CORONARY ARTERY DISEASE

DEFINITION
Coronary artery disease (CAD), also called coronary heart disease (CHD), ischemic heart
disease (IHD), or simply heart disease, involves the reduction of blood flow to the heart
muscle due to build-up of plaque (arthrosclerosis) in the arteries of heart.

EPIDEMIOLOGY
 The Registrar General of India reported that CHD led to 17% of total deaths and
26% of adult deaths in 2001-2003, which increased to 23% of total and 32% of
adult deaths in 2010-2013.
 According to WHO in India CHD prevalence was 1% to 9%-10% in urban
populations and <1% to 4%-6% in rural population over the last 60 years.

ANATOMY AND PHYSIOLOGY

The heart is a muscular organ situated in the centre of the chest behind the sternum. It
consists of four chambers: the two upper chambers are called the right and left atria, and the
two lower chambers are called the right and left ventricles. The right atrium and ventricle
together are often called the right heart, and the left atrium and left ventricle together
functionally form the left heart.
Layers of heart-
1. Myocardium – This is the muscular tissue of the heart.
2. Endocardium – This tissue lines the inside of the heart and protects the valves and
chambers.
3. Pericardium – This is a thin protective coating that surrounds the other parts

Cardiac cycle -
The human heart consists of four chambers, comprising left and right halves. Two upper
chambers include left and right atria; lower two chambers include right and left ventricles.
The key function of the right ventricle is to pump deoxygenated blood through the pulmonary
arteries and pulmonary trunk to the lungs.
While the left ventricle is responsible for pumping newly oxygenated blood to the body
through the aorta.
Following are the different phases that occur in a cardiac cycle:
Atrial Diastole: In this stage, chambers of the heart are calmed. That is when the aortic valve
and pulmonary artery closes and atrioventricular valves open, thus causing chambers of the
heart to relax.
Atrial Systole: At this phase blood flow from atrium to ventricle and at this period, atrium
contracts.
Isovolumic Contraction: At this stage, ventricles begin to contract. The atrioventricular
valves, valve, and pulmonary artery valves close, but there won’t be any transformation in
volume.
Ventricular Ejection: Here ventricles contract and emptying. Pulmonary artery and aortic
valve close.
Isovolumic Relaxation: In this phase, no blood enters the ventricles and consequently,
pressure decreases, ventricles stop contracting and begin to relax. Now due to the pressure in
the aorta – pulmonary artery and aortic valve close.
Ventricular Filling Stage: In this stage, blood flows from atria into the ventricles. It is
altogether known as one stage (first and second stage). After that, they are three phases that
involve the flow of blood to the pulmonary artery from ventricles.
Duration of cardiac cycle-
In a normal person, a heartbeat is 72 beats/minute. So, the duration of one cardiac cycle can
be calculated as:
1/72 beats/minute=.0139 minutes/beat
At a heartbeat 72 beats/minute, duration of each cardiac cycle will be 0.8 seconds.
Duration of different stages of the cardiac cycle is given below:

 Atrial systole: continues for about 0.1 seconds

 Ventricular systole: continues for about 0.3 seconds
 Atrial diastole: continues for about 0.7 seconds
 Ventricular diastole: continues for about 0.5 seconds
ETIOLOGY
Coronary artery disease is thought to begin with damage or injury to the inner layer of a
coronary artery, sometimes as early as childhood. The damage may be caused by various
factors, including:
MODIFIABLE FACTORS:

 Smoking – Two times more risk of CAD.

 High blood pressure – Damages blood vessels leading to atherosclerosis and
plague formation.
 High cholesterol – Increased CAD and atherosclerosis by causing built up in the
artery walls.
 Diabetes or insulin resistance – Two times increased risk in men and three times
in women
 Not being active (sedentary lifestyle)- Lack of exercise also is associated with
coronary artery disease and some of its risk factors, as well.
 Obesity- Excess weight typically worsens other risk factors.
 Stress – Increased catecholamine release; increased sympathetic response

NONMODIFIABLE FACTORS:

 Age – As the age increases the risk of damaged and narrowed arteries also
increases.
 Gender – Men are at more risk than women.
 Ethnicity
 Family history – Twice the risk of M.I with the first degree relative.
 Previous cardiovascular event

PATHOPHYSIOLOGY
Due to etiological factors
Injury to the endothelial cell that lining the artery
Inflammation and immune reaction

Accumulation of lipids in the intima of the arterial wall

T lymphocytes and monocytes that becomes as macrophages infiltrate the area to ingest the
lipids and die
Proliferation of smooth muscle cells within the vessels

