Chronic Coronary Artery Disease: Diagnosis and Management

Coronary artery disease (CAD) is the single most common cause of death in the developed world, responsible for about 1 in every 5 deaths. The morbidity, mortality, and socioeconomic importance of this disease make timely accurate diagnosis and cost-effective management of CAD of the utmost importance. This comprehensive review of the literature highlights key elements in the diagnosis, risk stratification, and management strategies of patients with chronic CAD. Relevant articles were identified by searching the PubMed database for the following terms: chronic coronary artery disease or stable angina. Novel imaging modalities, pharmacological treatment, and invasive (percutaneous and surgical) interventions have revolutionized the current treatment of patients with chronic CAD. Medical treatment remains the cornerstone of management, but revascularization continues to play an important role. In the current economic climate and with health care reform very much on the horizon, the issue of appropriate use of revascularization is important, and the indications for revascularization, in addition to the relative benefits and risks of a percutaneous vs a surgical approach, are discussed.BMS = bare metal stent; CABG = coronary artery bypass grafting; CAD = coronary artery disease; CCS = Canadian Cardiovascular Society; CT = computed tomography; DES = drug-eluting stent; FFR = fractional flow reserve; LAD = left anterior descending artery; LBBB = left bundle branch block; LV = left ventricular; MI = myocardial infarction; MRI = magnetic resonance imaging; OMT = optimal medical therapy; PCI = percutaneous coronary intervention; SYNTAX = Synergy Between PCI With TAXUS and Cardiac SurgeryChronic coronary artery disease (CAD) is estimated to affect 16.8 million people in the United States; of these, 9.8 million have angina pectoris, and nearly 8 million have had a myocardial infarction (MI).¹ In 2005, CAD was the single most frequent cause of death in American men and women, causing 607,000 deaths (about 1 in every 5 deaths).¹ In 2006, 1.76 million patients were discharged from US hospitals with a diagnosis of CAD. The estimated direct and indirect economic cost of CAD in the United States for 2009 is $165.4 billion.¹ Worldwide, cardiovascular disease is becoming pandemic as developing countries experience the epidemiologic transition described by Omran from pestilence and famine to receding pandemics and degenerative diseases.² In 2002, out of 57 million deaths worldwide, approximately 16.7 million were due to cardiovascular disease (as compared with approximately 5 million due to tuberculosis, human immunodeficiency virus, and malaria combined), and 80% of these cardiovascular deaths were in the developing world.³ Coronary artery disease (including acute MI) is responsible for about half of these cardiovascular deaths.⁴ Mortality from cardiovascular disease is predicted to reach 23.4 million in 2030. Moreover, in the developing world, cardiovascular disease tends to affect people at a younger age and thus could negatively affect the workforce and economic productivity.⁵ The morbidity, mortality, and socioeconomic importance of CAD make its diagnosis and management fundamental for all practicing physicians.The article provides a state-of-the-art review of the literature on chronic CAD for interested physicians; appropriate articles were identified by searching the PubMed database for the following terms: chronic coronary artery disease or stable angina. This article highlights key points in diagnosis and risk stratification and delineates evidence-based management strategies for patients with chronic CAD, with particular emphasis on the indications for revascularization and the preferred method for each patient.