- Typical exertional angina pectoris or its equivalents.
- Objective evidence of myocardial ischemia by electrocardiography,
myocardial imaging, or myocardial perfusion scanning.
- Likely occlusive coronary artery disease because of history
and objective evidence of prior myocardial infarction.
- Known coronary artery disease shown by coronary angiography.
For clinical purposes, patients with chronic ischemic heart disease fall into two general categories: those with symptoms related to
the disease, and those who are asymptomatic. Although the latter
are probably more common than the former, physicians typically see
symptomatic patients more frequently. The issue of asymptomatic
patients becomes important clinically when physicians are faced with
estimating the risk to a particular patient who is undergoing some
stressful intervention, such as major noncardiac surgery. Another
issue is the patient with known coronary artery disease who is currently
asymptomatic. Such individuals, especially if they have objective
evidence of myocardial ischemia, are known to have a higher incidence
of future cardiovascular morbidity and mortality. There is, understandably,
a strong temptation to treat such patients, despite the fact that
it is difficult to make an asymptomatic patient feel better, and
some of the treatment modalities have their own risks. In such cases,
strong evidence that longevity will be positively influenced by
the treatment must be present in order for its benefits to outweigh
In the industrialized nations, most patients with chronic ischemic
heart disease have coronary atherosclerosis. Consequently, it is
easy to become complacent and ignore the fact that other diseases
can cause lesions in the coronary arteries (Table
3–1). In young people, coronary artery anomalies should
be kept in mind; in older individuals, systemic vasculitides are
not uncommon. Today, collagen vascular diseases are the most common vasculitides
leading to coronary artery disease, but in the past, infections
such as syphilis were a common cause of coronary vasculitis. Diseases
of the ascending aorta, such as aortic dissection, can lead to coronary
ostial occlusion. Coronary artery emboli may occur as a result of
infectious endocarditis or of atrial fibrillation with left atrial
thrombus formation. Infiltrative diseases of the heart, such as tumor
metastases, may also compromise coronary flow. It is therefore essential
to keep in mind diagnostic possibilities other than atherosclerosis
when managing chronic ischemic heart disease.
Table 3–1. Nonatherosclerotic Causes of Epicardial Coronary Artery Obstruction. |Favorite Table|Download (.pdf)
Table 3–1. Nonatherosclerotic Causes of Epicardial Coronary Artery Obstruction.
- Congenital anomalies
- Myocardial bridges
- Aortic dissection
- Scarring from trauma, radiation
- Thrombus in situ
Myocardial ischemia is the result of an imbalance between myocardial oxygen supply and demand. Coronary atherosclerosis and other diseases reduce the supply of oxygenated blood by obstructing the coronary arteries. Although the obstructions may not be enough to produce
myocardial ischemia at rest, increases in myocardial oxygen demand during
activities can precipitate myocardial ischemia. This is the basis
for using stress testing to detect ischemic heart ...