Formation of fibrous cap over dead fatty core(atheroma)

Protrusion of atheroma into the lumen of vessel
Narrowing and obstruction
 If cap is the lipid core may grow causing it to rupture

Haemorrhage into plague allowing thrombus to develop

Thrombus and obstruct the blood flow leading to sudden cardiac death of myocardial
infraction

Angina and other symptoms

COMPONENTS OF CAD
  Fibrous elements such as connective tissue, extra cellular matrix, including collagen,
proteoglycans, and fibronectin elastic fibres;
 Lipids such as crystalline cholesterol, cholesteryl esters, and phospholipids;
 Smooth muscle cells, which are intimately associated with atherosclerotic plaque; and
 Inflammatory cells, such as monocyte-derived macrophages and t-lymphocytes,
which contribute to the inflammatory pathogenesis of atherosclerosis.

DIFFRENCE BETWEEN MYOCARDIAL INFRACTION AND ANGINA

PECTORIS

s.no ANGINA PECTORIS M.I

1. Location of pain Substantial or around chest Same as in angina pectoris
2. Radiation of pain Neck, jaw or arms Same in angina pectoris
3. Nature of pain Dull or heavy discomfort Same but maybe more tense
with a pressure or squeezing
sensation
4. Duration Usually lasts for 3 to 8 Usually last for 30 minutes or
minutes or rarely longer longer
5. Other symptoms Maybe none Perspiration, nausea, weakness
6. Precipitating Extremes in weather, Often none
factors exertion, stress, meals
7. Factors giving Stopping physical activity, Nitro-glycerine may give
relief reducing stress, nitro- incomplete or no relief
glycerine.

SIGN AND SYMPTOMS

 Chest pain- The chest pain, called angina, usually occurs on the middle or left side of
the chest. Angina is generally triggered by physical or emotional stress. The pain
usually goes away within minutes after stopping the stressful activity. In women, the
pain may be brief or sharp and felt in the neck, arm or back.
 Myocardial infraction- A myocardial infarction (MI) happens when an artery that
supplies oxygenated blood to the heart becomes blocked. The blood is unable to pass
through and supply the cardiac muscle properly.
 Diaphoresis- Sweating occurs due to activation of the symptomatic nervous system
with a "fight or flight" response.
 E.c.g changes- Up-sloping ST-segment depression with positive T waves is
increasingly recognized as a sign of regional sub endocardial ischemia associated with
 severe obstruction of the left anterior descending coronary artery. Widespread ST-
segment depression, often associated with inverted T waves and ST-segment
elevation in lead aVR during episodes of chest pain, may represent diffuse sub
endocardial ischemia caused by severe coronary artery disease.
 Dysrhythmia’s-
 Chest discomfort- Often, insufficient blood flow to coronary arteries can manifest
as indigestion-like chest discomfort. In general, true indigestion (not caused by CAD)
should occur shortly after eating and may worsen when a client is in a lying down
position.
 Dyspnoea- If the heart can't pump enough blood to meet the body's needs, one may
develop shortness of breath or extreme fatigue with activity.

 Fatigue- A sense of diminished energy and frequent or unexpected fatigue may occur
with CAD. This is a particularly concerning warning sign if you have other symptoms
of CAD as well, but it can be the only symptom.

HISTORY AND HEALTH ASSESSMENT

The most common and most important cardiac symptoms and history are;

1. CHEST PAIN AND DISCOMFORT

 Location- usually in the front of chest but can also be in the upper abdomen.
 Radiation- may spread to the neck, jaw, back, and left or right arm.
2. BREATHLESSNESS
 Cardiac causes include severe pulmonary oedema, acute myocardial
infraction, pericarditis.
 Cheyne-stokes or periodic breathing-this often occurs during sleep, with a
long cycle time.
3. PALPITATIONS
 It may be bumping, throbbing, or thumping.
Past medical history-
 Enquire about any raised blood pressure, heart problems, fainting fits, dizziness or
collapses.
 Note whether there have been any heart attacks, any history of angina and any
cardiac procedures or operations.
 Previous levels of lipids if ever checked or known.

Family history-Ask about hypertension, coronary artery disease, stroke, diabetes,

hyperlipidaemia.

Lifestyle-Smoking, obesity, diet, physical activity, occupation, stress level.

EXAMINATION –
General – Body built, look for pallor, jaundice, any syndrome such as down’s syndrome,

Cyanosis – Can be seen below the fingernails, and toenails but also in the lips, cheeks, ears
and nose.

Hands - Finger clubbing, sweaty palms, tremor.

