Best Dx/Best Rx: Heart Failure/Coronary Artery Disease

Heart Failure

Mariell Jessup, MD
University of Pennsylvania School of Medicine snd
University of Pennsylvania Health System, Philadelphia, PA

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References

Definition/Key Clinical Features

Defined as a clinical syndrome resulting from structural or functional cardiac disorder that impairs ability of ventricle to fill with or eject blood to meet needs of body
Primary manifestations include

Dyspnea
Fatigue
Fluid retention
Decreased exercise tolerance

Classification by disorder

Dilated cardiomyopathy

Dilatation and impaired function of left ventricle or both ventricles
Multiple etiologies include ischemia, valvular disease, infectious process, inflammatory process, toxins, familial/genetic cause, and idiopathic

Hypertrophic cardiomyopathy

Hypertrophy of left ventricle or both ventricles, often asymmetrical and involving the interventricular septum
Often associated with mutations in sarcoplasmic proteins

Restrictive cardiomyopathy

Usually associated with normal systolic function and impaired diastolic function
Can be idiopathic or associated with infiltrative diseases, such as amyloidosis, sarcoidosis, and endomyocardial fibrosis

Arrhythmogenic right ventricular cardiomyopathy

Replacement of myocardium with fatty tissue; can involve left ventricle as well
Associated with ventricular arrhythmias
May have a genetic component

Classification by underlying disease process

Ischemic heart disease; secondary to coronary artery disease
Valvular disease; caused by primary valvular disorder
Hypertension

Usually associated with left ventricular hypertrophy
Can involve systolic and/or diastolic dysfunction

Diabetes mellitus; associated with systolic and/or diastolic dysfunction and left ventricular hypertrophy, even independent of coexisting hypertension or coronary artery disease
Inflammatory/infectious disease

Systolic dysfunction from myocarditis
Multiple infectious etiologies, both viral (e.g., coxsackievirus, echovirus, HIV) and bacterial (rheumatic fever)

Metabolic disorders; associated with endocrine abnormalities (e.g., hyperthyroidism, hypothyroidism), electrolyte deficiencies (potassium, magnesium), nutritional deficiencies (e.g., beriberi), and glycogen storage disease (e.g., Pompe disease, Gaucher disease)
General systemic disease; associated with connective tissue diseases (e.g., systemic lupus erythematosus, rheumatoid arthritis) and infiltrative diseases (e.g., sarcoidosis, amyloidosis)
Muscular dystrophies; includes Duchenne, Becker, and myotonic muscular dystrophies
Neuromuscular disease; includes Friedreich ataxia and Noonan syndrome
Toxins

Associated with alcohol and cocaine abuse
Treatment with cardiotoxic chemotherapeutic agents (e.g., anthracyclines), and radiation therapy

Tachycardia; associated with uncontrolled tachycardias (e.g., atrial fibrillation and other supraventricular tachycardias)
Genetic/familial disorders

Associated with family history of cardiomyopathy and/or sudden death
Many cardiomyopathies previously designated as idiopathic may fall into this category

Pregnancy; manifests in peripartum period

ACC/AHA guidelines for the evaluation and management available at

ACC/AHA classification, defining four stages of the disorder

Stage A

Identifies patients who are at high risk for developing heart failure but who have no apparent structural abnormality of heart
Patients with systemic hypertension, coronary artery disease, diabetes mellitus, history of cardiotoxic drug therapy or alcohol abuse, history of rheumatic fever, family history of cardiomyopathy
Can be viewed as preclinical stage

Stage B

Denotes patients with structural abnormality of heart but in whom symptoms of heart failure have not yet developed
This group includes patients who have left ventricular hypertrophy or dilatation, a decreased LVEF, or valvular disease, as well as patients with prior myocardial infarction
Can be viewed as preclinical stage

Stage C

Refers to patients who currently have or who in past have had symptoms of heart failure associated with underlying structural heart disease
Patients with dyspnea or fatigue attributable to left ventricular systolic dysfunction; asymptomatic patients undergoing treatment for prior symptoms of heart failure, symptomatic patients with HFpEF

