Coronary Artery Disease: Therapy

General measures

  • If pectanginal complaints (“chest tightness”, chest pain) persist for more than 20 minutes or the complaints suddenly become more intense and occur at shorter intervals, then the patient must be immediately admitted to hospital accompanied by an emergency physician (because of suspected acute coronary syndrome = unstable angina pectoris or acute myocardial infarction/heart attack).
  • Nicotine restriction (refraining from tobacco use) – complete cessation of smoking (abstinence) is the most important single therapeutic measure in patients with vascular disease.
  • Avoidance of passive smoking
  • Limited alcohol consumption (men: < 30 g alcohol per day; women: max. 12 g alcohol per day).
  • Aim for normal weight! (regular weight control)Determination of BMI (body mass index, body mass index) or body composition using electrical impedance analysis.
    • BMI 25-35 → participation in a medically supervised weight loss program; weight reduction within the next 6 months by 5-10%.
    • BMI > 35 → Participation in a medically supervised weight loss program; weight reduction within the next 6 months by 10%.
  • Take a nap during the day – controlled 30-minute sleep by an alarm clock – at least three times a week – reduces the risk by 37% of dying from coronary heart disease (CHD; coronary artery disease) and its consequences (e.g., myocardial infarction/heart attack); the same is likely true for apoplexy (stroke).
  • Leisure activities and intimate life
    • Sauna: A Finnish proverb says: “The sauna is the pharmacy of the poor”. It reduces the risk of sudden cardiac death (PHT), has a beneficial effect on ventricular arrhythmias (cardiac arrhythmias originating in the ventricle/potentially life-threatening; rate of ventricular tachycardia ↓), and improves NYHA stage (scheme for grading heart failure/heart failure; BNP levels ↓). Furthermore, sauna has a positive effect on systolic and diastolic blood pressure. The frequency of angina pectoris attacks (“chest tightness”; sudden pain in the heart area) decreases.Conclusion: for patients after a myocardial infarction (heart attack) sauna does not seem to be dangerous.
    • Sports: see below sports medicine
    • Intimate life: Blood pressure only rises to 160/90 mmHg during the sexual act, pulse rate to 120/min – after which it takes only two to three minutes for heart rate and blood pressure to recover. For patients who can perform moderate physical activity (energy expenditure of 3 to 5 METs* without suffering angina, dyspnea (shortness of breath), cyanosis (blue discoloration of the skin), arrhythmias, or ST-segment depression (may indicate insufficient blood flow to the myocardium/cardiac muscle) can have sex pleasurably. The same is true for patients with NYHA stages I and II and for implantable cardioverter defibrillator (ICD; pacemaker) wearers.
  • Review of permanent medication due topossible impact on the existing disease.
  • Physical activity can reduce the risk of occurrence of heart disease and mortality (mortality) (positive effect on inflammatory parameters and parameters of cardiac and renal function: CRP, troponin T, NT-proBNP, creatinine, cystatin C).
  • Avoidance of psychosocial stress:
    • Stress
  • Avoidance of environmental stress:
    • Diesel dust
  • Travel recommendations:
    • Participation in a travel medical consultation required!
    • Note: Acute coronary syndromes occur most frequently during the first two days of travel. Therefore, comfortable travel conditions should be present during the first few days.

* Metabolic equivalent of task (MET); 1 MET ≡ energy expenditure of 4.2 kJ (1 kcal) per kilogram of body weight per hour).

Conventional nonsurgical therapeutic methods

  • Percutaneous coronary intervention (PCI) – procedure for dilatation (widening) of narrowed coronary arteries (see below Percutaneous coronary intervention (PCI)).
  • “Reducer” – system for coronary sinus narrowing: In this procedure, an implant is placed via catheter in the coronary sinus for focal narrowing of the coronary sinus. This increases the pressure in the coronary sinus, which should lead to an increased redistribution of blood towards the ischemic myocardial areas.Indication: patients with frequent distressing pectanginal pain who have severe diffuse coronary sclerosis (coronary artery disease), for whom revascularization (restoration of adequate blood supply, e.g., by bypass surgery) is no longer a therapeutic option, and who are resistant to drug therapy.In an initial study in 104 CHD patients, this new interventional therapeutic approach has been shown to be effective.