Pulse – Check pulse rate, rhythm of pulse, character of pulse, inequality of pulses, peripheral
pulses.

Check blood pressure – Should be measured in the brachial artery, using a cuff around the
upper arm.

Chest examination – Check the level of the jugular venous pressure, Feel

DIAGNOSIS

 History collection- Chest pain or pressure, or other symptoms of heart disease. The
nurse will ask you to describe the client symptoms. Also, the nurse will want to know
where any pain or pressure starts and if it spreads to other parts of your body. Your
nurse will also ask when it happens. Tell your doctor about other symptoms, such as
nausea, vomiting, shortness of breath, dizziness, fainting, rapid heartbeat, irregular
heartbeat, or "skipped" heartbeat, along with the client chest symptoms. Other
symptoms of coronary artery disease, such as fatigue, irregular or rapid heartbeats,
swelling, shortness of breath, coughing, or difficulty breathing when lying down.
Personal health history- The nurse will ask questions about your health and lifestyle.
The nurse will ask about your cholesterol levels, blood pressure, exercise habits,
stress level, and other areas of your life. Tell your nurse if you smoke or if you have
diabetes or any other health problems.
 Physical examination-
 A blood pressure check.
 An examination for fatty deposits (xanthomas) under the skin.
 A general assessment of blood circulation. Circulation can be evaluated by
checking skin colour, fingernails and toenails, and pulses in several locations,
including the neck, wrist, and feet.
 A funduscopic exam of the back of the eye (retina). Changes in the blood vessels
in the retina give clues to the presence and severity of high blood
pressure or diabetes .
 An examination of the blood vessels of the neck by looking at client and by
listening to blood flow using a stethoscope.
 Bulging or swollen neck veins may be a sign of heart failure .
 Changes in how the blood sounds as it flows through a narrowed artery can be
heard when listening to the arteries in the neck (carotid arteries).
  Listening to the heart with a stethoscope for heart murmurs and extra heart
sounds.
 Listening to the lungs for abnormal breath sounds. Soft crackling sounds
(crepitations or rales) may be a sign that heart failure has caused fluid to build up
in the lungs.
 An examination of the abdomen. Using a stethoscope, the doctor will listen to blood
flow in the abdomen. Changes in the sounds of blood flow (bruits) may indicate a
narrowed blood vessel in the abdomen. This is a sign of hardening of the arteries
( atherosclerosis ) in the large blood vessels that run through the abdomen.
 A check for swelling in the feet and legs (a sign of heart failure). Fluid build-up in the
legs causes swelling (oedema) and may be a sign of heart failure. To assess swelling
in the legs, the doctor will press down on the skin over the lower leg bone. Oedema is
present if the pressure leaves a dent in the skin.
 Cardiac enzymes- The heart releases cardiac enzymes (cardiac biomarkers) where
there is a heart damage or stress due to low oxygen. Troponin and creatinine
phosphokinase (CPK) levels rise after a heart attack. Elevated heart enzyme levels can
also indicate acute coronary syndrome or ischemia. Healthcare providers use enzyme
marker tests (blood tests) to measure cardiac enzymes.
 Electrocardiograms - An electrocardiogram records electrical signals as they travel
through your heart. An ECG can often reveal evidence of a previous heart attack or
one that's in progress.
 Echocardiograms- An echocardiogram uses sound waves to produce images of the
heart. During an echocardiogram, the doctor can determine whether all parts of the
heart wall are contributing normally to the heart's pumping activity. Parts that move
weakly may have been damaged during a heart attack or be receiving too little
oxygen. This may be a sign of coronary artery disease or other conditions.
 Stress test- If the signs and symptoms occur most often during exercise, doctor may
ask the client to walk on a treadmill or ride a stationary bike during an ECG.
Sometimes, an echocardiogram is also done while doing these exercises.
 Nuclear imaging - This test is similar to an exercise stress test but adds images to
the ECG recordings. It measures blood flow to client’s heart muscle at rest and during
stress. A tracer is injected into your bloodstream, and special cameras can detect areas
in your heart that receive less blood flow.
 Angiography -During cardiac catheterization, a doctor gently inserts a catheter into
an artery or vein in the groin, neck or arm and up to the heart. X-rays are used to
guide the catheter to the correct position. Sometimes, dye is injected through the
catheter. The dye helps blood vessels show up better on the images and outlines any
blockages. If a client has a blockage that requires treatment, a balloon can be pushed
through the catheter and inflated to improve the blood flow in the coronary arteries. A
mesh tube (stent) is typically used to keep the dilated artery open.
 PET scan- A PET scan is a very accurate way to diagnose coronary artery disease
and detect areas of low blood flow in the heart. PET can also identify dead tissue and
 injured tissue that’s still living and functioning. If the tissue is viable, you may benefit
from a PCI or coronary artery bypass surgery.
 CT scan - A CT scan of the heart can help the doctor to see calcium deposits in the
arteries that can narrow the arteries. If a substantial amount of calcium is discovered,
coronary artery disease may be likely. A CT coronary angiogram, in which the client
receives a contrast dye that is given by IV during a CT scan, can produce detailed
images of the client heart arteries.

