Learning Objectives:
- Identify the risk factors and goals for treatment of patients with chronic stable angina vs. asymptomatic CAD
- Describe the algorithm for the evaluation of suspected coronary artery disease as outlined per ACP (American College of Physicians) and ACC (American College of Cardiology)
- Describe the algorithm for the risk stratification of asymptomatic patients with CAD as per ACP and ACC
- Summarize in detail the 7 recommendations for evaluation and management of patients with chronic stable angina as per the Joint Practice Guidelines of ACP and ACC
- Understand the indications and contraindications of each class of cardiac medications (antiplatelets, B-blockers, lipid-lowering agents, ACE inhibitors, nitrates and CCB) for the prevention of MI and death vs. the reduction of symptoms.
- Review the pharmacotherapy recommendations for the prevention of MI/death and the reduction of symptoms in patients with chronic stable angina vs. asymptomatic patients with CAD
- Discuss the specific strategies (questions to be addressed, frequency of visits, cardiac testing) for the follow-up of patients with CAD by their primary care doctor
Case Reports:
1. A 40-year-old man presents to the office for evaluation of his risk for cardiovascular disease. He has not seen a physician for many years. He works in a business office and is inactive outside of work. He has no cardiac history and no chest pain or dyspnea during his normal activities. His family history is negative for premature coronary artery disease. The patient is a current smoker with a 10 pack-year history.
On physical examination, he is an obese man in no distress. Temperature is normal, blood pressure is 138/75 mm Hg, pulse is 74/min, and respiration rate is 16/min. BMI is 39, and waist circumference is 92 cm. Cardiac examination shows a regular rhythm with distant heart sounds but no murmur or gallop.
Laboratory studies:
Total cholesterol 216 mg/dL (5.6 mmol/L)
HDL cholesterol 38 mg/dL (1.0 mmol/L)
LDL cholesterol 142 mg/dL (3.7 mmol/L)
Triglycerides 180 mg/dL (2.0 mmol/L)
Glucose (fasting) 105 mg/dL (5.8 mmol/L)
Electrocardiogram shows sinus rhythm and nonspecific T-wave abnormalities.
Based on his systolic blood pressure, triglyceride level, and HDL cholesterol level, the patient meets the criteria for the diagnosis of metabolic syndrome.
What is his 10-year risk of a coronary artery disease event?
A) 5%
B) 11%
C) 18%
D) 22%
E) 50%
Which of the following is the most appropriate next step in the management of this patient?
A) Initiate lifestyle modifications
B) Initiate antihypertensive therapy
C) Initiate statin therapy
D) Obtain serum lipoprotein(a) and homocysteine levels
E) Order exercise stress treadmill testing
2. A 65-year-old man is evaluated during a routine follow-up examination for coronary artery disease. He was diagnosed with a myocardial infarction 5 years previously, and was started on medical therapy with aspirin, metoprolol, atorvastatin, lisinopril, and sublingual nitroglycerin. He was asymptomatic until 6 months ago, when he noted exertional angina after walking 4 flights of stairs. He now uses sublingual nitroglycerin on a twice weekly basis. He has not had any episodes of pain at rest or prolonged chest pain that were not relieved by sublingual nitroglycerin. He has hyperlipidemia and hypertension.
Physical examination shows a well-developed man who appears comfortable. Blood pressure is 140/60 mm Hg and heart rate is 85/min. Carotid upstrokes are normal with no bruits. Cardiac examination reveals no murmurs. The lungs are clear. Peripheral pulses are equal throughout and there is no peripheral edema.
His electrocardiogram is unchanged since the last visit, with no evidence of acute changes.
In addition to adding a long-acting nitrate, which of the following is the most appropriate management for this patient?
A) Add ranolazine
B) Increase metoprolol
C) Exercise treadmill stress testing
D) Coronary angiography
3. A 50-year-old man visits the office to discuss his cardiac history. He has a history of a drug eluting stent placement 4 years ago when he was admitted for chest pains but was told he did had a heart attack. Since then, he has been asymptomatic. He is concerned because he recently turned 50 years old, and his father died at age 52 years of a heart attack. He reports that his diet is mostly vegetarian and that he exercises about 4 days per week on a treadmill or stationary bicycle for 30 to 40 minutes. He has a history of cigarette smoking (1 pack per day for 4 years) but stopped at age 22 years. His only medication is a daily baby aspirin.
On physical examination, his blood pressure is 122/68 mm Hg, pulse is 74/min, and respiration rate is 14/min. His BMI is 24. The remainder of his cardiovascular and general physical examination is normal.
Laboratory studies:
Total cholesterol 221 mg/dL (4.9 mmol/L)
HDL cholesterol 72 mg/dL (1.9 mmol/L)
LDL cholesterol 101 mg/dL (2.3 mmol/L)
Triglycerides150 mg/dL (1.7 mmol/L)
An electrocardiogram demonstrates sinus rhythm, with a rate of 64/min.
Which of the following is the most appropriate management for this patient?
A) Begin clopidogrel
B) Begin lisinopril
C) Begin simvastatin
D) Order exercise electrocardiographic stress test
4. A 52-year-old man is evaluated regarding treatment of his coronary artery disease. He had a myocardial infarction 8 years ago and was treated with a coronary stent placed in his right coronary artery. Over the last 8 years he did well with medical therapy, with only mild episodes of exertional angina that resolved with rest or sublingual nitroglycerin. One month ago, he noted worsening of his exertional angina. Coronary angiography showed 50% stenosis of the left main coronary artery, severe disease (75% stenosis) of the left circumflex artery, severe disease (70% stenosis) of the proximal left anterior descending artery, and in-stent restenosis (80%) of the stent within the right coronary artery. Left ventricular systolic function is mildly reduced (ejection fraction, 50%). His medical therapy was increased, and he has remained pain-free with activity. He is active and is a construction worker.
Medical history is notable for diabetes mellitus, hyperlipidemia, and hypertension. Current medications are aspirin, ramipril, atorvastatin, metoprolol, isosorbide mononitrate, diltiazem, and metformin.
Physical examination shows a well-developed man who appears comfortable. Blood pressure is 110/60 mm Hg and heart rate is 60/min. BMI is 28. Neck examination demonstrates a right carotid bruit and no jugular venous distention. Cardiac examination reveals normal heart sounds and no murmurs. Lungs are clear bilaterally and there is no peripheral edema.
Which of the following is the most appropriate treatment for this patient?
A) Enhanced external counterpulsation
B) Percutaneous coronary intervention
C) Start ranolazine
D) Coronary artery bypass graft surgery
Required Reading Materials:
- “Evaluation of Primary Care Patients with Chronic Stable Angina”: Guidelines from the American College of Physicians and the American College of Cardiology, July 2004
- “Primary Care Management of Chronic Stable Angina and Asymptomatic Suspected or Known Coronary Artery Disease”: A Clinical Practice Guideline from the American College of Physicians and the American College of Cardiology, October 2004