eMedicine Specialties > Cardiology > Atherosclerosis and Risk Factors

Coronary Artery Atherosclerosis: Follow-up

Author: Vibhuti N Singh, MD, MPH, FACC, FSCAI, Director, Suncoast Cardiovascular Center; Chair, Cardiology Division and Cath Labs, Department of Medicine, Bayfront Medical Center; Clinical Assistant Professor, Division of Cardiology, University of South Florida College of Medicine
Coauthor(s): Prakash C Deedwania, MD, FACC, FAHA, FACP, FCCP, Professor of Medicine, University of California, San Francisco School of Medicine; Chief, Cardiology Section, Veterans Affairs Medical Center, UCSF Program at Fresno, California; Director, Cardiovascular Research, UCSF Central San Joaquin Program; Rakesh K Sharma, MD, FACC, Adjunct Associate Professor of Medicine and Cardiology; University of Arkansas for Medical Sciences, Medical Center of South Arkansas
Contributor Information and Disclosures

Updated: Oct 29, 2009

Follow-up

Further Inpatient Care

Stable CAD

 Patients presenting with stable angina or ischemia after physiologic testing and who have undergone revascularization therapy, either in the form of PTCA or stent placement or bypass surgery, benefit from the following modalities:

  • Adjuvant pharmacologic therapy: In post-PTCA or stent patients, adjuvant pharmacologic therapy, such as administration of intravenous glycoprotein IIb/IIIa inhibitors (eg, eptifibatide, abciximab), oral aspirin, clopidogrel, or ticlopidine, significantly reduces cardiovascular outcomes.
  • Aggressive risk reduction: Consultation with a cardiac rehabilitation team for assistance with smoking cessation, weight management, physical exercise, and lipid control is recommended. Patients who are discharged on antilipid medications that were begun in the hospital tend to stay on the therapy and to derive significant reduction in the recurrent cardiac event rate. The American Heart Association has promulgated its Get With The Guidelines program, which involves an Internet-based checklist of discharge medications to ensure that CAD patients are started on aspirin, beta-blockers, ACE inhibitors, and statins (if needed) in the hospital.47

Acute coronary syndromes

  • ST-elevation MI
    • Time is an important factor. Patients with acute ST-elevation MI must be quickly triaged and then treated with either intravenous thrombolytic therapy (goal = door-to-needle time of <30 min) or direct percutaneous intervention (goal = door-to-balloon time of <120 min).
    • Further adjuvant therapy with antithrombin agents (eg, heparin, low–molecular-weight heparins), antiplatelet agents (eg, aspirin), and intravenous nitroglycerine should be provided.
    • Combination therapies using various dose combinations of thrombolytic (fibrinolytic) agents and glycoprotein IIb/IIa inhibitors have yet to show incremental benefit over fibrinolytic therapy alone. Some trials are already concluded; others are underway.
    • Beta-blockers, ACE inhibitors, and statins should be considered in all patients.
  • Non–ST-elevation ACS
    • These patients include those with acute non–Q-wave MI and unstable angina. Fibrinolytic therapy is not effective. The principal therapy includes antithrombin agents (eg, heparin, low–molecular-weight heparins), intravenous nitroglycerine, and oral antiplatelet agents (eg, aspirin).
    • Patients must then be risk stratified into high- or low-risk subgroups. The TIMI group's TIMI score is a handy tool that uses 7 clinical criteria, including age, risk factors, prior aspirin use, ECG change, and cardiac enzymes. Low-risk patients can be treated and stabilized over 48-72 hours. They should then be subjected to a stress test to re–risk stratify them for conservative or aggressive therapy.
    • Patients who have a TIMI score of more than 3 benefit from the use of intravenous glycoprotein IIb/IIIa infusion and an early invasive approach.
    • Beta-blockers, ACE inhibitors, and statins should be considered in all patients.

Further Outpatient Care

  • Cardiac rehabilitation
  • Smoking cessation
  • Regular physical activity
  • Weight management
  • Lipid management
  • Antiplatelet agents
  • ACE inhibitors (if indicated)
  • Close follow-up care to quickly identify restenosis or progression of atherosclerosis
  • Management and follow-up care of complications of CAD or its acute manifestations

Inpatient & Outpatient Medications

  • Aspirin - Clopidogrel for patients with aspirin allergy or resistance
  • Beta-blockers
  • Statins
  • ACE inhibitors
  • Medicines for treating risk factors (eg, antihypertensive medications, antidiabetic medications)
  • Folic acid for patients with hyperhomocystinemia
  • Vitamin E - Not found to be beneficial in the HOPE study

Transfer

Transfer during ACS presentation requires an ambulance (ground or air) with fully equipped facilities and trained personnel to conduct the advanced cardiac life support protocol.

