Internal Medicine

0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53

Chronic Coronary Artery Disease (CAD) 315

differential diagnosis

■Non-cardiac:

➣Gastroesophageal reflux: do EGD

➣Chest wall pain: may be apparent on physical exam.

➣Cervical spondylitis: do x-ray or MRI

■Cardiac:

➣Pericarditis (especially after CABG): do ECG and echo.

➣Tachyarrhythmias: 24-h Holter monitor; event monitor

➣Substance abuse, especially cocaine: toxicology screen

management

What to Do First

■Resting ECG

■Exercise test with or without scintigraphy; pharmacologic stress echo

or scintigram

■If younger with convincing history, coronary angiography may be

indicated without stress test

General Measures

■Dietary counseling: reduce fat intake, weight loss

■Discontinue tobacco; may need group Rx

■Exercise prescription

■Optimal diabetes control

specific therapy

■Indication for following is diagnosis of chronic CAD:

➣ASA

➣Statin, fibrate, and/or niacin depending on lipid profile

➣Prophylactic and therapeutic sublingual nitroglycerin

➣Beta-blocker Rx

➣Optimal BP control with additional medications as necessary

(long-acting dihydropyridine calcium channel antagonist, ACE

inhibitor, hydrochlorothiazide, angiotensin II antagonist, cloni-

dine [oral or patch])

➣If ACE inhibitor not necessary for BP control, add low-dose ACE

inhibitor for cardiac and renal protection, especially in patients

with left ventricular dysfunction. Patients with normal left ven-

tricular function may not benefit.

➣Long-acting nitrates

➣Hormone replacement therapy: controversial. May have adverse

cardiovascular effects. Use only for serious menopausal symp-

toms, not for prevention of heart attack or stroke.