TREATMENT MODALITIES
NURSING MANAGEMENT-
Treatment for coronary artery disease usually involves lifestyle changes and, if necessary,
drugs and certain medical procedures.
1.Lifestyle changes
Making a commitment to the following healthy lifestyle changes can go a long way toward
promoting healthier arteries:

 Quit smoking.
 Eat healthy foods.
 Exercise regularly.
 Lose excess weight.
 Reduce stress.

MEDICAL MANAGEMENT-
Various drugs can be used to treat coronary artery disease, including:

 Cholesterol-modifying medications. These medications reduce (or modify) the

primary material that deposits on the coronary arteries. As a result, cholesterol
levels — especially low-density lipoprotein (LDL, or the "bad") cholesterol —
decrease. The doctor can choose from a range of medications, including statins,
niacin, fibrates and bile acid sequestrants.
 Aspirin. The doctor may recommend taking a daily aspirin or other blood
thinner. This can reduce the tendency of blood to clot, which may help prevent
obstruction of the coronary arteries. If a client had a heart attack, aspirin can
help prevent future attacks. But aspirin can be dangerous if you have a bleeding
disorder or you're already taking another blood thinner, so ask the doctor before
taking it.
 Beta blockers. These drugs slow the heart rate and decrease the blood pressure,
which decreases the heart's demand for oxygen. If a client had a heart attack,
beta blockers reduce the risk of future attacks.
  Calcium channel blockers. These drugs may be used with beta blockers if beta
blockers alone aren't effective or instead of beta blockers if a client is able to
take them. These drugs can help improve symptoms of chest pain.
 Ranolazine. This medication may help the clients with chest pain (angina). It
may be prescribed with a beta blocker or instead of a beta blocker if a client
can't take it.
 Nitro-glycerine. Nitro-glycerine tablets, sprays and patches can control chest
pain by temporarily dilating the coronary arteries and reducing the heart's
demand for blood.
 Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II
receptor blockers (ARBs). These similar drugs decrease blood pressure and
may help prevent progression of coronary artery disease.

SURGICAL MANAGEMENT-
Procedures to improve and restore blood flow Angiotensin
Sometimes more aggressive treatment is needed. Here are some options:
Angioplasty and stent placement (percutaneous coronary revascularization)
The doctor inserts a long, thin tube (catheter) into the narrowed part of the artery. A wire with
a deflated balloon is passed through the catheter to the narrowed area. The balloon is then
inflated, compressing the deposits against the artery walls.
A stent is often left in the artery to help keep the artery open. Most stents slowly release
medication to help keep the arteries open.

Coronary artery bypass surgery

A surgeon creates a graft to bypass blocked coronary arteries using a vessel from another part
of the body. This allows blood to flow around the blocked or narrowed coronary artery.
Because this requires open-heart surgery, it's most often reserved for clients who have
multiple narrowed coronary arteries.
NURSING ASSESSMENT

Chest pain is provoked by exertion or stress and is relieved by nitro-glycerine and rest.

1. Character Substernal chest pain, pressure, heaviness, or discomfort. Other sensations

include a squeezing, aching, burning, choking, strangling, or cramping pain.
2. Severity. Pain maybe mild or severe and typically present with a gradual build-up of
discomfort and subsequent gradual fading away.
3. Location. Behind middle or upper third of sternum; the patient will generally will make
a fist over the site of pain (positive Levine sign; indicates diffuse deep visceral pain),
rather than point to it with fingers.
4. Radiation. Usually radiates to neck, jaw, shoulders, arms, hands, and posterior
intrascapular area. Pain occurs more commonly on the left side than the right; may
produce numbness or weakness in arms, wrist, or hands.
5. Duration. Usually, last 2 to 10 minutes after stopping activity; nitro-glycerine relieves
pain within 1 minute.
6. Precipitating factors. Physical activity, exposure to hot or cold weather, eating a heavy
meal, and sexual intercourse increase the workload of the heart and, therefore, increase
oxygen demand.
7. Associated manifestation. Diaphoresis, nausea, indigestion, dyspnoea, tachycardia, and
increase in blood pressure.
8. Signs of unstable angina:
 A change in frequency, duration, and intensity of stable angina symptoms.
 Angina pain last longer than 10 minutes, is unrelieved by rest or sublingual nitro-
glycerine, and mimics signs and symptoms of impending myocardial infarction.

