Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

The Medical Treatment of Stable Angina

Introduction The Context Medical therapy of stable angina aims to address the key factor mediating myocardial ischemia: oxygen supply/demand imbalance. Pain is not the only symptom that a patient with myocardial ischemia may experience; there may also be severe fatigue, dyspnea, abdominal pain, nausea, sweating, and, occasionally, a sense of imminent death (angor animi) . Understanding cardiac pain requires knowledge of the interplay of ischemic, metabolic,…

Obesity and the Obesity Paradox

Introduction After smoking, obesity is probably the second leading cause of preventable death in the United States and most of the westernized world. The estimated prevalence of obesity is almost 80 million, with close to 130 million in the United States being overweight, and currently almost 10 million being severely obese. In fact, during the past 50 years, the average life expectancy in the United States…

Lifestyle Interventions

More than 90% of all cardiovascular disease (CVD) deaths are thought to be preventable through lifestyle changes. In the INTERHEART study, a case-control study of myocardial infarction (MI) in 52 countries worldwide, nine lifestyle-related risk factors accounted for 90% of the risk in men and 94% of the risk in women. The nine risk factors were: (1) abnormal lipids, (2) smoking, (3) hypertension, (4) diabetes, (5)…

Global Risk Assessment

Introduction This chapter is focused on tools for risk assessment in patients with stable coronary heart disease. In general, patients with stable ischemic heart disease have a good prognosis. However, these data summarize the population average, and the clinician is able to significantly refine the estimate of risk for the individual using methods described in this chapter.The central goal of risk assessment is to guide therapeutic…

Goals of Therapy

By its definition, chronic stable coronary artery disease (CAD) refers predominantly to patients who have a prior history of or current demonstrable obstructive atherosclerotic disease of the epicardial coronary arteries and who are either asymptomatic, or have stable symptoms, with no evidence of recent symptomatic, hemodynamic, or electrical decompensation. Because the process of atherosclerosis usually evolves over several decades, the natural history of CAD typically involves…

Putting It All Together: Which Test for Which Patient?

The Challenge of Noninvasive Test Selection for Stable Chest Pain The prevalence of angina is high in the general population and increases with age in both sexes, from approximately 3% to 4% in patients aged 40–59 years to 10% to 11% in those older than 80 years old. New-onset stable chest pain among patients without known coronary artery disease (CAD) is a common clinical problem that…

Invasive Testing

When noninvasive testing for coronary artery disease (CAD) is inconclusive or suggests significant pathology, invasive testing is necessary. X-ray coronary angiography provides an overview of the coronary circulation and in particular helps to identify obstructive epicardial CAD. However, the coronary angiogram is often misleading. Significant-appearing CAD may not be responsible for myocardial ischemia and symptoms, whereas occult diffuse epicardial disease not apparent on the angiogram can…

CT and MRI

Introduction There are multiple aspects of imaging in the context of coronary artery disease. On the one hand, imaging is used to identify the presence of coronary artery stenoses, through two possible approaches. One approach is to visualize ischemia as the consequence of hemodynamically relevant coronary artery lesions. In clinical practice, this is most frequently done by stress echocardiography, stress cardiac magnetic resonance, or nuclear medicine…

Nuclear Imaging and PET

Fundamentals of Radionuclide Imaging Radionuclide imaging techniques are widely used in the evaluation of patients with known or suspected coronary artery disease (CAD). The basic principle underlying this approach is the use of radiolabeled agents or radiopharmaceuticals that are injected intravenously and enter viable cells (e.g., myocytes, autonomic neurons) or bind to cell receptors or other targets. These techniques use radiolabeled drugs or radiopharmaceuticals, which are…

Echocardiography

Introduction Over many decades, echocardiography has evolved considerably to provide a comprehensive assessment of cardiac structure and function in a truly bedside manner. Echocardiography is a readily available technique that is portable, inexpensive, and free from radiation. Echocardiographic imaging modalities now include M-mode, two-dimensional, flow Doppler, color flow mapping, tissue Doppler, contrast, three-dimensional, and speckle-tracking strain imaging. Echocardiography may also be applied in conjunction with exercise…

