Phys · cardiovascular
Coronary Artery Disease
Also known as ischaemic heart disease · coronary heart disease · acute coronary syndrome · ACS · myocardial infarction · STEMI · NSTEMI · unstable angina · stable angina · chronic coronary syndrome
Consultant-physician-depth guide to coronary artery disease — atherosclerotic pathophysiology, stable angina, the ACS spectrum (UA/NSTEMI/STEMI), troponin and ECG interpretation, acute reperfusion strategy, and secondary prevention — structured for FRACP DWE and DCE preparation.
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Target exams
Red flags
- Acute ischaemic chest pain with ST elevation — STEMI requiring immediate reperfusion
- Chest pain with haemodynamic compromise or cardiogenic shock
- New mechanical complication post-MI: VSD, papillary muscle rupture, free wall rupture (days 1–5)
- Sustained ventricular tachycardia or ventricular fibrillation post-MI
- Troponin rise with ongoing chest pain but nondiagnostic ECG — high-risk NSTE-ACS needing early angiography
Coronary Artery Disease
Meet the patient
A 66-year-old taxi driver arrives with three episodes of crushing central chest pain at rest over 24 hours, the last four hours ago, on a background of type 2 diabetes, hypertension, hyperlipidaemia and a 40-pack-year smoking habit. His ECG shows dynamic ST depression in V4 to V6, and his troponin is positive. He is having a high-risk non-ST-elevation myocardial infarction, and the next decision is the timing of his angiogram.[1]
The two questions his stem plants are the two that govern every coronary patient: is the artery occluded? (the ECG answers within ten minutes) and is the risk high enough to warrant an invasive strategy? (a score answers over the next hours). Hold those two, and the spectrum below slots into place.[1]
References9ShowHide
- [1]Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease N Engl J Med, 2009.PMID 19228612
- [2]Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease N Engl J Med, 2007.PMID 17387127
- [3]Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation N Engl J Med, 2001.PMID 11519503
- [4]Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes N Engl J Med, 2009.PMID 19717846
- [5]Sabatine MS, Giugliano RP, Keech AC, et al. Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease N Engl J Med, 2017.PMID 28304224
- [6]Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes N Engl J Med, 2007.PMID 17982182
- [7]Cannon CP, Blazing MA, Giugliano RP, et al. Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes N Engl J Med, 2015.PMID 26039521
- [8]Mega JL, Braunwald E, Wiviott SD, et al. Rivaroxaban in patients with a recent acute coronary syndrome N Engl J Med, 2012.PMID 22077192
- [9]Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients N Engl J Med, 2000.PMID 10639539