Coronary artery disease (angina pectoris and chest pain)
Which are the symptoms?
Angina pectoris generally has a duration of 5-10 minutes, arising during and immediately after exertion (exertional angina) or even at rest, immediately after eating (postprandial angina), with cold (frigid angina) or in the first hours of physical activity (warm-up). In some rare cases, in generally younger patients, angina may occur only at rest and during sleep, typically between 1:00 and 5:00 a.m. (Prinzmetal angina). Symptoms may be a sign of poor blood supply to the heart (ischemia). This is usually caused by significant narrowing of the arteries that supply the coronary arteries due to the presence of atherosclerotic plaques obstructing flow (in classic exertional angina); or by vasoconstriction of the coronary arteries on plaques that are not very critical (mixed angina); or by severe vascostriction of the coronary arteries that are free of atheroclerotic plaques (coronary spasm in Prinzmetal's angina). Finally, angina may be due to a functional/anatomical alteration of the small capillaries of the microcirculation of the heart (microvascular angina) that lie downstream of the coronary circulation.
- chest discomfort in the center of the chest at exertion or at rest
- sense of constriction, oppression, closure in the throat, which can be radiated to the jaw and even to the teeth
- deep discomfort in the shoulders (interscapularis) and sometimes in the arms on the lower side and the last two-three fingers of the hand (usually left)
- stomach pain on exertion or even at rest (in the epigastrium), which can be confused with a gastritis or indigestion
How is it diagnosed?
Cardiologist examination with echocardiogram taking.
Noninvasive investigation methods:
- physical stress test;
- stress echocardiography;
- myocardial perfusion scintigraphy after stimulation (physical stress, drugs with dipyridamole as active ingredient);
Cardiologist examination helps to perform general clinical evaluation and calculate cardiovascular risk factors (probability of connection of thoracic pain with the heart).
Coronarography is applied only when noninvasive examination has revealed the signs of incomplete heart blood supply, namely:
- physical stress shows revealed changes in the electrocardiogram;
- myocardial scintigraphy shows areas that do not receive radioactive tracers after the patient was physically loaded;
- stress echocardiography shows myocardial segments that do not move after physical or pharmacological stress.
How is it treated?
The surgical treatment of coronary artery disease (CAD), according to the last European Guidelines for myocardial revascularization, is the gold standard treatment and should be preferred than PCI in case of two-vessel disease involving proximal left anterior descending (LAD) stenosis or three-vessel disease in patients with diabetes mellitus. CABG should be performed rather than PCI even in case of left main or three-vessel disease without diabetes mellitus in patients with high or intermediate SYNTAX score (a measure of anatomical complexity of CAD). The principal objective of CABG is to obtain complete revascularization by bypassing all severe stenoses (at least 50% diameter reduction) in all coronary arterial trunks and branches having a diameter of about 1 mm or more. The surgical revascularization by coronary artery bypass grafting (CABG) is performed with a median sternotomy approach, using arterial or venous conduits as bypass grafts. As vein graft the right or left greater saphenous vein is used, harvested from the leg with open or endoscopic technique. As arterial graft a single (mostly the left), or a double internal thoracic artery (ITA) is used; alternative arterial grafts are the non-dominant arm radial artery or the right gastroepiploic artery. Because three or more individual conduits cannot be conveniently used in most patients, at least some of the grafts, especially venous, may require sequential (side-to-side) anastomoses. Surgery can be performed either "on-pump", cross-clamping the aorta with cardioplegic arrest of the heart or "off-pump" with beating heart. CABG offers complete myocardial revascularization and better long-term outcome in patients with multivessel or left main CAD, especially with intermediate or high anatomical complexity.
Where do we treat it?
Page edited by: Carlo De Vincentiis