Coronary Artery Disease

Coronary artery disease (CAD) – colloquially called coronary artery disease – (synonyms: Angina pectoris; arteriosclerosis of coronary arteries; arteriosclerosis of a cardiac vessel; arteriosclerotic heart disease; arteriosclerotic cardiomyopathy; arteriosclerotic cardiopathy; atherosclerosis of coronary arteries; atherosclerosis of coronary arteries; CHD; CIHK; CIHK [chronic ischemic heart disease]; chronic cardiovascular disease; chronic cardiac ischemia; chronic coronary insufficiency; chronic hypertensive ischemic heart disease; chronic ischemic heart disease; chronic cardiac circulatory disorder; coronary sclerosis; coronary sclerosis; IHK; ischemic heart disease; CHD; coronary artery sclerosis; coronary circulatory disorder; coronary artery disease (CAD); coronary sclerosis; coronary stenosis; stenocardia; ischemic heart disease; coronary artery disease (CAD), coronary heart disease (CHD), ischemic heart disease (IHD);ICD-10-GM I25.-: Chronic ischemic heart disease) is a disease in which there is a mismatch between oxygen demand and oxygen supply in the myocardium (heart muscle) due to stenosis (narrowing) of the coronary arteries (coronary arteries). The most common cause is atherosclerosis (hardening of the arteries) of the vessels supplying the heart.It is also called chronic ischemic heart disease or chronic coronary syndromes (CCS).Classification of coronary artery disease (CAD) into:

  • Latent CHD – asymptomatic (asymptomatic) deficiency; “silent myodardial ischemia”.
  • Stable CHD or also called chronic CHD (angina pectoris; chest tightness, heart pain; ICD-10-GM I20.-: angina pectoris) – reversible symptoms on exertion or exposure to cold.

From the classic angina pectoris is to be distinguished Prinzmetal angina, which is a special form of angina pectoris. It is triggered by spasms of the coronary vessels (coronary spasm) and therefore also called spastic angina. The ST elevations in the ECG are reversible and there is also no troponin and CK rise. In coronary artery disease, a further distinction is made between chronic coronary artery disease and acute events. The term acute coronary syndrome (ACS) is used to refer to those phases of CHD that are immediately life-threatening. These include:

  • Unstable angina or chest tightness or heart pain (iAP; unstable angina, UA) – unstable angina is said to occur when the symptoms have increased in intensity or duration compared with previous angina attacks
  • Acute myocardial infarction (heart attack):
    • Non-ST-segment-elevation myocardial infarction (NSTEMI; English : non ST-segment-elevation myocardial infarction; NSTE-ACS).
    • ST-segment-elevation myocardial infarction (STEMI; engl.)
  • Sudden cardiac death (PHT)

The severity of coronary insufficiency can be divided into:

  • Grade I – asymptomatic (absence of symptoms at rest and on exertion).
  • Grade II – exertional angina (heart tightness under physical exertion).
  • Grade III – Severe angina pectoris – significant reduction in performance even at low levels of stress or even at rest.
  • Grade IV – Myocardial infarction (heart attack)

Furthermore, CHD can be classified according to the extent of atherosclerotic changes in:

  • Single-vessel disease – one or more stenoses in a main branch of the coronary arteries.
  • Branch vessel disease – one or more stenoses in two main branches of the coronary arteries
  • Three-vessel disease – one or more stenoses in three main branches of the coronary arteries or
  • Main stem stenosis (HSS) – narrowing of one major vessel, e.g., the entire left coronary artery.

Sex ratio: men have increased coronary risk compared with women before menopause (menopause). However, after menopause, coronary risk also increases in women. After age 75, the sex ratio is balanced. Peak incidence: the disease occurs predominantly in middle to older age (men ≥ 55 yr and women ≥ 65 yr). The lifetime prevalence of chronic CHD in Germany is 9.3% (95% CI 8.4-10.3%) in 40-79 year olds (n = 5 901). Chronic ischemic heart disease represents the most common cause of death in industrialized countries.20% of deaths in Germany are caused by coronary heart disease. Course and prognosis: Angina pectoris attacks (heart palpitations, heart pain) occur in particular when the body’s oxygen demand is increased due to physical or mental stress, but the myocardium (heart muscle) is no longer supplied with sufficient oxygen due to the disease. Chronic ischemic heart disease is a progressive disease that can lead to cardiac arrhythmias, heart failure, myocardial infarction and sudden cardiac death. The prognosis depends on how many coronary stenoses (narrowing of the coronary arteries) the patient has. It is not possible to cure the disease, but the prognosis can be improved by pharmacotherapy (drug treatment) and, if necessary, surgical interventions (percutaneous coronary intervention (PCI); aortocoronary vein bypass (ACVB) – see “Surgical therapy” below). The lethality (mortality relative to the total number of people with the disease) is 3 to 4% for single-vessel disease, 6-8% for two-vessel disease, and 10-13% for three-vessel disease. Comorbidities: Coronary artery disease (CAD) is often associated with depression. Furthermore, peripheral atherosclerosis (arteriosclerosis, hardening of the arteries) is present in 10-15% of cases. Note: The likelihood of the presence of any other prognostically relevant mental disorder (anxiety disorders, posttraumatic stress disorder, schizophrenia, bipolar disorder) or psychosocial risk constellation (low socioeconomic status, social isolation, lack of social support, occupational or family stress) should be assessed by appropriate history questions or questionnaires.