Coronary heart disease (CHD): symptoms, diagnosis and treatment

Coronary heart disease (CHD): symptoms, diagnosis and treatment

1st April 2007
Finnish Medical Society Duodecim
Summary,

Source: National Guidelines Clearinghouse

GUIDELINE OBJECTIVE(S)

Evidence-Based Medicine Guidelines collect, summarize, and update the core clinical knowledge essential in general practice. The guidelines also describe the scientific evidence underlying the given recommendations.

TARGET POPULATION

Individuals with suspected or confirmed stable angina and coronary heart disease

INTERVENTIONS AND PRACTICES CONSIDERED

Diagnosis

  1. Assessment of symptoms of angina (pectoris) including classification of chest pain
  2. Physical investigations (blood pressure, heart rate, heart sounds, palpation, presence of pallor, signs of heart failure, other physical signs)
  3. Electrocardiography
  4. Laboratory investigations (serum lipids, blood glucose, blood haemoglobin, chest x-ray, myocardial enzymes or markers)
  5. Exercise tolerance test
  6. Radionuclide imaging
  7. Exercise echocardiography
  8. Coronary angiography
  9. Special diagnostic considerations in women

Assessment/Treatment of Risk Factors

  1. Assessment of modifiable and nonmodifiable risk factors
  2. Drugs (aspirin, a beta-blocker, a statin) to slow down atherosclerosis and prevent myocardial infarction
  3. Folic acid (and vitamins B6 & B12) to lower elevated homocysteine levels (a risk factor for accelerated atherogenesis)
  4. Smoking cessation
  5. Treatment of hypertension
  6. Assessment of lipid profile and reduction of hyperlipidaemia by using statins
  7. Treatment of obesity, including recognition of metabolic syndrome and consideration of combination therapy with a statin and fibrate
  8. Physical exercise
  9. Comprehensive cardiac rehabilitation including combination of exercise, psychological and educational interventions

Treatment

  1. Aspirin (clopidogrel for patients not responding to aspirin)
  2. Low-molecular-weight heparin
  3. Coronary care unit monitoring
  4. Sublingual or aerosol nitrates
  5. Long-acting nitrates (a nitrate patch)
  6. Beta-blockers, such as carvedilol
  7. Angiotensin-converting enzyme (ACE) inhibitor in combination with beta-blocker
  8. Dihydropyridine derivatives (amlodipine, felodipine, isradipine, nisoldipine) in combination with beta-blockers
  9. Calcium antagonists, such as diltiazem
  10. Revascularization (percutaneous transluminal coronary angioplasty [PTCA], coronary artery bypass grafting [CABG] surgery, off-pump coronary artery bypass [OP-CAB] grafting , coronary stenting, corticosteroids for postpericardiotomy syndrome [PPS])
MAJOR OUTCOMES CONSIDERED
  • Sensitivity and specificity of diagnostic tests
  • Risk reduction for cardiovascular events and death
  • Mortality (total or overall)
  • Coronary heart disease mortality
  • Morbidity
  • Reductions in blood pressure
  • Reductions in smoking
  • Reductions in blood lipids
  • Improvements in exercise tolerance
  • Incidence of cardiac events
  • Incidence of reinfarction
  • Restenosis rate
  • Arterial graft patency
  • Adverse effects
  • Cardiac death rate
  • Number of angina episodes per week