What are the guideline sources, guidelines and references for Coronary artery disease ?
Guideline sources The following summarized guidelines for the evaluation and management of coronary artery disease (CAD) are prepared by our editorial team based on guidelines from the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the European Society of Cardiology (ESC/EACTS 2019), the European Society of Cardiology (ESC/ESVS 2018), the American College of Endocrinology (ACE/AACE 2016), the Society for Cardiovascular Angiography and Interventions (SCAI/PCNA/STS/AATS/AHA/ACC 2014), and the American Heart Association (AHA/ACC 2014; 2010). 1 2 3 5 6 8 9 10 10 10 11 12 Definition https://web.pathway.md/diseases/recSHPrW2vaQCzHTn 1/7 6/23/23, 3:37 AM Coronary artery disease Pathway CAD is a disorder characterized by a reduction in blood flow to the myocardium caused by formation of atherosclerotic plaque in the coronary arteries. 10 Epidemiology The process leading to the development of atherosclerotic plaques in the coronary arteries can be divided into five key steps, which are 1) endothelial dysfunction, 2) formation of lipid layer or fatty streak within the intima, 3) migration of leukocytes and smooth muscle cells into the vessel wall, 4) foam cell formation and 5) proliferation of extracellular matrix. 10 Pathophysiology In the United States, the prevalence of CAD in adults 40 years of age is estimated at 8.0%. 11 Disease course CAD can manifest as various clinical syndromes, which include stable angina, unstable angina, myocardial infarction, ischemic cardiomyopathy, and sudden cardiac death. 10 Prognosis and risk of recurrence In patients with multivessel CAD undergoing revascularization with CABG or PCI, 5-year survival is 91.4-91.9%. 12 Calculator Calculator Calculator Canadian Cardiovascular Societ Cardiac Anesthesia Risk Evaluati Dual Antip Guidelines 1. Screening and diagnosis Cardiovascular risk assessment: As per ACC 2014 guidelines, assess cardiovascular risk using global risk scores such as the Framingham Risk Score in asymptomatic adults without a clinical history of coronary heart disease. B Show 3 more As per AHA 2010 guidelines, consider measuring Hgb A1C for cardiovascular risk assessment in asymptomatic adults with or without diabetes mellitus. C 2. Classification and risk stratification https://web.pathway.md/diseases/recSHPrW2vaQCzHTn 2/7 6/23/23, 3:37 AM Coronary artery disease Pathway Risk assessment scores: As per SCAI 2022 guidelines: Calculate the STS risk score to help stratify patient risk in candidates for CABG. B Consider obtaining assessment of CAD complexity, such as the SYNTAX score, in patients with multivessel CAD to guide revascularization. C As per ESC 2019 guidelines, calculate the STS score to assess in-hospital or 30-day mortality and in-hospital morbidity after CABGing. B Show 2 more As per ACC 2014 guidelines, consider calculating the STS and SYNTAX scores in patients with unprotected left main and complex CAD. C 3. Diagnostic investigations History and physical examination: as per ACC 2014 guidelines, elicit a thorough history and perform a physical examination to assess the probability of ischemic heart disease before obtaining additional testing in patients with chest pain. B Show 3 more Resting electrocardiogram: obtain a resting ECG in all patients with chest pain for with no obvious non-cardiac explanation. B Transthoracic echocardiogram: Obtain a resting TTE to assess LV systolic and diastolic function and evaluate for abnormalities of myocardium, heart valves, or pericardium in patients with known or suspected ischemic heart disease and a history of myocardial infarction, pathological Q waves, symptoms or signs suggestive of HF, complex ventricular arrhythmias, or an undiagnosed heart murmur. B Consider obtaining a resting TTE to assess cardiac structure and function in patients with hypertension or diabetes mellitus and an abnormal ECG. C Exercise stress testing: As per ESC 2019 guidelines, consider obtaining noninvasive stress imaging (cardiac MRI, stress echocardiography, single-photon emission computerized tomography or PET) for the assessment of myocardial ischemia and viability in patients with HF and CAD (considered suitable for coronary revascularization) before the decision on revascularization. C As per ACC 2014 guidelines, obtain standard exercise ECG testing in patients with an intermediate pretest probability of ischemic heart disease with an interpretable ECG and at least moderate physical functioning or no disabling comorbidity. A