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Last Updated: 4/21/2015  

Coronary Heart Disease

Prevention
  • Identify asymptomatic persons at high risk for coronary morbidity and mortality.

  • Modify risk factors for ASCVD, including diabetes mellitus, hypertension, dyslipidemia, obesity, physical inactivity, poor dietary habits, excessive alcohol consumption, and tobacco use.

  • Consider the use of aspirin for primary and secondary prevention in individuals at high risk for ASCVD events.

Screening
  • Do not screen for CHD in asymptomatic persons except in special circumstances.

Diagnosis
  • Use a risk stratification approach based on the estimated pretest probability of CAD.

  • Use exercise electrocardiographic testing as a primary modality in individuals with low pretest probabilities for CAD.

  • Consider the addition of stress radionuclide imaging, stress echocardiography, and invasive coronary angiography in individuals with higher pretest probabilities for CAD.

  • Consider additional testing to evaluate for causes of chest pain other than CAD and to look for cardiac and extracardiac conditions that can produce secondary angina in the absence of significant CAD.

Consultation
  • Consider consulting a cardiovascular disease specialist in the following settings: indeterminate results or high-risk features on noninvasive testing, new onset or newly recognized HF, new onset atrial fibrillation, ventricular arrhythmias, acute coronary syndromes, including MI, refractory angina, and survivors of sudden cardiac arrest.

Hospitalization
  • Evaluate and treat all patients with acute coronary syndromes in a monitored setting.

Therapy
  • Prescribe aspirin and/or dual antiplatelet therapy in all patients with CAD.

  • Implement risk-factor modification as recommended for prevention.

  • Use β-blockers, ACE inhibitors, or ARB therapy and calcium channel blockers as first-line antihypertensives.

  • Consider high-intensity statin therapy in individuals with CAD.

  • Treat angina medically with β-blockers, calcium channel blockers, and long-acting nitrates, and consider the addition of ranolazine in refractory cases.

  • Treat conditions producing secondary angina, such as anemia and HF.

  • Consider coronary revascularization in high-risk patients: those with left-main stenosis, three-vessel CAD, and low LVEF; sudden cardiac arrest survivors; and those with angina refractory to medical therapy.

  • Consider the addition of mineralocorticoid receptor antagonists and/or digitalis glycosides to existing therapy with β-blockers and ACE or ARB therapy in patients with CAD and HF.

  • Refer specific subsets of patients with CAD and LVEF less than 40% for ICD or CRT implantation.

  • Refer patients with CAD and angina, acute coronary syndromes, and ischemic cardiomyopathy for cardiopulmonary rehabilitation.

  • Provide ongoing patient education, monitor for changes in clinical condition, and continue risk-factor modification during all follow-up visits.

DOI: 10.7326/d032
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Author(s) and Disclosures:
Paul R. Sutton, MD, PhD has nothing to disclose. Stephan D. Fihn, MD, MPH has nothing to disclose. Vera Bittner, MD, MSPH is involved in studies for University of Alabama at Birmingham that received research grants and contracts from Amgen, Bayer Healthcare, Janssen Pharma, Pfizer, Sanofi, and AstraZeneca and has consultantships with Amgen and Eli Lilly. Gautam Reddy, MD has nothing to disclose.

One or more of the present or past ACP Smart Medicine physician editors worked on this module and had nothing to disclose: Davoren Chick, MD, FACP; Deborah Korenstein, MD, FACP; Marjorie Lazoff, MD; Richard Lynn, MD, FACP.

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