Deterrence/Prevention

  • Aggressive risk reduction
  • Weight reduction
  • Cessation of use of tobacco products
  • Regular physical activity
  • Control of hypertension
  • Management of diabetes

Complications

  • Acute coronary syndromes
  • Cardiomyopathy
  • Congestive heart failure
  • Complications of acute events
  • Complications of therapy
  • Complications of procedures

Prognosis

Prognosis depends on the following factors:

  • Presence of inducible ischemia
  • Left ventricular function
  • Presence of arrhythmias
  • Revascularization potential (complete vs incomplete)
  • Aggressiveness of risk alteration
  • Compliance with medical therapy

Patient Education

Education regarding CAD is extremely important.

Miscellaneous

Medicolegal Pitfalls

Patients presenting with chest pain or similar symptoms pose a significant medicolegal challenge. An appropriate and rapid workup and therapy consistent with current guidelines must always be initiated.

Special Concerns

  • CAD is still the paramount killer. The prevalence of some risk factors appears to be increasing (eg, diabetes, obesity, dysmetabolic syndrome).
  • CAD in women, African Americans, and Asians has not been contained well, and prevalence may be increasing in these populations.
  • Comprehensive, consistent, and aggressive steps are necessary to properly treat CAD.
 


More on Coronary Artery Atherosclerosis

Overview: Coronary Artery Atherosclerosis
Differential Diagnoses & Workup: Coronary Artery Atherosclerosis
Treatment & Medication: Coronary Artery Atherosclerosis
Follow-up: Coronary Artery Atherosclerosis
Multimedia: Coronary Artery Atherosclerosis
References
[ CLOSE WINDOW ]

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Further Reading

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Keywords

coronary heart disease, heart disease, atherosclerosis, hardening of the arteries, heart attack, atherosclerotic coronary artery disease, myocardial ischemia, myocardial infarction, acute coronary syndrome, ACS, congestive heart failure

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Contributor Information and Disclosures

Author

Vibhuti N Singh, MD, MPH, FACC, FSCAI, Director, Suncoast Cardiovascular Center; Chair, Cardiology Division and Cath Labs, Department of Medicine, Bayfront Medical Center; Clinical Assistant Professor, Division of Cardiology, University of South Florida College of Medicine
Vibhuti N Singh, MD, MPH, FACC, FSCAI is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Florida Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Prakash C Deedwania, MD, FACC, FAHA, FACP, FCCP, Professor of Medicine, University of California, San Francisco School of Medicine; Chief, Cardiology Section, Veterans Affairs Medical Center, UCSF Program at Fresno, California; Director, Cardiovascular Research, UCSF Central San Joaquin Program
Prakash C Deedwania, MD, FACC, FAHA, FACP, FCCP is a member of the following medical societies: American Association for the Advancement of Science, American Association of Physicians of Indian Origin, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Federation for Clinical Research, American Heart Association, American Society for Clinical Pharmacology and Therapeutics, American Society of Hypertension, American Thoracic Society, Heart Failure Society of America, and New York Academy of Sciences
Disclosure: Nothing to disclose.

Rakesh K Sharma, MD, FACC, Adjunct Associate Professor of Medicine and Cardiology; University of Arkansas for Medical Sciences, Medical Center of South Arkansas
Rakesh K Sharma, MD, FACC is a member of the following medical societies: American College of Cardiology, American College of International Physicians, American College of Physicians, American Heart Association, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

George A Stouffer III, MD, Henry A Foscue Distinguished Professor of Medicine and Cardiology, Director of Interventional Cardiology, Cardiac Catheterization Laboratory, Chief of Clinical Cardiology, Division of Cardiology, University of North Carolina Medical Center
George A Stouffer III, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, Phi Beta Kappa, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Marschall S Runge, MD, PhD, Charles and Anne Sanders Distinguished Professor of Medicine, Chairman, Department of Medicine, Vice Dean for Clinical Affairs, University of North Carolina at Chapel Hill School of Medicine
Marschall S Runge, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Federation for Medical Research, American Heart Association, American Physiological Society, American Society for Clinical Investigation, American Society for Investigative Pathology, Association of American Physicians, Association of Professors of Cardiology, Association of Professors of Medicine, Southern Society for Clinical Investigation, and Texas Medical Association
Disclosure: Pfizer Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Orthoclinica Diagnostica Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Yasmine Subhi Ali, MD, MSCI, Assistant Professor of Medicine, Director of Preventive Cardiology, Director of Echocardiography, Meharry Medical College; Assistant Clinical Professor of Medicine, Vanderbilt University School of Medicine
Yasmine Subhi Ali, MD, MSCI is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Echocardiography, American Society of Nuclear Cardiology, and National Lipid Association
Disclosure: Pfizer I own a small number of shares of Pfizer stock. These were NOT given to me by Pfizer, but rather purchased by myself as a personal investor for my diversified investment portfolio. None

 
 
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