Show 6 more Pharmacological stress testing: as per ACC 2014 guidelines, obtain pharmacological stress with either nuclear myocardial perfusion imaging or echocardiography (or stress echocardiography) for risk assessment in patients with stable ischemic heart disease and LBBB on ECG, regardless of ability to exercise to an adequate workload. B Show 4 more https://web.pathway.md/diseases/recSHPrW2vaQCzHTn 3/7 6/23/23, 3:37 AM Coronary artery disease Pathway Coronary computed tomography angiography: as per ACC 2014 guidelines, consider obtaining coronary CT angiography in patients with an intermediate pretest probability of ischemic heart disease meeting any of the following criteria: continued symptoms with prior normal test findings inconclusive results from prior exercise or pharmacological stress testing inability to undergo stress testing with nuclear myocardial perfusion imaging or echocardiography. C Show 2 more Coronary artery calcium scoring: consider obtaining non-contrast cardiac CT to determine the CAC score in patients with a low to intermediate pretest probability of obstructive ischemic heart disease. C Screening for peripheral artery disease: Consider screening for PAD of lower extremities by ABI measurement for risk stratification in patients with CAD. C Consider screening for PAD of lower extremities in patients undergoing CABG and requiring saphenous vein harvesting. C 4. Diagnostic procedures Coronary angiography: as per ACC 2014 guidelines, consider performing coronary angiography in patients with suspected symptomatic stable ischemic heart disease unable to undergo diagnostic stress testing, or having indeterminate or nondiagnostic stress tests, if there is a high likelihood that the findings will result in important changes to therapy. C Show 13 more Coronary catheterization: As per ACC 2022 guidelines: Assess the fractional flow reserve or instantaneous wave-free ratio to guide the decision to proceed with PCI in patients with angina or an anginal equivalent, undocumented ischemia, and angiographically intermediate stenoses. A Do not perform PCI in stable patients with angiographically intermediate stenoses and fractional flow reserve > 0.80 or instantaneous wave-free ratio > 0.89. D Landmark trials: FLAVOUR In adult patients being evaluated for PCI for the treatment of intermediate stenosis, fractional flow reserve guidance was noninferior to intravascular ultrasound guidance with respect to the composite outcome of death, myocardial infarction, or revascularization at 24 months. Bon-Kwon Koo et al. N Engl J Med. 2022 Sep 1. https://web.pathway.md/diseases/recSHPrW2vaQCzHTn 4/7 6/23/23, 3:37 AM Coronary artery disease Pathway As per ESC 2019 guidelines: Obtain fractional flow reserve or instantaneous wave-free ratio when evidence of ischemia is not available to assess the hemodynamic relevance of intermediate-grade stenosis. A Consider performing PCI in patients with multivessel disease undergoing PCI guided by fractional flow reserve. C Intravascular ultrasound: As per ACC 2022 guidelines, consider performing intravascular ultrasound to help define lesion severity in patients with intermediate stenosis of the left main artery. C As per ESC 2019 guidelines, consider performing intravascular ultrasound imaging to assess the severity of unprotected left main coronary artery lesions. C 5. Medical management 6. Nonpharmacologic interventions Weight loss: Encourage weight maintenance or reduction through an appropriate balance of lifestyle physical activity, structured exercise, caloric intake, and formal behavioral programs, in order to maintain or achieve a BMI between 18.5 and 24.9 kg/m and a waist circumference < 102 cm in males and < 88 cm in females. B Target a reduction in body weight by approximately 5-10% from baseline as an initial goal for weight-loss therapy. B Dietary modifications: advise reduced intake of saturated fats (to < 7% of total calories), trans fatty acids (to < 1% of total calories), and cholesterol (to < 200 mg/day) in all patients wit ischemic heart disease. B Exercising: encourage all patients to engage in 30-60 minutes of moderate-intensity aerobic activity, such as brisk walking, at least 5 days and preferably 7 days per week, supplemented by an increase in daily lifestyle activities to improve cardiorespiratory fitness and move patients out of the least-fit, least-active, high-risk cohort (bottom 20%). B Show 2 more Smoking cessation: encourage smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home in all patients with stable