NURSING DIAGNOSIS

1. Acute pain related to imbalance between myocardial oxygen supply and demand
of the heart as evidenced by assessment of the client.
 2. Ineffective tissue perfusion related to interruption of arterial blood flow.
3. Ineffective coping related to affects of acute illness and major changes in lifestyle.
4. Impaired gas exchange related to ineffective breathing pattern and decreased
systemic tissue perfusion.
5. Activity intolerance related to compromised oxygen support secondary to
coronary artery disease as manifested by cold and clammy skin condition on
extremities, decreased capillary refill, fatigue and body weakness.

CASE VIGNETEE

A 61-year-old man with Type II diabetes mellitus presents to the emergency room you are
working at complaining of “heaviness” in his chest. He says the discomfort began as a
pressure pain sensation in the middle of his chest shortly after starting to shovel snow from
his driveway. He is sweaty and complains of nausea. He says the pain subsided somewhat
when he sat down, but has persisted as a heaviness.

NURSING CONSIDERATIONS

A. Relieving pain
1.Determine intensity of patient’s angina.
A. Ask patient to compare the pain with other pain experienced in past and, on a scale of 0 to
10, rate current pain.
B. observe for associated sign and symptoms, including diaphoresis, shortness of breath,
protective body posture, dusky facial colour, and/or changes in level of consciousness.
2. Position patient for comfort; Fowler’s position promotes ventilation.
3. Administer oxygen, if appropriate.
4. Obtain BP, apical heart rate and respiratory rate.
5. Obtain a 12 lead ECG.
6. Administer anti-anginal drug, as prescribed.
7. Report findings to health care providers.
8. Monitor for relief of pain and note duration of anginal episode.
9. Take vital signs every 5 to 10 minutes until angina pain subsides.
10. Monitor for progression of stable angina to unstable angina: increase in frequency and
intensity of pain, pain occurring at rest or at low levels of exertion, pain lasting longer than 5
minutes.
11. Determine level of activity that precipitated anginal episode.
12. Reinforce the importance of notifying nursing staff when angina pain is experienced.
B. Maintaining cardiac output
1. Carefully monitor the patient response to drug therapy.
a. Take BP and heart rate in a sitting and lying position on initiation of long-term therapy.
b. Recheck vital signs as indicated by onset of action of drug and at time of drug’s peak
effect.
c. Note changes in BP of more than 10 mm hg and changes in heart rate of more than 10
beats/minute.
d. Continuous e.c.g monitoring.
e. Evaluate for development of heart failure
f. Obtain daily weight and intake and output.
g. Auscultate lung fields for crackle and assess for shortness of breath.
h. Monitor for the presence of oedema.
i. Monitor central venous pressure, if applicable.
j. Assess jugular vein distention.
k. Monitor cardiac markers.
2. Monitor for poor perfusion.
a. Decreasing blood pressure
b. Weak pulses
c. Dizziness
d. Shortness of breath
3. Be sure to remove previous nitrous patch before applying new patch (prevents
hypotension) and to reapply on different body site.
4. Report adverse side effects to health care provider.
C. Decreasing anxiety
1. Rule out physiologic etiologies for increasing or new onset anxiety before administrating
as needed sedatives.
2. Explain to patient and family reasons for hospitalisation, diagnostic tests, and therapies
administered.
3. Encourage patient to verbalize fears and concerns about illness through frequent
conversations.
4. Answer patient’s questions with concise explanations.
5. Explain to patient the importance of anxiety reduction to assist in control of angina.
6. Discuss measures to be taken when an anginal episode occurs.
COMPLICATION
Coronary artery disease can lead to:

Chest pain (angina). When the coronary arteries narrow, the heart may not receive enough
blood when demand is greatest — particularly during physical activity. This can cause chest
pain (angina) or shortness of breath.
Heart attack. If a cholesterol plaque ruptures and a blood clot forms, complete blockage of
the heart artery may trigger a heart attack. The lack of blood flow to your heart may damage
the heart muscle. The amount of damage depends in part on how quickly you receive
treatment.