Stage D

Patients with advanced structural heart disease and marked symptoms of heart failure at rest despite maximal medical therapy; need for specialized interventions
Patients who are frequently hospitalized for heart failure and cannot be safely discharged from hospital; patients in hospital awaiting heart transplantation; patients at home receiving continuous intravenous support for symptom relief or support with mechanical circulatory assist device; patients in a hospice setting for the management of heart failure

Incidence in United States

Approaches 10 per 1,000 population after 65 years of age
At 40 years of age, the lifetime risk for both men and women 1 in 5
Did not decline during past two decades, although survival rate has improved overall

Therapy has been shown to have different efficacies depending on racial, ethnic, and genetic backgrounds
Pathophysiologic models

Hemodynamic, concentration on role of increased load on failing ventricle
Neurohormonal, identification of critical importance of renin-angiotensin-aldosterone axis and the sympathetic nervous system in progression of cardiac dysfunction
Mechanical, recognition that progressive ventricular dilatation serves as marker for disease progression has focused attention on myocyte and on role of cardiac interstitium
Other, including important implications of renal disease, role of aortic stiffness and impedance and skeletal muscle vasodilatory capacity

Differential Diagnosis

Acute respiratory distress syndrome
Anaphylaxis
Anemia, acute
Bronchitis
Chronic obstructive pulmonary disease
Emphysema
Hypertension
Hyperventilation syndrome
Myopathies
Pericarditis and cardiac tamponade
Pneumonia
Pneumomediastinum
Pulmonary embolism
Shock, septic

Best Tests

History, medical and genetic

Stage A patients

To identify patients who are at risk for developing the syndrome
To check for risk factors including alcohol abuse or exposure to cardiotoxic drugs (e.g., certain chemotherapeutic agents, cocaine), a history of rheumatic fever, or a family history of cardiomyopathy or sudden death
Reversible risk factors should be aggressively treated to prevent heart failure from developing

Physical examination

Stage A patients

To identify patients who are at risk for developing the syndrome
To check for high blood pressure, signs of lung congestion, abnormal heart sounds, fluid buildup in abdomen and legs
Reversible risk factors should be aggressively treated to prevent heart failure from developing

Stages C and D patients

Weight should be measured to assess for fluid retention
Jugular venous pressure, hepatojugular reflux, gallop rhythm, and peripheral edema can aid in making initial diagnosis and guiding need for diuresis
A 6-minute corridor test is often used to measure functional capacity

Laboratory studies

Stages C and D patients, tests primarily used to exclude other potential causes of dyspnea or fatigue include

Urinalysis
Complete blood count
Serum chemistries
Liver function studies
Thyroid-stimulating hormone measurement
Brain natriuretic peptide [BNP] or NT-proBNP measurement

Marked elevation of natriuretic peptide levels suggests that dyspnea is cardiac rather than pulmonary in origin
Low natriuretic peptide level is quite helpful to exclude heart failure syndrome
Use in diagnosis of heart failure with preserved ejection fraction

Echocardiography

Stage B patients

To uncover left ventricular hypertrophy or dilatation, valvular disease, or wall motion abnormalities indicative of previous myocardial infarction
Current ACC/AHA guidelines do not recommend routine screening echocardiography for large number of patients at risk for development of heart failure; however, they do recommend that noninvasive evaluation of left ventricular function be performed in patients who have strong family history of cardiomyopathy or have been exposed to cardiotoxic therapies

Two-dimensional, with Doppler flow studies

Stages C and D patients, used to exclude other potential causes of dyspnea or fatigue
Use in diagnosis of heart failure with preserved ejection fraction

Electrocardiography

Stages C and D patients, used to exclude other potential causes of dyspnea or fatigue

Chest radiography

Stages C and D patients, used to exclude other potential causes of dyspnea or fatigue

Coronary angiography

Stages C and D patients, ACC/AHA guidelines strongly encourage using this test rather than noninvasive testing for evaluation of patients with heart failure

Best Therapy*

Treatment for heart failure is keyed to stage of syndrome as defined by ACC/AHA guidelines and is aimed at preventing or palliating remodeling process
Stage A