Vaccinations

The following vaccinations are advised:

Regular checkups

  • Regular medical checkups

Nutritional medicine

  • Nutritional counseling based on nutritional analysis
  • Nutritional recommendations according to a mixed diet taking into account the disease at hand. This means, among other things:
    • Reduced sugar intake
    • Daily total of 5 servings of fresh vegetables and fruits (≥ 400 g; 3 servings of vegetables and 2 servings of fruits).
    • Fresh sea fish once or twice a week, i.e. fatty marine fish (omega-3 fatty acids) such as anchovies, herring, salmon, mackerel, sardines, tuna – Regular consumption of fish may reduce the risk of coronary heart disease.
    • High-fiber diet (cereals and cereal products (oats and barley products), whole grains, legumes, pectin-rich fruits such as apples, pears and berries).
    • Unsalted nuts
  • Observance of the following special dietary recommendations:
    • Avoidance of:
      • Too high calorie intake
      • Diet too rich in fats (high intake of saturated fatty acids, trans fatty acids – occur especially in convenience foods, frozen foods, fast foods, snacks – and cholesterol).
      • Too high intake of animal protein (protein), especially including processed meat.
      • Too low intake of unsaturated fatty acids (monounsaturated and polyunsaturated fatty acids such as omega-3 fatty acids (marine fish)); CHD is also inversely associated (linked) with the intake of linoleic acid.
    • Diet rich in:
  • Selection of appropriate food based on the nutritional analysis
  • See also under “Therapy with micronutrients (vital substances)” – if necessary, taking a suitable dietary supplement.
  • Detailed information on nutritional medicine you will receive from us.

Sports Medicine

  • Endurance training (cardio training) and strength training (muscle training).
    • Aerobic endurance training 3 to 7 times per week, 15-30-60 minutes each, under pulse control at a heart rate reserve exhaustion of 40-60% (= intensity of exercise) of maximal exercise capacity below the angina pectoris threshold, i.e., in the ischemia-free range Heart rate reserve (according to Karvonen) = (maximal heart rate – resting heart rate) x intensity of exercise + heart rate at rest Maximal heart rate (MHF, HFmax) = 220 – age of life.
    • High-intensity interval training (HIT): comparison moderate aerobic endurance training (MCT: moderate-intensity continuous training) and HIT (Here: 4×4-minute protocol): VO2 max after 4 weeks (HIT. Improvement 10% versus 4% MCT); after 12 months (10% versus 7%)Conclusion: HIT may be a complement or alternative to classical endurance training.
    • Note: In case of high and very high risk (SCORE ≥ 5 percent), other risk factors or low physical activity to date, a stress test is obligatory beforehand (including CT angiography (CCTA) if necessary).Competitive sports (except in individual cases of skill sports for example golf or shooting) are discouraged in individuals at high risk for exercise-induced complications and those with existing residual ischemia (residual reduced blood flow) (III C).
  • Suitable sports are fast walking or hiking, Nordic walking (endurance sport in which fast walking is supported by the use of two sticks in rhythm with the steps), slow running, cycling, cross-country skiing and swimming.
  • Strength training (dynamic strength loads) 2 to 3 times per week should be performed additionally; high isometric components should be avoided.
  • Patients who had all had either myocardial infarction (heart attack) or cardiac revascularization and coronary ischemia (reduced blood flow to the coronary arteries) or angiographically confirmed coronary stenosis (narrowing of the coronary arteries) with a degree of stenosis greater than 50% benefited maximally from physical activity once or twice a week for at least 20 minutes, up to shortness of breath and increased heart rate. The mortality rate (death rate) of this group during a follow-up period of 5 years was about 20% lower than that of participants in the groups of patients who reported little physical activity (group 1) or light physical activity without exertion (group 2); group 1 had the highest mortality rate (HR 1.32). If participants had exercise three times or even more per week, this did not bring any further benefit to those.
  • Exercise-based cardiac rehabilitation was associated with a reduction in cardiovascular mortality/ mortality rate (RR 0.74; 95% confidence interval 0.64-0.86) and hospital admissions (RR 0.82; 95% confidence interval 0.70-0.96) compared with patients without exercise. Furthermore, it led to an improvement in quality of life.
  • Notes for CHD patients who wish to participate in competitive sports:
    • Participation in competitive sports means that patients must be able to exert maximal cardiocirculatory effort without an increased risk of cardiac events. This requires a comprehensive cardiovascular examination: e.g., maximal workload in an exercise ECG; ergometric documentation of maximal exercise capacity including detection of any ischemic changes, arrhythmias; examination of blood pressure behavior under exerciseNote: If ergometry results are inconclusive (e. ST depression of 0.15 mV or atypical ascending ST depression) or in case of uninterpretable ECGs in patients with previously known block patterns, further cardiac evaluation by means of stress testing is recommended (stress echo/ MRI/PET/SPECT). In the presence of abnormal ergometry, coronary CT or coronary angiography is recommended to be performed
    • The following is a checklist for determining the likelihood of cardiac events; a low likelihood of cardiac events is when all items are met:
      • No critical coronary stenoses (<70%) of the major coronary arteries (arteries that surround the heart in a coronary shape and supply blood to the heart muscle) or <50% of the left main stem.
      • Normal left ventricular systolic function (≥ 50%) and no detectable wall motion abnormalities (echocardiography, MRI, or angiography).
      • Exclusion of ischemia on ergometry.
      • Exclusion of ventricular tachycardic arrhythmias at rest and during exercise
      • Age-related performance within the normal range

