J Korean Med Assoc.  2004 Aug;47(8):726-735. 10.5124/jkma.2004.47.8.726.

Medical Management of Coronary Artery Disease

• Kim BO

• KMID: 2183492
• DOI: http://doi.org/10.5124/jkma.2004.47.8.726

Abstract

Coronary artery disease is manifested by angina, acute myocardial infarction, sudden cardiac death, and heart failure and classified into chronic stable angina and acute coronary syndrome by pathogenesis. Acute coronary syndrome begins with the rupture of an unstable atheromatous plaque and the formation of intra-coronary thrombus. It is classified into unstable angina, non-Q wave myocardial infarction, and Q wave myocardial infarction by the severity of disturbance of coronary blood flow, the presence of myocardial injury, and the electrocardiographic (ECG) manifestations. The therapeutic strategies of acute coronary syndrome depends on the presence of ST segment elevation on ECG. Patients presenting with ST segment elevation myocardial infarction (STEMI) are candidates for reperfusion therapy (either pharmacological or catheter-based) to restore the flow in the occluded epicardial infarctrelated artery. Patients presenting without ST segment elevation (NSTEMI) are not candidates for pharmacological reperfusion and should receive anti-ischemic therapy. Antithrombin and anti-platelet therapy should be administered to all patients with an acute coronary syndrome. The therapeutic strategies of chronic stable angina are to prevent myocardial infarct or death, and to control the ischemic symptoms. The new insights on the pathogenesis of coronary atherosclerosis will change the preventive measures against cardiovascular events. We have to pay attention not only to the conventional measures such as reducing the LDL cholesterol level, correcting hypertension, and prescribing anti-platelet agents, but also to the new measures such as reducing non-HDL cholesterol, and lifestyle modifications.

Keyword

Coronary artery disease; Medical management; Acute coronary syndrome; Angina; Risk

MeSH Terms

Acute Coronary Syndrome
Angina, Stable
Angina, Unstable
Arteries
Cholesterol
Cholesterol, LDL
Coronary Artery Disease*
Coronary Vessels*
Death, Sudden, Cardiac
Electrocardiography
Heart Failure
Humans
Hypertension
Life Style
Myocardial Infarction
Reperfusion
Rupture
Thrombosis
Cholesterol
Cholesterol, LDL

Reference

1. Braunwald EB, editor. Heart disease : A textbook of cardiovascular medicine. 2001. 6th ed. Philadelphia: WB Saunders;1114–1231.

2. ACC/AHA Guidelines for the Management of Patients with Acute Myocardial Infarction, 1999 Updated Guideline Web version. www.acc.org/www.americanheart.org.

3. White HD. Thrombolytic therapy and equivalence trials. J Am Coll Cardiol. 1998. 31:494–496.

4. Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT-2) Investigators : Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction : The ASSENT-2 double-blind randomised trial : Assessment of the Safety and Efficacy of a New Thrombolytic Investigators. Lancet. 1999. 354:716–722.

5. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Smith SC Jr, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction : a report of the ACC/AHA Task Force on Practice Guidelines. J Am Coll Cardiol. 2000. 36:970–1062.

6. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Theroux P, et al. ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction-2002 : a report of the ACC/AHA Task Force on Practice Guidelines. Circulation. 2002. 106:1893–1900.

7. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. Platelet Receptor Inhibition in Ischemic Syncrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Investigators. N Engl J Med. 1998. 338:1488–1497.

8. Inhibition of platelet glycoprotein IIb/IIIa receptor with eptifibatide in patients with acute coronary syndromes. The PURSUIT Trial Investigators. Platelet Glycoprotein IIb/IIIa in Unstable Angina : Receptor Suppression Using Integrilin Therapy. N Engl J Med. 1998. 339:436–443.

9. ISIS-2(Second International Study of Infarct Survival) Colaborative Group. Randomized trial of intravenous streptokinase, oral aspirin, both or neither among 17,817 cases of suspected acute myocardial infarction. Lancet. 1988. 2:349.

10. CAPRIE Steering Committee. A randomized, blinded, trial of clopidogrel vs. aspirin in patients at risk of ischemic events (CAPRIE). Lancet. 1996. 348:1329–1339.

11. The CURE investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST segment elevation. N Engl J Med. 2001. 109:52–58.

12. Eikelboom JW, Anand SS, Malmberg K, Weitz JI, Ginsberg JS, Yusuf S, et al. Unfractionated heparin and low-molecular-weight heparin in acute coronary syndrome without ST elevation : a meta-analysis. Lancet. 2000. 355:1936–1942.

13. AHA/ACC/ACP-ASIM guidelines for the management of the patients with chronic stable angina : Executive Summary and Recommendations. Circulation. 1999. 99:2829–2848.

14. Opie LH. First line drugs in chronic stable effort angina-the case for newer, longer-acting calcium channel blocking agents. J Am Coll Cardiol. 2000. 36:1967–1971.

15. The Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of an ACE inhibitor, ramipril, on cardiovascular events in high risk patients. N Engl J Med. 2000. 342:145–153.

16. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Williams SV, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina : a report of the ACC/AHA Task Force on Practice Guidelines. Circulation. 2003. 107:149–158.

17. UK Prospective Diabetes Study Group. Intensive blood glucose control with sulfonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet. 1998. 352:837–853.

18. Executive Summary of the third report of the National Cholesterol Education Program Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults(Adult Treatment Panel III). JAMA. 2001. 285:2486–2497.