Goal is to prevent structural heart disease which is achieved by controlling risk factors
Treat hypertension

Decreases left ventricular hypertrophy and cardiovascular mortality
Can also reduce the incidence of heart failure by 30 to 50%

Encourage smoking cessation
Treat lipid disorders
Encourage regular exercise
Discourage alcohol intake and illicit drug use
Prescribe ACE inhibitors or ARBs in appropriate patients with vascular disease or diabetes

Stage B

Treat hypertension
Encourage smoking cessation
Treat lipid disorders
Encourage regular exercise
Discourage alcohol intake, illicit drug use
Prescribe ACE inhibitors or ARBs in appropriate patients with vascular disease or diabetes

Captopril (Capoten)

Initial Daily Dose: 6.25 mg t.i.d.
Maximum Daily Dose: 50 mg t.i.d.
Carefully monitor serum potassium and creatinine levels

Enalapril (Vasotec)

Initial Daily Dose: 2.5 mg b.i.d.
Maximum Daily Dose: 10–20 mg b.i.d.
Carefully monitor serum potassium and creatinine levels

Fosinopril (Monopril)

Initial Daily Dose: 5–10 mg
Maximum Daily Dose: 40 mg
Carefully monitor serum potassium and creatinine levels

Lisinopril (Prinivil, Zestril)

Initial Daily Dose: 2.5–5 mg
Maximum Daily Dose: 20–40 mg
Carefully monitor serum potassium and creatinine levels

Quinapril (Accupril)

Initial Daily Dose: 10 mg b.i.d.
Maximum Daily Dose: 40 mg b.i.d.
Carefully monitor serum potassium and creatinine levels

Ramipril (Altace)

Initial Daily Dose: 1.25–2.5 mg
Maximum Daily Dose: 10 mg
Carefully monitor serum potassium and creatinine levels

Candesartan (Atacand)

Initial Daily Dose: 4 mg
Maximum Daily Dose: 32 mg
Use if patients have cough or angioedema on ACE inhibitor; may be used as first-line therapy

Irbesartan (Avapro)

Initial Daily Dose: 75 mg
Maximum Daily Dose: 300 mg
Use if patients have cough or angioedema on ACE inhibitor; may be used as first-line therapy
This drug is not approved for use in the United States for heart failure

Losartan (Cozaar)

Initial Daily Dose: 25 mg
Maximum Daily Dose: 150 mg
Use if patients have cough or angioedema on ACE inhibitor; may be used as first-line therapy
This drug is not approved for use in the United States for heart failure

Valsartan (Diovan)

Initial Daily Dose: 80 mg
Maximum Daily Dose: 320 mg
Use if patients have cough or angioedema on ACE inhibitor; may be used as first-line therapy

Prescribe beta blockers if appropriate

Bisoprolol (Zebeta)

Initial Daily Dose: 1.25 mg
Maximum Daily Dose: 10 mg
Titrate dosage up over 2- to 4-week intervals, carefully monitoring for signs and symptoms of fluid overload
This drug is not approved for use in the United States for heart failure

Carvedilol (Coreg)

Initial Daily Dose: 3.125 mg b.i.d.
Maximum Daily Dose: 25 mg b.i.d. (50 mg b.i.d. for patients > 85 kg)
Titrate dosage up over 2- to 4-week intervals, carefully monitoring for signs and symptoms of fluid overload

Metoprolol succinate extended release (Toprol-XL)

Initial Daily Dose: 12.5–25 mg
Maximum Daily Dose: 200 mg
Titrate dosage up over 2- to 4-week intervals, carefully monitoring for signs and symptoms of fluid overload

Nebivolol (Bystolic)

Initial Daily Dose: 2.5 mg
Maximum Daily Dose: 40 mg
Titrate dosage up over 2- to 4-week intervals, carefully monitoring for signs and symptoms of fluid overload
This drug is not approved for use in the United States for heart failure

Stage C

Therapy intended to relieve the disabling symptoms of the disease
Treat hypertension
Encourage smoking cessation
Treat lipid disorders
Encourage regular exercise
Discourage alcohol intake, illicit drug use
Dietary salt restriction
Drugs for routine use:

