Subscribe for unlimited access to DynaMed content, CME/CE & MOC credit, and email alerts on content you follow.

Already subscribed? Sign in now

Learn more about CME

Coronary Artery Disease (CAD)

MoreVert
AddCircleOutlineFollow
ShareShare
AddCircleOutlineFollow
Follow
ShareShare
Share

General Information

Description

  • atherosclerotic narrowing of coronary arteries that is often asymptomatic early in the course of the disease but with progressive thickening or plaque rupture of the arterial wall may lead to stable or unstable angina and/or myocardial infarction1,2,3,4
  • most common cause of death in United states

Also called

  • atherosclerotic coronary artery disease (ASCAD)
  • heart disease
  • coronary heart disease (CHD)
  • coronary disease
  • coronary atherosclerosis
  • stable ischemic heart disease (IHD)
  • obstructive coronary artery disease
  • asymptomatic coronary artery disease
  • old myocardial infarction (MI)
  • silent MI

References

General references used

  1. Menees DS, Bates ER. Evaluation of patients with suspected coronary artery disease. Coron Artery Dis. 2010 Nov;21(7):386-90OpenInNew
  2. Lawton JS. Sex and gender differences in coronary artery disease. Semin Thorac Cardiovasc Surg. 2011 Summer;23(2):126-30OpenInNew
  3. Fihn SD, Gardin JM, Abrams J, et al. American College of Cardiology Foundation, American Heart Association Task Force on Practice Guidelines, American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012 Dec 18;60(24):e44-e164OpenInNewfull-textOpenInNew
  4. Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2014 Nov 4;130(19):1749-67OpenInNewfull-textOpenInNew

Recommendation grading systems used

  • Canadian Cardiovascular Society (CCS) grading system for recommendations
    • strength of recommendation
      • Strong
      • Conditional (weak)
    • quality of evidence
      • High - future research unlikely to change confidence in estimate of effect; multiple well-designed, well-conducted clinical trials
      • Moderate - further research likely to have important impact on confidence in estimate of effect and may change estimate; limited clinical trials, inconsistency of results, or study limitations
      • Low - further research very likely to have significant impact on estimate of effect and is likely to change estimate; small number of clinical studies or cohort observations
      • Very Low - estimate of effect is very uncertain; case studies
    • good practice statement - recommended best practice based on clinical experience of guideline development group but lacking direct evidence
    • Reference - 27865641Can J Cardiol 2017 Jan;33(1):17OpenInNew
  • American College of Cardiology/American Heart Association (ACC/AHA) 2016 grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - high-quality evidence from > 1 randomized controlled trial or meta-analysis of high-quality randomized controlled trials
      • Level B-R - moderate-quality evidence from ≥ 1 randomized controlled trial or meta-analysis of moderate-quality randomized controlled trials
      • Level B-NR - moderate-quality evidence from ≥ 1 well-designed nonrandomized trial, observational studies, or registry studies, or meta-analysis of such studies
      • Level C-LD - randomized or nonrandomized studies with methodological limitations or meta-analyses of such studies
      • Level C-EO - consensus of expert opinion based on clinical experience
  • American College of Cardiology Foundation/American Heart Association (ACCF/AHA) grading system for recommendations
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
  • American College of Physicians (ACP) maintained levels of evidence as designated by 2002 ACC/AHA guidelines
    • Level A - based on evidence from several randomized trials with large numbers of patients
    • Level B - based on evidence from limited number of randomized trials with small numbers of patients, careful analyses of nonrandomized studies, or observational registries
    • Level C - based on expert consensus
    • Reference - ACP guideline on primary care management of chronic stable angina and asymptomatic suspected or known coronary artery disease (15466774Ann Intern Med 2004 Oct 5;141(7):562OpenInNew), correction can be found in Ann Intern Med 2005 Jan 4;142(1):79, commentary can be found in 15755372J Fam Pract 2005 Mar;54(3):206OpenInNew
  • American College of Chest Physicians (ACCP) grades
    • Grade 1 - strong recommendation based on clear risk/benefit balance
    • Grade 2 - weak recommendation based on unclear or close risk/benefit balance
    • Grade A - high-quality evidence based on consistent evidence from randomized trials without important limitations or exceptionally strong evidence from observational studies
    • Grade B - moderate-quality evidence based on randomized trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise results) or very strong evidence from observational studies
    • Grade C - low- or very low-quality evidence based on evidence for ≥ 1 critical outcome from observational studies, case series, or randomized trials with serious flaws or indirect evidence
    • Reference - ACCP evidence-based clinical practice guideline on methodology for development of antithrombotic therapy and prevention of thrombosis (22315256Chest 2012 Feb;141(2 Suppl):53SOpenInNewfull-textOpenInNew), commentary can be found in 23546508Chest 2013 Apr;143(4):1190OpenInNew
  • United States Preventive Services Task Force (USPSTF) grades of recommendation (after July 2012)
    • Grade A - USPSTF recommends the service with high certainty of substantial net benefit
    • Grade B - USPSTF recommends the service with high certainty of moderate net benefit or moderate certainty of moderate-to-substantial net benefit
    • Grade C - USPSTF recommends selectively offering or providing the service (based on professional judgment and patient preference) with at least moderate certainty of small net benefit
    • Grade D - USPSTF recommends against providing the service with moderate-to-high certainty of no net benefit or harms outweighing benefits
    • Grade I - insufficient evidence to assess balance of benefits and harms
    • Reference - USPSTF Grade DefinitionsOpenInNew
  • European Society of Cardiology/European Society of Anaesthesiology (ESC/ESA) grading system for recommendations
    • classes of recommendations
      • Class I - evidence and/or general agreement that given treatment or procedure is beneficial, useful, and effective
      • Class II - conflicting evidence and/or divergence of opinion about usefulness/efficacy of given treatment or procedure
        • Class IIa - weight of evidence/opinion in favor of usefulness/efficacy
        • Class IIb - usefulness/efficacy less well established by evidence/opinion
      • Class III - evidence or general agreement that given treatment or procedure is not useful/effective, and in some cases may be harmful
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized clinical trial or large nonrandomized studies
      • Level C - consensus of opinion of experts and/or small studies, retrospective studies, registries

