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Last Updated: 9/3/2014  

Coronary Heart Disease

Prevention
  • Encourage smoking cessation, regular physical activity, and a diet rich in fresh fruits and vegetables and low in cholesterol, saturated fats, and refined sugars.

  • Screen for dyslipidemia in asymptomatic, average-risk men over age 35 and women over age 45 and use a risk calculator to identify patients who may benefit from statin therapy.

  • Treat hypertension to <140/90 mm Hg in most patients and <150/90 mm Hg in patients over age 60.

  • Assess the benefits and risks of aspirin for primary prevention in patients with multiple CHD risk factors.

Screening
  • Do not screen for CHD in low-risk asymptomatic persons.

Diagnosis
  • Determine the pretest probability of CHD based on the type of pain (angina, atypical angina, noncardiac chest pain) and the presence of cardiac risk factors.

  • Examine patients for signs of CHD and comorbid diseases that may precipitate angina (e.g., hypertrophic obstructive cardiomyopathy, aortic stenosis, anemia, hyperthyroidism, cocaine use).

  • Obtain a resting ECG in all patients without an obvious noncardiac cause of chest pain.

  • Obtain a chest X-ray in all patients with HF, valvular heart disease, pericardial disease, or aortic dissection or aneurysm.

  • Obtain echocardiography in patients with possible valvular disease or outflow obstruction, HF, or history of MI.

  • Perform an exercise treadmill test in patients who are able to exercise and do not have baseline abnormalities on their resting ECG.

Therapy
  • Encourage smoking cessation, regular physical activity, and a diet rich in fresh fruits and vegetables and low in cholesterol, saturated fats, and refined sugars.

  • Prescribe β-blockers as the first-line anti-anginal therapy and calcium-channel blockers as the second-line treatment.

  • Add long-acting nitrates to β-blockers or calcium-channel antagonists or as monotherapy in patients not tolerant of first-line agents.

  • Begin all patients on aspirin and high-intensity statin therapy, and most patients on an ACE inhibitor.

  • Refer patients at high risk for death due to CHD or with persistent symptoms despite maximal medical therapy for evaluation for revascularization, including those with left-main stenoses ≥50%; severely symptomatic patients with three-vessel disease (stenoses ≥70%); high-risk exercise treadmill scores; multiple moderate or single large anterior perfusion defect on stress imaging; and LV function ≤35% to 40%.

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.
Authors and Disclosures:
Paul R. Sutton, MD, PhD has nothing to disclose. Stephan D. Fihn, MD, MPH has nothing to disclose. John F. Beltrame, BSc, BMBS, FRACP, PhD, FESC, FACC, FCSANZ was involved in a collaborative study that surveyed chronic stable angina patients with Servier Pharmaceuticals and Adelaide University, and reports that a consultancy fee was paid for Adelaide University, and will be supported by a grant to Adelaide University from Servier Pharmaceuticals..

The following editors of ACP Smart Medicine have nothing to disclose: Deborah Korenstein, MD, FACP, Editor in Chief; Richard B. Lynn, MD, FACP, Editor; and Davoren Chick, MD, FACP, Editor.

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