ACE inhibitors or ARBs

Captopril (Capoten)

Initial Daily Dose: 6.25 mg t.i.d.
Maximum Daily Dose: 50 mg t.i.d.
Carefully monitor serum potassium and creatinine levels

Enalapril (Vasotec)

Initial Daily Dose: 2.5 mg b.i.d.
Maximum Daily Dose: 10–20 mg b.i.d.
Carefully monitor serum potassium and creatinine levels

Fosinopril (Monopril)

Initial Daily Dose: 5–10 mg
Maximum Daily Dose: 40 mg
Carefully monitor serum potassium and creatinine levels

Lisinopril (Prinivil, Zestril)

Initial Daily Dose: 2.5–5 mg
Maximum Daily Dose: 20–40 mg
Carefully monitor serum potassium and creatinine levels

Quinapril (Accupril)

Initial Daily Dose: 10 mg b.i.d.
Maximum Daily Dose: 40 mg b.i.d.
Carefully monitor serum potassium and creatinine levels

Ramipril (Altace)

Initial Daily Dose: 1.25–2.5 mg
Maximum Daily Dose: 10 mg
Carefully monitor serum potassium and creatinine levels

Candesartan (Atacand)

Initial Daily Dose: 4 mg
Maximum Daily Dose: 32 mg
Use if patients have cough or angioedema on ACE inhibitor; may be used as first-line therapy

Irbesartan (Avapro)

Initial Daily Dose: 75 mg
Maximum Daily Dose: 300 mg
Use if patients have cough or angioedema on ACE inhibitor; may be used as first-line therapy
This drug is not approved for use in the United States for heart failure

Losartan (Cozaar)

Initial Daily Dose: 25 mg
Maximum Daily Dose: 150 mg
Use if patients have cough or angioedema on ACE inhibitor; may be used as first-line therapy
This drug is not approved for use in the United States for heart failure

Valsartan (Diovan)

Initial Daily Dose: 80 mg
Maximum Daily Dose: 320 mg
Use if patients have cough or angioedema on ACE inhibitor; may be used as first-line therapy

Beta blockers

Bisoprolol (Zebeta)

Initial Daily Dose: 1.25 mg
Maximum Daily Dose: 10 mg
Titrate dosage up over 2- to 4-week intervals, carefully monitoring for signs and symptoms of fluid overload
This drug is not approved for use in the United States for heart failure

Carvedilol (Coreg)

Initial Daily Dose: 3.125 mg b.i.d.
Maximum Daily Dose: 25 mg b.i.d. (50 mg b.i.d. for patients > 85 kg)
Titrate dosage up over 2- to 4-week intervals, carefully monitoring for signs and symptoms of fluid overload

Metoprolol succinate extended release (Toprol-XL)

Initial Daily Dose: 12.5–25 mg
Maximum Daily Dose: 200 mg
Titrate dosage up over 2- to 4-week intervals, carefully monitoring for signs and symptoms of fluid overload

Nebivolol (Bystolic)

Initial Daily Dose: 2.5 mg
Maximum Daily Dose: 40 mg
Titrate dosage up over 2- to 4-week intervals, carefully monitoring for signs and symptoms of fluid overload
This drug is not approved for use in the United States for heart failure

Diuretics for fluid retention

Bumetanide (Bumex)

Initial Daily Dose: 0.5–1 mg q.d. or b.i.d.
Maximum Daily Dose: Up to 10 mg
Titrate to achieve dry weight; carefully monitor serum potassium and creatinine levels

Furosemide (Lasix)

Initial Daily Dose: 20–40 mg q.d. or b.i.d.
Maximum Daily Dose: Up to 400 mg
Titrate to achieve dry weight; carefully monitor serum potassium and creatinine levels

Torsemide (Demadex)

Initial Daily Dose: 10–20 mg q.d. or b.i.d.
Maximum Daily Dose: Up to 200 mg
Titrate to achieve dry weight; carefully monitor serum potassium and creatinine levels

Drugs or devices for selected patients:

Aldosterone antagonists

Spironolactone (Aldactone)