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • Peter Oettgen MD, FACC, FAHA, FACP (Editor in Chief; Cardiologist, Beth Israel Deaconess Medical Center; Associate Professor of Medicine, Harvard Medical School, Massachusetts, United States)
  • Dr. Oettgen declares no relevant financial conflicts of interest.
  • Zbys Fedorowicz, MSc, DPH, BDS, LDSRCS (Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain)
  • Dr. Fedorowicz declares no relevant financial conflicts of interest.
  • Eli Gelfand, MD (Assistant Professor of Medicine, Harvard Medical School; Director, Ambulatory Cardiology, Beth Israel Deaconess Medical Center; Massachusetts, United States)
  • Dr. Gelfand declares no relevant financial conflicts of interest.
  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.
  • Choosing Wisely Canada acknowledges dissemination of their recommendations through DynaMed Plus to reach the point of clinical decision-making.
  • The Canadian Medical Association provides review for the incorporation of Choosing Wisely Canada recommendations.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T116156, Coronary Artery Disease (CAD); [updated 2018 Dec 04, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T116156. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also called

  • KeyboardArrowRight

    Epidemiology

    • Who is most affected

    • Incidence/Prevalence

    • Likely risk factors

    • Possible risk factors

    • Factors not associated with increased risk

    • Factors associated with decreased risk

    • Associated conditions

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Family history (FH)

      • Social history (SH)

    • KeyboardArrowRight

      Physical

      • General physical

      • Skin

      • HEENT

      • Neck

      • Chest

      • Cardiac

      • Lungs

      • Abdomen

      • Extremities

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • Clinical prediction rules

    • Blood tests

    • KeyboardArrowRight

      Imaging studies

      • KeyboardArrowRight

        Nuclear myocardial perfusion imaging (MPI)

        • Stress nuclear MPI

        • Single photon emission computed tomography (SPECT)

        • Positron emission tomography (PET)

      • Computed tomography (CT)

      • KeyboardArrowRight

        Magnetic resonance imaging (MRI)