ECG and Standard Exercise Stress Testing

Introduction The 12-lead electrocardiogram (ECG) has remained the standard initial evaluation tool in patients with suspected or known ischemic and electrophysiologic cardiac conditions for more than half a century. With the first description of the string galvanometer by Einthoven in the early part of the 20th century, the electrical activity of the human heart could be directly represented in an interpretable format. Advances in ECG technology…

Standard and Novel Biomarkers

Introduction Several diagnostic tools exist to clinically assess the prevalence and severity of coronary heart disease and to enhance the ability to identify the “vulnerable” patient at risk of developing cardiovascular events. In addition, the assessment of biomarkers is one option to improve the diagnosis of disease, to better identify high-risk individuals, to improve prognostication, and to optimize the selection of and response to chronic artery…

Lipid Measurements

Introduction Atheromatous plaque in arterial wall is the pathologic substrate for myocardial infarction and ischemic stroke and is intimately related to the deposition of oxidized lipids from the circulation into the subintimal space, initiating a vicious cycle of local inflammation, macrophage foam cell formation, and smooth muscle recruitment. The measurement of circulating lipids has led to significant improvements not only in understanding the pathophysiology of atherosclerotic…

History and Physical Examination

Introduction Despite continuing technological advances in cardiovascular medicine, the history and physical examination remain vital to establish an accurate diagnosis of chronic coronary artery disease (CAD). Whereas many patients may describe typical angina, providers cannot rely on these symptoms alone to diagnose ischemia because silent (asymptomatic) ischemia remains a common presentation, estimated to affect almost half of patients with CAD. Conversely, some patients may endorse symptoms…

Precipitants of Myocardial Ischemia

Introduction Myocardial ischemia occurs when the ability to supply oxygen and nutrients to the myocardium is exceeded by the myocardium’s oxygen and nutrient requirements. The heart is primarily an aerobic organ and has a narrow threshold for a deficit in oxygen delivery. The myocardium, and consequently the coronary circulation, must be able to adapt quickly to meet the body’s varying hemodynamic requirements. The development of acute…

Coronary Microvascular Dysfunction

Introduction Atherosclerotic disease of the epicardial coronary arteries has been recognized as the cause of angina pectoris for more than 2 centuries, and sudden thrombotic occlusion of an epicardial coronary artery has been well established as the cause of acute myocardial infarction (AMI) for more than 100 years. The introduction of coronary arteriography in the late 1950s has made it possible to visualize the contour of…

Basic Mechanisms of Atherosclerosis

Introduction Atherosclerosis is a chronic inflammatory process triggered by accumulation of cholesterol-containing low-density lipoprotein (LDL) particles in the arterial wall. Major etiologic factors include hyperlipidemia, hypertension, diabetes, and cigarette smoking, all of which are thought to initiate and promote vascular inflammation. The notion of atherosclerosis as an inflammatory disease has emerged based on observations of immune activation and inflammatory signaling in human atherosclerotic lesions, inflammatory biomarkers…

Genetics of Coronary Atherosclerosis

Introduction This chapter reviews current understanding of the genetic architecture of coronary atherosclerosis as gleaned from Mendelian and common, complex forms of the disease. Newly identified pathways and biologic mechanisms are highlighted before discussing the present and future role of genetic testing for the diagnosis, prognosis, and treatment of patients with coronary artery disease (CAD). Heritability of Coronary Artery Disease Familial clustering of CAD has long…

The Global Perspective of Ischemic Heart Disease

Introduction Cardiovascular disease (CVD) and specifically ischemic heart disease (IHD) have long been the leading cause of death in high-income countries (HICs); indeed, “disease of the heart,” in all its manifestations, has topped the Centers for Disease Control and Prevention cause of death list since 1921. Coronary artery disease accounts for the majority of this disease burden. With the progression of global development, the burden of…

Epidemiology of Chronic Coronary Artery Disease

Introduction Coronary artery disease (CAD) is a major cause of death and disability in developed countries. Although CAD mortality rates worldwide have declined over the past 4 decades, CAD remains responsible for approximately one-third or more of all deaths in individuals over age 35, and it has been estimated that nearly half of all middle-aged men and one-third of middle-aged women in the United States will…