ischemic heart disease. Offer follow- up, referral to special programs, pharmacotherapy, and a stepwise strategy for smoking cessation. B Alcohol restriction: consider advising patients with stable ischemic heart disease to limit alcohol intake to 1 drink/day for females and 1-2 drinks/day for males, unless alcohol is contraindicated (such as in pregnancy, alcohol dependence, or liver disease). C Exposure to air pollution: consider advising patients with stable ischemic heart disease to avoid exposure to increased air pollution to reduce the risk of cardiovascular events. C https://web.pathway.md/diseases/recSHPrW2vaQCzHTn 5/7 6/23/23, 3:37 AM Coronary artery disease Pathway Psychological interventions: consider screening for depression in patients with stable ischemic heart disease, and referring or initiating treatment when indicated. C Supplements: do not use vitamin C, vitamin E, -carotene D , garlic, coenzyme Q10, selenium, or chromium to reduce cardiovascular risk or improve clinical outcomes in patients with stable ischemic heart disease. D Show 2 more Acupuncture: do not offer acupuncture for the purpose of improving symptoms or reducing cardiovascular risk in patients with stable ischemic heart disease. D 7. Therapeutic procedures 8. Perioperative care General principles: Establish multidisciplinary, evidence-based perioperative management programs to optimize analgesia, minimize opioid exposure, prevent complications and to reduce time to extubation, length of stay, and healthcare costs in patients undergoing CABG. B Ensure a comprehensive approach to reduce sternal wound infection in patients undergoing CABG. B Periprocedural antiplatelet therapy, for PCI: As per SCAI/AHA/ACC 2022 guidelines, administer a loading dose of aspirin followed by daily dosing to reduce ischemic events in patients undergoing PCI. B Show 5 more Landmark trials: SMART-CHOICE (3-year follow-up) In patients who underwent PCI with drug-eluting stent, P2Y12 inhibitor monotherapy was noninferior to prolonged dual antiplatelet therapy with respect to major adverse cardiac and cerebrovascular events at 3 years. Ki Hong Choi et al. JAMA Cardiol. 2022 Nov 1. As per EACTS/ESC 2019 guidelines, initiate clopidogrel (600 mg loading dose, 75 mg daily maintenance dose) in patients undergoing elective PCI once the coronary anatomy is known and a decision is made to proceed with PCI. A Show 7 more Periprocedural antiplatelet therapy (for CABG): continue aspirin until the time of surgery to reduce ischemic events in patients undergoing CABG already taking daily aspirin preoperatively. B Show 6 more https://web.pathway.md/diseases/recSHPrW2vaQCzHTn 6/7 6/23/23, 3:37 AM Coronary artery disease Pathway Periprocedural anticoagulant therapy: administer UFH as the standard anticoagulant (70-100 U/kg). B Show 2 more Perioperative beta-blockers: consider administering preoperative -blockers, if not contraindicated, to reduce the incidence of postoperative AF in patients undergoing CABG. C Show 4 more Perioperative amiodarone: consider administering preoperative amiodarone to reduce the incidence of postoperative AF in patients undergoing CABG. C Intraoperative insulin infusion: administer intraoperative continuous insulin infusion to maintain serum glucose level < 180 mg/dL to reduce sternal wound infection in patients undergoing CABG. B Show 2 more Postprocedural antiplatelet therapy: initiate life-long single antiplatelet therapy, usually with aspirin. A Show 7 more 9. Surgical interventions Technical considerations for CABG: As per SCAI 2022 guidelines, calculate the STS risk score to help stratify patient risk in candidates for CABG. B Show 5 more Landmark trials: OPTIMAL In adult patients undergoing cardiac surgery with cardiopulmonary bypass, high-dose tranexamic acid regimen was superior to low-dose tranexamic acid regimen with respect to allogeneic RBC transfusion. Jia Shi et al. JAMA. 2022 Jul 26. As per EACTS 2019 guidelines, calculate the STS score to assess in-hospital or 30-day mortality and in-hospital morbidity after CABGing. B Show 14 more As per ESC 2018 guidelines, consider sparing the autologous great saphenous vein for potential future use for surgical peripheral revascularization in patients with PAD of lower extremities undergoing CABG. C Transmyocardial revascularization: Consider performing transmyocardial revascularization as an adjunct to CABG to improve symptoms in patients with viable ischemic myocardium perfused by arteries not amenable to https://web.pathway.md/diseases/recSHPrW2vaQCzHTn 7/7