Heart failure. If some areas of the heart are chronically deprived of oxygen and nutrients
because of reduced blood flow, or if the heart has been damaged by a heart attack, the heart
may become too weak to pump enough blood to meet the body's needs. This condition is
known as heart failure.

Abnormal heart rhythm (arrhythmia). Inadequate blood supply to the heart or damage to
heart tissue can interfere with the heart's electrical impulses, causing abnormal heart rhythms.

REHABLITATION
A. Instruct patient and family about coronary artery disease.
1. Assess readiness to learn about the diseased condition.
2. Explain about the heart with the help of diagram and about the angina.
3. Tell the risk factors of the disease and highlight those risk factors that can be modified and
controlled to reduce risk.
4. Discuss for patient the different signs and symptoms of angina.
B. Identify suitable activity level to prevent angina.
1. Avoid activities known to cause anginal pain-sudden exertion, extreme of temperature,
high altitude and emotional stressful situations.
2. Refrain from engaging in physical activity for 2hrs after meals. Rest after each meal.
3. Do not perform activities requiring heavy effort.
4. Lose weight, if necessary, to reduce cardiac load.
5. Try to avoid cold weather, if possible; dress warmly and walk more slowly.
C. Instruct about appropriate use of medications and side effects.
1. Carry nitro-glycerine at all times and keep it in dark container away from heat and light.
2. Place nitro-glycerine under the tongue at first sign of chest discomfort.
3. Instruct patient on administration of transdermal nitro-glycerine patches.
4. Teach patient about potential adverse effects of other medications like;
a. Constipation -verapamil
b. Ankle oedema – nifedipine
c. Dizziness – vasodilators, antihypertensives
D. Counsel on risk factors and lifestyle changes
1. Inform patient of methods of stress reduction, such as biofeedback and stress reduction.
2. Explain AHA guidelines, which recommend eating fish at least twice per week, especially
fish high in omega-3 oils.
3. Inform patient of available cardiac rehabilitation programmes that offer structured classes
on exercise, smoking cessation and weight control.
4. Instruct patient to avoid excessive caffeine intake, which can increase the heart rate and
produce angina.
5. Encourage patient to avoid alcohol or drink only in moderation.
6. Encourage follow up visits for control of diabetes, hypertension and hyperlipidaemia.

Low-Dose Radiation Advances in Coronary Computed Tomography

Angiography in the Diagnosis of Coronary Artery Disease

Background: Coronary computed tomography angiography (CCTA) is now widely used in

the diagnosis of coronary artery disease since it is a rapid, minimally invasive test with a
diagnostic accuracy comparable to coronary angiography. However, to meet demands for
increasing spatial and temporal resolution, higher x-ray radiation doses are required to
circumvent the resulting increase in image noise. Exposure to high doses of ionizing radiation
with CT imaging is a major health concern due to the potential risk of radiation-associated
malignancy. Given its increasing use, a number of dose saving algorithms have been
implemented to CCTA to minimize radiation exposure to "as low as reasonably achievable
(ALARA)" without compromising diagnostic image quality.

Objective: The purpose of this review is to outline the most recent advances and current
status of dose saving techniques in CCTA.

Method: PubMed, Medline, EMBASE and Scholar databases were searched to identify
feasibility studies, clinical trials, and technology guidelines on the technical advances in CT
scanner hardware and reconstruction software.

Results: Sub-millisievert (mSv) radiation doses have been reported for CCTA due to a
combination of strategies such as prospective electrocardiogram-gating, high-pitch helical
acquisition, tube current modulation, tube voltage reduction, heart rate reduction, and the
most recent novel adaptive iterative reconstruction algorithms.

Conclusion: Advances in radiation dose reduction without loss of image quality justify the
use of CCTA as a non-invasive alternative to coronary catheterization in the diagnosis of
coronary artery disease.

Keywords: Coronary computed tomography angiography; effective radiation dose; image

quality; iterative reconstruction; prospective electrocardiogram- gating; tube current
modulation; tube voltage reduction.

Coronary artery disease in renal transplant recipients: an angiographic

study
Abstract

Background

Cardiovascular disease is the leading cause of mortality in renal transplant recipients

(RT). Coronary artery disease (CAD) in such patients is poorly studied.

Methods

During 2012–2017, 50 patients with a renal graft (functioning for a minimum of 6 months)
were subjected to coronary angiography in our institution. They were matched (for age,
gender, diabetes, and indication for angiography) with 50 patients with end-stage renal
disease (ESRD) undergoing chronic dialysis and 50 patients with normal renal function who
were subjected to coronary angiography during the same period. The extent and severity of
CAD were assessed by using the SYNTAX score.

