Chronic Coronary Disease

Even though chronic coronary disease mortality rates have declined since 1970 it is still the leading cause of death in many western countries and in an increasing number of non western countries.

The cause of the reduction in mortality rates is mainly due to rapid recognition at special cardiac care units and the possibility of early intervention. But because survivors of a myocardial infarction still face a substantial risk of further cardiovascular events and a stitch in time saves nine, recognizing and reducing of risk factors is very important.

The following risk factors for chronic coronary disease are modifiable and should be tackled. Cigarette smoking damages the endothelium of the blood vessels making it easy for the cholesterol to adhere. Smoking is therefore a leading preventable cause of coronary disease. All patients who smoke should be counselled to give up smoking. Nicotine replacement therapy and behavioural therapy can help.

Hypertension is like smoking disadvantageous for the endothelium of the blood vessels and so hypertension contributes to the progression of atherosclerosis. Hypertension is defined as a systolic pressure >140 mmHg and/or diastolic pressure >90 mmHg. Patients with hypertension should be first treated with non pharmacologic therapies, including salt restriction, weight reduction in overweight/obese patients, and avoidance of excess alcohol intake. Antihypertensive drugs are indicated in patients with persistent hypertension despite non pharmacologic therapy. Most patients will require multiple antihypertensive drug therapies.

Cholesterol is the felon in the atherosclerosis tale and therefore cholesterol levels in the blood should be optimal, meaning low LDL levels and high HDL levels. This can be achieved by using statins.

Exercise lowers morbidity and mortality from coronary disease.

Obesity increases several risk factors for coronary heart disease, including hypertension, high cholesterol and insulin resistance as well as diabetes. Data show a linear relationship of higher body weight with morbidity and mortality from coronary disease. All patients who are willing, ready and able to lose weight should receive information about behaviour modification, diet, and increased physical activity.

A healthy diet results in a significantly lower risk of coronary disease. A healthy diet consists of high intake of fruit and vegetables, high fiber intake, a low glycemic index and load, unsaturated fat rather than saturated fat, a limited intake of red or processed meat and intake of omega 3 fatty acids.

Several studies have shown that people who have a high intake of fruit and vegetables have a reduce risk coronary disease. It is possible that this is due to specific compounds in vegetables and fruits, or because people who eat more vegetables and fruits tend to eat less meat and saturated fat.

In diabetes mellitus tight glycemic control is important to protect against many vascular complications, including coronary disease. A small amount of alcohol results in a lower risk of morbidity and mortality from coronary disease.

Screening

Because extensive coronary disease can exist with minimal or no symptoms screening for coronary disease has been suggested. Although screening results in indentifying patients at increased risk there is lack of evidence that screening actually improves outcome.

BRONNEN:

Artikelen:

1. Heberden, W. (1772) Med. Trans. Coll. Phycns 2, 59.
2. Chronic coronary artery disease: Diagnosis and management. Andrew Cassar, MD, MRCP, David R. Holmes Jr, MD, Charanjit S. Rihal, MD, and Bernard J. Gersh, MBChB, DPhil, FRCP. 2009 Mayo Foundation for Medical Education and Research

Boeken:

1. NVVC Hartwijzer

Sites: http://nhg.artsennet.nl/kenniscentrum/k_richtlijnen/k_nhgstandaarden/NHGStandaard/M43_std.htm#Anamnese

Up do date:

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1. Overview of the management of stable angina pectoris
2. Pathofysiology and clinical presentation of ischemic chest pain
3. Overview of the acute management of unstable angina pectoris and acute non ST elevation myocardial infarction
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3. Overview of the non acute management of acute ST elevation myocardial infarction
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6. Coronary artery bypass graft surgery after acute ST elevated myocardial infarction
7. Overview of the acute management of acute non ST elevation myocardial infarction
8. Overview of the non acute management of acute non ST elevation myocardial infarction

Chronic coronary disease:

1. Epidemiology of coronary heart disease
2. Overview of primary prevention of coronary heart disease
3. Prognosis after myocardial infarction
4. Screening for coronary disease