Initial Daily Dose: 12.5 mg q.d.
Maximum Daily Dose: 100 mg q.d.
50 mg q.d. was maximum spironolactone dosage used
In RALES trial; use carefully with concurrent ACE inhibitor or ARB; carefully monitor serum potassium and creatinine levels; use if potassium < 5.0 mmol/L, creatinine < 2.5 mg/dL

Eplerenone (Inspra)

Initial Daily Dose: 12.5 mg q.d.
Maximum Daily Dose: 50 mg q.d.
50 mg q.d. was maximum spironolactone dosage used
In RALES trial; use carefully with concurrent ACE inhibitor or ARB; carefully monitor serum potassium and creatinine levels; use if potassium < 5.0 mmol/L, creatinine < 2.5 mg/dL

Digitalis

Digoxin (Lanoxin)

Initial Daily Dose: 0.125–0.25 mg
Maximum Daily Dose: 0.125–0.25 mg
Narrow therapeutic window; monitor levels carefully in older patients and those with renal insufficiency

Other vasodilators
Biventricular pacing
Implantable defibrillators

Stage D

Therapy intended to relieve the disabling symptoms of the disease
Treat hypertension
Encourage smoking cessation
Treat lipid disorders
Encourage regular exercise
Discourage alcohol intake, illicit drug use
Dietary salt restriction
Drugs for routine use:

ACE inhibitors or ARBs

Captopril (Capoten)

Initial Daily Dose: 6.25 mg t.i.d.
Maximum Daily Dose: 50 mg t.i.d.
Carefully monitor serum potassium and creatinine levels

Enalapril (Vasotec)

Initial Daily Dose: 2.5 mg b.i.d.
Maximum Daily Dose: 10–20 mg b.i.d.
Carefully monitor serum potassium and creatinine levels

Fosinopril (Monopril)

Initial Daily Dose: 5–10 mg
Maximum Daily Dose: 40 mg
Carefully monitor serum potassium and creatinine levels

Lisinopril (Prinivil, Zestril)

Initial Daily Dose: 2.5–5 mg
Maximum Daily Dose: 20–40 mg
Carefully monitor serum potassium and creatinine levels

Quinapril (Accupril)

Initial Daily Dose: 10 mg b.i.d.
Maximum Daily Dose: 40 mg b.i.d.
Carefully monitor serum potassium and creatinine levels

Ramipril (Altace)

Initial Daily Dose: 1.25–2.5 mg
Maximum Daily Dose: 10 mg
Carefully monitor serum potassium and creatinine levels

Candesartan (Atacand)

Initial Daily Dose: 4 mg
Maximum Daily Dose: 32 mg
Use if patients have cough or angioedema on ACE inhibitor; may be used as first-line therapy

Irbesartan (Avapro)

Initial Daily Dose: 75 mg
Maximum Daily Dose: 300 mg
Use if patients have cough or angioedema on ACE inhibitor; may be used as first-line therapy
This drug is not approved for use in the United States for heart failure

Losartan (Cozaar)

Initial Daily Dose: 25 mg
Maximum Daily Dose: 150 mg
Use if patients have cough or angioedema on ACE inhibitor; may be used as first-line therapy
This drug is not approved for use in the United States for heart failure

Valsartan (Diovan)

Initial Daily Dose: 80 mg
Maximum Daily Dose: 320 mg
Use if patients have cough or angioedema on ACE inhibitor; may be used as first-line therapy

Beta blockers

Bisoprolol (Zebeta)

Initial Daily Dose: 1.25 mg
Maximum Daily Dose: 10 mg
Titrate dosage up over 2- to 4-week intervals, carefully monitoring for signs and symptoms of fluid overload
This drug is not approved for use in the United States for heart failure

Carvedilol (Coreg)

Initial Daily Dose: 3.125 mg b.i.d.
Maximum Daily Dose: 25 mg b.i.d. (50 mg b.i.d. for patients > 85 kg)
Titrate dosage up over 2- to 4-week intervals, carefully monitoring for signs and symptoms of fluid overload

Metoprolol succinate extended release (Toprol-XL)