Results

RT had a significantly longer duration of ESRD than patients on dialysis (17.5±7.1 vs.
8.5±8.7 years, p<0.01). Mean SYNTAX score was 13.3±12.0 in RT, 20.6±17.5 in patients on
dialysis, and 9.4±9.2 in control patients (p<0.01). At least one significantly calcified lesion
was present in 75.7% of RT recipients, 92.1% of patients on dialysis, and 15.8% of control
patients (p<0.01). Percutaneous coronary intervention (PCI) was successful in 93.8% of the
attempted cases in RT, 75% of patients on chronic dialysis, and 100% of control patients
(p=0.04). In the RT group, SYNTAX score significantly correlated with smoking (p=0.02)
and the total vintage of ESRD (p=0.04).

Conclusions

In this angiographic study, CAD was less severe in RT than in patients on long-term dialysis
despite a longer duration of ESRD. Coronary artery calcification was highly prevalent
after renal transplantation. PCI in RT had a high rate of angiographic success.

Conclusion: Advances in radiation dose reduction without loss of image quality justify the
use of CCTA as a non-invasive alternative to coronary catheterization in the diagnosis of
coronary artery disease.

Pragmatic Analysis of Dyslipidaemia Involvement in

Coronary Artery Disease: A Narrative Review
Abstract
Background
Dyslipidaemia is the main factor involved in the occurrence and progression of coronary
artery disease.

Objective
The research strategy is aimed at analysing new data on the pathophysiology of
dyslipidaemia involvement in coronary artery disease, the modalities of atherogenic risk
estimation and therapeutic advances.

Methods
Scientific articles published in PubMed from January 2017 to February 2018 were searched
using the terms “dyslipidaemia” and “ischemic heart disease”.

Results
PCSK9 contributes to the increase in serum levels of low-density lipoprotein-cholesterol and
lipoprotein (a). The inflammation is involved in the progression of hyperlipidaemia and
atherosclerosis. Hypercholesterolemia changes the global cardiac gene expression profile and
is thus involved in the increase of oxidative stress, mitochondrial dysfunction, and apoptosis
initiated by inflammation. Coronary artery calcifications may estimate the risk of coronary
events. The cardio-ankle vascular index evaluates the arterial stiffness and correlates with
subclinical coronary atherosclerosis. The carotid plaque score is superior to carotid intima-
media thickness for risk stratification in patients with familial hypercholesterolemia and both
can independently predict coronary artery disease. The lipoprotein (a) and familial
hypercholesterolemia have a synergistic role in predicting the risk of early onset and severity
of coronary atherosclerosis. A decrease in atherosclerotic coronary plaque progression can be
achieved in patients with plasma LDL-cholesterol levels below 70 mg/dL. A highly durable
RNA interference therapeutic inhibitor of PCSK9 synthesis could be a future solution.

Conclusion
The prophylaxis and treatment of coronary artery disease in a dyslipidaemia patient should be
based on a careful assessment of cardio-vascular risk factors and individual metabolic
particularities, so it may be personalized.

Gender difference in clinical outcomes of the patients with coronary artery

disease after percutaneous coronary intervention: A systematic review and
meta-analysis

Abstract

Background and objectives: Previous researches have reported the controversial results
regarding the gender difference in clinical outcomes of patients with coronary artery disease
after percutaneous coronary intervention. Hence, this systematic review and meta-analysis
was designed to investigate whether gender difference existed in patients with coronary artery
disease after percutaneous coronary intervention.

Methods: PubMed, Embase, and the Cochrane Library database were searched up to
February 10, 2018. Studies comparing the gender-specific effect on clinical outcomes of
patients with coronary artery disease after percutaneous coronary intervention were
identified, to analyse mortality, major adverse cardiovascular events (MACE) and
revascularization. Statistical software RevMan was utilized in this meta-analysis.

Results: A total of 49 studies, involving 1,032,828 patients (774,115 males and 258,713
females) reporting gender-specific outcomes, were included in this study. The in-hospital
mortality, 30-day mortality, 1-year mortality, and at least 2-years mortality in male patients
with coronary artery disease after percutaneous coronary intervention were significantly
lower than those of females (odds ratio [OR] 0.58 95% confidence interval [CI] 0.52-0.63, P
< .001; OR 0.64, 95% CI 0.61-0.66, P = .04; OR 0.67, 95% CI 0.60-0.75, P < .001 and OR
0.71, 95% CI 0.63-0.79, P = .005, respectively). The MACE was significantly decreased in
male subjects after initial percutaneous coronary intervention compared with females in <1-
year or at least 1-year (OR 0.67, 95% CI 0.56-0.80, P < .001 and OR 0.84, 95% CI 0.76-0.93,
P < .001). The male patients after percutaneous coronary intervention harboured higher rate
of revascularization compared with females for at least 1-year (OR 1.17, 95% CI 1.00-1.36, P
< .001), while the rate of revascularization in male patients for < 1-year was lower than that
of females (OR 0.93, 95% CI 0.69-1.26, P < .001).

