or in combination with the other two) can lead to transient myocardial ischaemia as in patients with coronary artery disease (CAD) or cardiomyopathy (CMP) or to severe acute ischaemia as observed in Takotsubo syndrome. CFR, coronary flow reserve.

Primary Prevention

• Healthful lifestyle & diet
  • Mediterranean Diet
• No Routine Aspirin in Primary Prevention if >70 y or if bleeding risk
• Goal LDL: (See Approach to Hyperlipidemia)
  • Known ASCVD <55
  • Primary Prevention < 100
• Three Q’s/Four Groups (See mermaid diagram in Approach to Hyperlipidemia)
  • ASCVD
  • LDL≥190 (Familial Hyperlipidemia)
  • Diabetes
  • Non-DM
• Assess Risk:
  • High-risk
  • Diabetes
  • Risk-enhancers
  • Coronary Artery Calcium (CAC)
• Consider Lp(a) if Fam Hx early ASCVD
• Consider ApoB if TG ≥ 200

Footnotes

1. Hwang, D., Park, S.-H., & Koo, B.-K. (2023). Ischemia With Nonobstructive Coronary Artery Disease. JACC: Asia, 3(2), 169–184. https://doi.org/10.1016/j.jacasi.2023.01.004 ↩

2. Crea F, Camici PG, Bairey Merz CN. Coronary microvascular dysfunction: an update. Eur Heart J. 2014 May;35(17):1101-11. doi: 10.1093/eurheartj/eht513. Epub 2013 Dec 23. PMID: 24366916; PMCID: PMC4006091. ↩