Note: This article is aimed at beginners, intended to provide a quick overview of the general diagnostic and treatment approach. Many details are omitted; specific implementation requires guidance from experienced practitioners. For more information, please refer to the references at the bottom.
Applicable scenarios include:
- Just started dealing with coronary heart disease (CAD) patients and don’t understand what medications they are taking and why
- Suspecting a patient of a CAD attack and unsure how to proceed beyond contacting a senior doctor
As of now, I have only treated five or six CAD patients. This article will be continuously expanded in the future, but if you have more clinical experience than I do, you probably won’t gain much from reading it.
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Before viewing the detailed content, please try to answer the following questions. Voting is welcome, and future content will be developed based on related topics. You can also ask other questions in the comments section.
- Classification of CAD
- Diagnosis of CAD
- Secondary prevention of CAD
- How to determine ischemic location from ECG
- Management of UA/NSTEMI
- Management of STEMI
- Interpretation of coronary angiography
- Coronary artery anatomy
- Brief introduction to coronary intervention
- Home management and precautions for CAD
- Classification of CAD
- Diagnosis of CAD
- Secondary prevention of CAD
- How to determine ischemic location from ECG
- Management of UA/NSTEMI
- Management of STEMI
- Interpretation of coronary angiography
- Coronary artery anatomy
- Brief introduction to coronary intervention
- Home management and precautions for CAD
- Classification of CAD
- Diagnosis of CAD
- Secondary prevention of CAD
- How to determine ischemic location from ECG
- Management of UA/NSTEMI
- Management of STEMI
- Interpretation of coronary angiography
- Coronary artery anatomy
- Brief introduction to coronary intervention
- Home management and precautions for CAD
What is Coronary Artery Disease (CAD)? Why does one get CAD?
Coronary Atherosclerotic Heart Disease (Coronary Artery Disease, CAD)
The myocardium is mainly supplied by the coronary arteries. Coronary atherosclerosis + coronary spasm leads to insufficient myocardial blood supply and increased myocardial oxygen demand, causing symptoms like chest tightness and chest pain (for more symptoms, see internal medicine).
- Coronary atherosclerosis
- Endothelial damage (hypertension, hyperglycemia)
- Hyperlipidemia
- Hemodynamic disturbances (vascular deformation caused by hypertension), etc.
- For more mechanisms of atherosclerosis, see pathophysiology
- Coronary spasm
- Causes?
- Increased myocardial oxygen consumption
- Increased physical activity, emotional factors
How to diagnose CAD? How to assess severity and urgency?
The more severe the coronary artery blockage, the more serious the myocardial ischemia, symptoms, and auxiliary tests.
- The gold standard is coronary angiography to directly visualize the degree of coronary blockage.
- Next-level diagnostics include the “four myocardial infarction markers”: Troponin T (TNT), Troponin I (TnI), Creatine kinase-MB (CK-MB), Myoglobin—these are substances released during myocardial infarction.
- Also electrocardiogram (ECG), which if unclear, can be temporarily set aside.
- Next is clinical judgment based on symptoms (chest tightness/pain, radiating pain to shoulder/arm, dyspnea, etc.; see diagnostics for more), signs (heart sounds abnormalities), medical history (hyperlipidemia, hypertension, hyperglycemia, history of infarction or embolism, family history of CAD), triggers (exertion, emotional stress), and relief factors (rest).
Considering the above factors, CAD can be classified into four categories according to severity and urgency (there are more detailed classifications as well as symptoms, signs, and tests; see internal medicine). Here is a list from mild to severe:
- Chronic coronary disease (defined as coronary intervention standard, coronary artery blockage < 50%)
- Stable angina: mild blockage, mild symptoms, stable condition, controlled by regular medication
- Acute coronary syndrome (ACS) (coronary artery blockage ≥ 50%)
- Unstable angina: acute worsening of stable angina, no myocardial necrosis yet
- Non-ST elevation myocardial infarction (NSTEMI): myocardial ischemic necrosis begins but limited
- ST elevation myocardial infarction (STEMI): entire myocardial territory supplied by the coronary artery is necrotic
For patients already diagnosed with CAD:
Critical/Emergency
- Acute cases (how to judge acute?)
- Provide thrombolysis (r-tPA) or intervention (coronary dilation, stent placement), both require antithrombotic therapy with bleeding risk. Be cautious in patients with bleeding history or risk factors (gastric ulcers, cirrhosis, alcohol consumption). Otherwise, the patient might suffer life-threatening bleeding before thrombus resolution, which is counterproductive.
More stable
Conservative treatment methods can be used.
Symptomatic treatment
Traditional Chinese Medicine (TCM)
- TCM injections, especially Xuesaitong and Shuxuening, with high evidence value, good clinical effect, and few adverse reactions
- TCM appropriate technology
- Decoctions based on syndrome differentiation
- Oral Chinese patent medicines, especially Shexiang Baoxin Pills and Tongxinluo Capsules
Western Medicine
- Nitrates, such as nitroglycerin (short-acting, approx. 30 min), isosorbide mononitrate (long-acting, approx. 6 h)
- Improve microcirculation: Nicorandil
- Control heart rate: beta blockers, non-dihydropyridine calcium channel blockers
Improving prognosis — double-ABCDE
- Anti-thrombosis (be cautious of bleeding risk)
- ACEI/ARB/ARNI, improving myocardial structure (generally allowed openly)
- Beta Blockers (monitor for bradycardia)
- Blood Pressure control (see relevant hypertension content)
- Cholesterol control (e.g., Atorvastatin)
- Cigarette smoking cessation; nicotine damages vascular endothelium
- Diabetes management; hyperglycemia damages vascular endothelium
- Diet
- Education
- Exercise
References
Cardiology Manual 心血管科住院医师工作手册
Internal Medicine Mind Map https://zhuanlan.zhihu.com/p/556681054
Finally
Thanks to Dr. Wang Dayang for providing the foundational approach.
Thanks to all colleagues rotating together (Meng Shanshan, Liu Jiayu, Pan Chenyu)
