Coronary artery disease: Clinical

Coronary artery disease can lead to myocardial ischemia which is when the myocardium isn’t getting a sufficient blood supply; so there isn’t enough oxygen to meet the heart’s demands.

And coronary artery disease is characterized by a type of chest pain called angina pectoris, which can be due to either vasospastic disease and atherosclerotic disease.

Vasospastic disease, also called Prinzmetal angina, is when for unclear reasons there’s transient vasoconstriction of a coronary artery, leading to transient ischemia.

These attacks generally occur at rest, during the night or early morning, and occur in clusters.

Atherosclerotic disease is when a coronary artery narrows due to build up of atherosclerotic plaque, and it can be further divided into stable angina, unstable angina, and myocardial infarction.

Unstable angina and myocardial infarction are collectively called acute coronary syndrome.

Patients with stable angina don’t feel pain at rest, but they do feel chest pain during intense physical exercise, because that’s when the myocardium has increased oxygen demand, which leads to transient or demand ischemia.

The chest pain stops when the exercise stops, so these patients often just rest rather than going to the emergency department or ED.

Now, angina is considered unstable if it presents at rest, or if it becomes more frequent, lasts longer, or occurs with less exertion than previous episodes of angina.

In unstable angina there’s prolonged myocardial ischemia, but there’s no myocardial cell death yet, so it’s not a myocardial infarction.

But if it’s not taken care of promptly, the ischemia can get prolonged and can lead to myocardial infarction, which is life-threatening.

When a patient comes into the ED with acute chest pain, a number of things have to be done within 10 minutes to confirm or exclude a myocardial ischemia.

The differential diagnosis includes gastroesophageal reflux, pulmonary embolism, aortic dissection, a pneumonia, or a panic attack.