Initial Daily Dose: 12.5–25 mg
Maximum Daily Dose: 200 mg
Titrate dosage up over 2- to 4-week intervals, carefully monitoring for signs and symptoms of fluid overload

Nebivolol (Bystolic)

Initial Daily Dose: 2.5 mg
Maximum Daily Dose: 40 mg
Titrate dosage up over 2- to 4-week intervals, carefully monitoring for signs and symptoms of fluid overload
This drug is not approved for use in the United States for heart failure

Diuretics for fluid retention

Bumetanide (Bumex)

Initial Daily Dose: 0.5-1 mg q.d. or b.i.d.
Maximum Daily Dose: Up to 10 mg
Titrate to achieve dry weight; carefully monitor serum potassium and creatinine levels

Furosemide (Lasix)

Initial Daily Dose: 20-40 mg q.d. or b.i.d.
Maximum Daily Dose: Up to 400 mg
Titrate to achieve dry weight; carefully monitor serum potassium and creatinine levels

Torsemide (Demadex)

Initial Daily Dose: 10-20 mg q.d. or b.i.d.
Maximum Daily Dose: Up to 200 mg
Titrate to achieve dry weight; carefully monitor serum potassium and creatinine levels

Drugs or devices for selected patients:

Aldosterone antagonists

Spironolactone (Aldactone)

Initial Daily Dose: 12.5 mg q.d.
Maximum Daily Dose: 100 mg q.d.
50 mg q.d. was maximum spironolactone dosage used
In RALES trial; use carefully with concurrent ACE inhibitor or ARB; carefully monitor serum potassium and creatinine levels; use if potassium < 5.0 mmol/L, creatinine < 2.5 mg/dL

Eplerenone (Inspra)

Initial Daily Dose: 12.5 mg q.d.
Maximum Daily Dose: 50 mg q.d.
50 mg q.d. was maximum spironolactone dosage used
In RALES trial; use carefully with concurrent ACE inhibitor or ARB; carefully monitor serum potassium and creatinine levels; use if potassium < 5.0 mmol/L, creatinine < 2.5 mg/dL

Digitalis

Digoxin (Lanoxin)

Initial Daily Dose: 0.125–0.25 mg
Maximum Daily Dose: 0.125–0.25 mg
Narrow therapeutic window; monitor levels carefully in older patients and those with renal insufficiency

Other vasodilators
Biventricular pacing
Implantable defibrillators

Mechanical assist devices
Heart transplantation
Continuous (not intermittent) I.V. inotropic infusions for palliation
Hospice care
Experimental surgery or drugs

Best References

Hood WB Jr, Dans AL, Guyatt GH, et al. J Card Fail 10:155–64, 2004 [PMID 15101028]

Lloyd-Jones DM, Larson MG, Leip EP, et al. Circulation 106:3068–72, 2002 [PMID 12473553]

McMurray J, Pfeffer MA. Circulation 105:2099–106, 2002 [PMID 11980691]

McMurray J, Pfeffer MA. Circulation 105:2223–8, 2002 [PMID 11994259]

Pfisterer M, Buser P, Rickli H, et al. JAMA 301:383–92, 2009 [PMID 19176440]

* To obtain additional drug information, click on the DrugInfo tab in the left column, or click on the following link: http://search.medscape.com/drug-reference-search?queryText=

The author has served as a member of the Medtronic Independent Physician Quality Panel for which she receives a modest honorarium. The Heart Failure/Transplant program with which she is associated at the Hospital of the University of Pennsylvania receives research grants from Amgen, Celladon, Scios, and Medtronic.