        • Stress magnetic resonance imaging

        • Detection of coronary arterial stenosis

        • Coronary magnetic resonance-guided care

      • Measurement of left ventricular function

      • Coronary angiography

    • Electrocardiography (ECG)

    • Wellens' electrocardiography (ECG) pattern (also called Wellens' syndrome)

    • Cardiac stress testing

  • KeyboardArrowRight

    Management

    • Management overview

    • KeyboardArrowRight

      Counseling

      • Patient education

      • Psychological management

    • Lifestyle modification

    • KeyboardArrowRight

      Medications

      • Drugs for secondary prevention

      • KeyboardArrowRight

        Antibiotics without efficacy for treating cardiovascular disease

        • Efficacy of antichlamydial therapy

        • Efficacy of azithromycin

        • Efficacy of clarithromycin

        • Efficacy of roxithromycin

    • KeyboardArrowRight

      Surgery and procedures

      • Coronary revascularization

      • Perioperative cardiac management for noncardiac surgery

    • KeyboardArrowRight

      Other management

      • Assessment of fitness for specific activities

      • Music

      • Bone marrow stem cell transplant

    • Secondary prevention of CAD

    • Management of angina

    • Follow-up

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • KeyboardArrowRight

      Prognosis

      • Overall risk for major adverse cardiac events

      • Risk scores

      • Clinical history

      • KeyboardArrowRight

        Test results

        • Cardiac stress testing

        • Cardiac troponins

        • C-reactive protein

        • Brain natriuretic peptide (BNP) or NT-pro-BNP

        • Other biomarkers

        • Renal impairment and proteinuria

        • Electrocardiographic (ECG) findings

        • Imaging

        • Coronary blood flow

        • Psychosocial factors and prognosis

        • Other risk factors

  • KeyboardArrowRight

    Prevention and Screening

    • Prevention

    • KeyboardArrowRight

      Screening

      • KeyboardArrowRight

        Recommendations for screening

        • United States Preventive Services Task Force (USPSTF) recommendations

        • American College of Cardiology/American Heart Association (ACC/AHA) 2013 guideline on cardiovascular risk assessment

        • American College of Cardiology Foundation/American Heart Association (ACCF/AHA) 2010 guideline for cardiovascular risk assessment in asymptomatic adults

        • Choosing Wisely recommendations

        • Exercise testing guideline recommendations for screening

        • Recommendations for imaging tests in screening

      • Risk prediction

      • Evidence for patients with diabetes

      • Further evaluation

  • KeyboardArrowRight

    Quality Improvement

    • Physician Quality Reporting System Quality Measures

    • Quality and Outcomes Framework Indicators

    • Choosing Wisely

    • Choosing Wisely Canada

    • Choosing Wisely Australia

    • American College of Cardiology (ACC)/American Heart Association (AHA) Performance Measures

    • Quality improvement evidence

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • Asian guidelines

      • Swedish guidelines

      • Quality indicators

    • Review articles

    • MEDLINE search

  • Patient Decision Aids

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Eli Gelfand MD
KeyboardArrowDown
Affiliations

Assistant Professor of Medicine, Harvard Medical School; Massachusetts, United States; Director, Ambulatory Cardiology, Beth Israel Deaconess Medical Center; Massachusetts, United States

Conflicts of Interest

Dr. Gelfand declares no relevant financial conflicts of interest.

Recommendations Editor
Zbys Fedorowicz MSc, DPH, BDS, LDSRCS
KeyboardArrowDown
Affiliations

Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain

Conflicts of Interest

Dr. Fedorowicz declares no relevant financial conflicts of interest.

Deputy Editor
Peter Oettgen MD
KeyboardArrowDown
Affiliations

Editor in Chief, DynaMed; Cardiologist, Beth Israel Deaconess Medical Center; Massachusetts, United States; Associate Professor of Medicine, Harvard Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Oettgen declares no relevant financial conflicts of interest.

Produced in collaboration with American College of Physicians

Images in topic (1)

View all
Inverted T waves

Inverted T waves

CheckCircle
Subscribe for unlimited access to DynaMed content.
Already subscribed? Sign in

top