    Contact sports should be avoided during dual antithrombotic therapy!

  • Development of atherosclerotic plaques (“vascular deposits”) in competitive athletes in relation to the type of sport:
    • Marathon runners develop more coronary changes (heart disease vascular changes) over time than less athletically active individuals
    • Cyclists are significantly less likely to develop atherosclerotic plaques (adjusted odds ratio 0.41)
      • Prevalence of coronary artery calcification (CAC) was lower in cyclists compared with runners.
      • Probability of calcified and thus more stable plaques was significantly higher in cyclists compared with runners (aOR 3.59).
  • Preparation of a fitness or training plan with appropriate sports disciplines based on a medical check (health check or athlete check).
  • Detailed information on sports medicine you will receive from us.

Psychotherapy

Complementary treatment methods

  • Acupuncture – led to a significant decrease in pectanginal symptoms in chronic stable angina (CSA).
  • Electroacupuncture according to TCM rules (acupuncture points LU9 and LU6) – was able to significantly reduce the number of pain attacks in Chinese patients with stable angina, but without myocardial infarction (heart attack) or cardiac arrhythmia historyNote: The Chinese study with 404 participants proves the effect of electroacupuncture as adjunctive therapy of stable angina.

Rehabilitation

Patients after ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and coronary artery bypass graft surgery are recommended to undergo rehabilitation. In this context, the transition to the rehabilitation facility should take place after only a few days if the course is uncomplicated. Rehabilitation therapy is composed of the following three phases:

Phase I

  • Early mobilization of patients, beginning in the hospital.

Phase II

  • Rehabilitation (outpatient or inpatient), which takes place immediately after completion of acute inpatient treatment (follow-up treatment (AHB), follow-up rehabilitation (AR)).
  • Somatic rehabilitation – medical control, mobilization, secondary prevention.
  • Educational rehabilitation – education, counseling, training about CHD.
  • Psychological rehabilitation – for depression, anxiety.
  • Socio-medical rehabilitation – counseling for social and professional reintegration.

Phase III

  • Long-term treatment – stabilization of therapeutic success, improvement of the course of the disease.