February 2010

Coronary Artery Disease

Mariell Jessup, MD
University of Pennsylvania School of Medicine and
University of Pennsylvania Health System, Philadelphia, PA

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References

Definition/Key Clinical Features

Defined as a complex disease in which plaque builds up inside the coronary arteries that causes reduced or absent blood flow; the disease may be focal or diffuse
Usually a degenerative disease, uncommon as a clinical problem before age of 30 years and common by age of 60 years
Resulting ischemic cardiomyopathy, most common cause of heart failure with systolic dysfunction in United States
Associated with roughly two thirds of cases of heart failure in United States
Patients with diabetes mellitus have a high incidence of CAD
Disease symptoms include

Chest pain (angina)

Usually triggered by physical or emotional stress
Typically goes away within minutes after stopping stressful activity
Pain may be fleeting or sharp and may spread to the left arm or neck, back, throat, or jaw

Numbness or a loss of feeling, may be present in the arms, shoulders, or wrists
Shortness of breath, may develop with exertion
Extreme fatigue, may develop with exertion
Heart attack

Presented as pressure in chest and pain in shoulder or arm, sometimes with shortness of breath and sweating
Sometimes occurs without any apparent signs or symptoms

Risk factors include

Hypertension, high systolic pressure seems to be most significant
Hypercholesterolemia, specifically serum LDL concentrations
Diabetes
Obesity
Smoking
High stress
Physical inactivity
Family history of heart disease

Prevention centers on modifying risk factors by avoiding a sedentary lifestyle, making healthy dietary choices, and stopping smoking

Differential Diagnosis

Angina pectoris
Aortic stenosis
Cardiac arrhythmia
Congestive heart failure
Cardiomyopathy
Gastric ulcer
Gastroesophageal reflux
Hiatal hernia
Hypertension
Myocardial infarction

Best Tests

History, medical and genetic

To identify patients who are at risk for developing the disease
To check for risk factors
To determine family history of heart disease, stroke, high blood pressure or diabetes, and any major stresses or recent life changes

Physical examination

To identify patients who are at risk for developing the disease
To check for high blood pressure, high cholesterol, abnormal heart sounds, fluid buildup in abdomen and legs
Reversible risk factors should be aggressively treated to prevent disease development

Laboratory studies

Lipid panel, blood sugar, hsCRP

Electrocardiogram (ECG or EKG)

Stress test, to show how heart responds to increasing exercise
Can often reveal evidence of a previous heart attack or one that's in progress

Echocardiography

Used to identify wall motion abnormalities
Can be used to evaluate hemodynamically significant valvular stenoses

Nuclear imaging

Used to assess patient's exercise tolerance and to identify zones of inducible ischemia, and/or to assess myocardial viability
Can be used to quantify coronary flow reserve

Used to depict zones of impaired blood supply

CT scan

Multidetector-row, used to clarify coronary anatomy and to determine whether a vessel is occluded

Coronary angiography

Considered the criterion standard for evaluating coronary artery disease

CT angiography (CTA)

Multidetector-row, has shown potential as screening alternative to coronary angiography for the identification of coronary blockages

Best Therapy*

Drug therapy

Cholesterol-reducing agents, particularly statins, to decrease primary material that deposits on coronary arteries
Aspirin, to reduce blood clots forming at sites of blockages
Beta blockers, to block the effects of chemical and hormonal signals to heart, and to decrease heart rate to decrease myocardial oxygen demand
Nitroglycerin, to widen or dilate arteries and improve blood flow to heart
Angiotensin-converting enzyme (ACE) inhibitors, to decrease blood pressure and may help prevent progression of coronary artery disease
Calcium channel blockers, to keep arteries open and reduce blood pressure by relaxing smooth muscle that surrounds arteries

Surgical therapy

Angioplasty and surgical revascularization improve ischemic symptoms and can lead to improved cardiac function
Coronary artery bypass surgery, a graft is created to bypass blocked arteries which allows blood to flow around blocked or narrowed artery; most often reserved for cases of multiple narrowed coronary arteries; may be a better alternative in diabetic patients

Best References

Klein L, Gheorghiade M. Med Clin North Amer 88:1209-35, 2004 [PMID 15331314]

Lloyd-Jones D, Adams R, Carnethon M, et al. Circulation 119:480-6; 2009 [PMID 19171871]

Massie B, Shah N. Am Heart J 133:703-12; 1997 [PMID 9200399]

Wilhelmsen L, Rosengren A, Eriksson H, Lappas G. J Intern Med 249:253-61, 2001 [PMID 11285045]

* To obtain additional drug information, click on the DrugInfo tab in the left column, or click on the following link: http://search.medscape.com/drug-reference-search?queryText=

February 2010