Conclusions: The systematic review and meta-analysis suggests that the prognosis of male
patients with coronary artery disease after percutaneous coronary intervention is better than
that of females, except for long-term revascularization.

Study on syndrome differentiation and treatment in the management of

chronic stable coronary artery disease to improve quality of life
Study on syndrome differentiation and treatment in the management of chronic stable
coronary artery disease to improve quality of life
Abstract
Background:
Chronic stable coronary artery disease (SCAD) is a general term for all kinds of coronary
artery disease (CAD), which includes patients with chronic stable angina, old myocardial
infarctions, and also stable condition after revascularization (i.e., percutaneous coronary
intervention, coronary artery bypass graft). According to 2012 AHA/ACC guidelines, the
objective of the treatment for SCAD is to maintain or recover patients’ exercise tolerance,
quality of life, and avoid complication like heart failure, so as to decrease mortality, eliminate
symptoms, and avoid adverse reactions. Traditional Chinese medicine (TCM) has 2000 years
of history in managing CAD and has its advantages in improving quality of life. Using
scientific method to evaluate, demonstrate, and conclude the clinical curative effect of TCM
is an extremely important task for both TCM and integrative Chinese and Western medicine
in the treatment of CAD.

Methods:
This research is to collect real effective cases from authoritative TCM cardiologists’ clinic, so
as to build a TCM diagnosis and treatment information database that involve 2000 patients
from 32 different top-3 hospitals of China. The primary outcome includes EuroQol-5
Dimensions and Four diagnostic method of TCM, and secondary outcome includes angina
score and some laboratory indexes like electrocardiograms, dynamic electrocardiogram,
ultrasonic cardiogram, and treadmill exercise testing. This research uses SPSS17.0. to do the
statistical analysis application. Enumeration data use χ2 test and measurement data which fit
normality test use t test. The analysis of drugs usage in different diseases, different
syndromes and different life quality effect will use principal component analysis, factorial
analysis, clustering analysis. and point mutual information method, and so on.

Results:
This research, based on past syndromes research and real clinical effective chronic SCAD
cases, aim to build a TCM diagnosis and treatment information database.

Quality of life in patients with risk factors of coronary heart disease

Aim: The objective of the study was to assess the subjective health state and selected
parameters of health-related quality of life (QL) in subjects with risk factors of coronary heart
disease (CHD). Demographic and clinical variables were analysed in order to determine
factors influencing an individual's satisfaction.

Material and methods: The study enrolled a total of 541 persons (278 women and 263 men;
mean age 52 +/- 16.5 years). All the participants were divided into four groups i.e., healthy
subjects, persons with one risk factor (hypertension), persons with three risk factors
(hypertension, smoking, hypercholesterolemia) and patients with CHD. Quality of life
assessment was carried out by means of the international, standardized general questionnaire
analysing mobility, self-care, usual activities, pain, anxiety/depression (five questions, each
with three levels) and subjective health state (visual analogue score, VAS).

Results: Persons without any of the analysed risk factors scored significantly higher within
all studied dimensions of QL and VAS. The lowest level of satisfaction was noticed in patient
with CHD, especially after myocardial infarction. Patients with untreated hypertension,
smoking, hypercholesterolemia, obesity and sedentary lifestyle reported significantly higher
degree of disability than persons with well controlled hypertension, free of smoking habit,
with no lipid disorders, slim and with at least moderate physical activity level. Among all
analysed risk factors the strongest correlation was found for untreated hypertension and
sedentary lifestyle. In healthy subject’s demographic variables, as age, sex, marital status,
education and employment were the most important determinants of quality of life. The rates
of reported problems increased significantly with age; women tended to score lower than
men. Pain or discomfort was the most frequent disorder in healthy persons while anxiety or
depression and pain in patients with risk factors and coronary heart disease.

Conclusion: Patients with risk factors of coronary heart disease, as hypertension, smoking,
hypercholesterolemia, obesity and sedentary lifestyle clearly reported high degree of
disability and poor subjective health state. Prevention and treatment should focus especially
on effective control of hypertension and promoting physical activity as the strongest
determinants of quality of life.