Table Of ContentCORONARY ARTERY
DISEASE –
CURRENT CONCEPTS
IN EPIDEMIOLOGY,
PATHOPHYSIOLOGY,
DIAGNOSTICS AND
TREATMENT
Edited by David Gaze
Coronary Artery Disease – Current Concepts in Epidemiology, Pathophysiology,
Diagnostics and Treatment
Edited by David Gaze
Published by InTech
Janeza Trdine 9, 51000 Rijeka, Croatia
Copyright © 2012 InTech
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First published March, 2012
Printed in Croatia
A free online edition of this book is available at www.intechopen.com
Additional hard copies can be obtained from [email protected]
Coronary Artery Disease – Current Concepts in Epidemiology, Pathophysiology,
Diagnostics and Treatment, Edited by David Gaze
p. cm.
ISBN 978-953-51-0262-5
Contents
Preface IX
Part 1 Epidemiology and Pathophysiology
of Coronary Artery Disease 1
Chapter 1 Epidemiology of Coronary Artery Disease 3
John F. Beltrame, Rachel Dreyer and Rosanna Tavella
Chapter 2 Gender Differences in Coronary Artery Disease 31
Ryotaro Wake and Minoru Yoshiyama
Chapter 3 Coronary Flow: From Pathophysiology
to Clinical Noninvasive Evaluation 43
Francesco Bartolomucci, Francesco Cipriani and Giovanni Deluca
Chapter 4 Coronary Microvascular Dysfunction in CAD:
Consequences and Potential Therapeutic Applications 65
Alan N. Beneze, Jeffrey M. Gold and Betsy B. Dokken
Chapter 5 Coronary Artery Disease and Pregnancy 81
Titia P.E. Ruys, Mark R. Johnson and Jolien W. Roos-Hesselink
Part 2 Coronary Artery Disease Diagnostics 101
Chapter 6 Cardiovascular Biomarkers for the Detection
of Cardiovascular Disease 103
David C. Gaze
Chapter 7 Do We Need Another Look at Serum Uric Acid
in Cardiovascular Disease? Serum Uric Acid as
a Predictor of Outcomes in Acute Myocardial Infarction 123
Siniša Car and Vladimir Trkulja
Chapter 8 Stress Testing and Its Role in Coronary Artery Disease 147
Rajkumar K. Sugumaran and Indu G. Poornima
VI Contents
Chapter 9 Reassessing the Value of the Exercise
Electrocardiogram in the Diagnosis of Stable Chest Pain 171
Peter Bourdillon
Part 3 Treatment Regimens for Coronary Artery Disease 183
Chapter 10 Effectiveness and Efficiency of Drug Eluting Stents 185
José Moreu, José María Hernández, Juan M Ruiz-Nodar,
Nicolás Vázquez, Ángel Cequier,
Felipe Fernández-Vázquez and Carlos Crespo
Chapter 11 Coronary Revascularization in Diabetics:
The Background for an Optimal Choice 213
Giuseppe Tarantini and Davide Lanzellotti
Chapter 12 Diastolic Heart Failure After Cardiac Surgery 229
Ahmed A. Alsaddique, Colin F. Royse,
Mohammed A. Fouda and Alistair G. Royse
Chapter 13 Spinal Cord Stimulation for Managing
Angina from Coronary Artery Disease 257
Billy Huh
Preface
Cardiovascular disease is ranked as the leading cause of death world wide. According
to the World Heart Federation, cardiovascular disease is responsible for 17.1 million
deaths globally each year. Surprisingly, 82% of these deaths occur in the developing
world. Such numbers are often difficult to comprehend. The gravity of the situation is
enhanced when portrayed as the following: Heart disease kills one person every 34
seconds in the USA alone. 35 people under the age of 65 die prematurely in the UK
every day due to cardiovascular disease (12,500 deaths per annum). Although the
leading killer, the incidence of cardiovascular disease has declined in recent years due
to a better understanding of the pathology, implementation of lipid lowering therapy
new drug regimens including low molecular weight heparin and antiplatelet drugs
such as glycoprotein IIb/IIIa receptor inhibitors and acute surgical intervention.
The disease burden has a great financial impact on global healthcare systems and
major economic consequences for world economies. Cardiovascular disease cost the
UK healthcare system £14.4 billion (€16.7 billion; $22.8 billion) in 2006. Hospital care
for patients with cardiovascular disease accounts for approximately 70% of the cost
with 20% spent on pharmacological agents. The total cost should include non-
healthcare costs such as production losses in the workforce and informal care of
people with the disease. Production loss is estimated to cost the UK economy £8.2
billion in 2006 (55% due to death and 45% due to illness). Informal care cost the UK
economy £8.0 billion in 2006. Overall cardiovascular disease is estimated to cost the
UK economy £30.7 billion per annum.
This text aims to deliver the current understanding of coronary artery disease and is
split into three main sections:
1. Epidemiology and pathophysiology of coronary artery disease where the spectrum of the
disease will be described in relation to geographical location. Data from the
industrialised countries on rates of myocardial infarction and angina are
discussed in particular with reference to the wider healthcare and socioeconomic
status. In the second chapter gender differences in rates and type of
cardiovascular diseases are discussed. Often women view cardiovascular disease
as a lower disease category than breast or cervical cancer. The differences in
atherosclerotic pathology between men and women are discussed as well as the
X Preface
different approaches to diagnostic regimens, treatment and mortality. Coronary
blood flow is discussed with reference to the turbulence caused by atherosclerotic
lesions and the clinical importance of Doppler Echocardiography in the
evaluation of ischemic myocardium. In clinical practice, many patients present
with angina and reduced coronary flow reserve despite normal coronary
angiography of the large epicardial arteries. In this situation the vessels that limit
flow to myocardium are the more distal epicardial prearterioles and
intramyocardial arterioles typically too small to be visualized by conventional
coronary angiography. Coronary microvascular dysfunction is poorly understood
and difficult to manage. In addition, the presence of coronary microvascular
dysfunction can be a confounding factor in the management of cardiac patients
and is discussed in detail. The final chapter in this section deals with coronary
artery disease during pregnancy. The incidence of pregnancy related acute
coronary syndrome is 6 per 100,000 deliveries. One of the most important risk
factors is maternal age. Pregnancy is a hypercoagulable state and has a major
impact on hemodynamics. The presence of reduced left ventricular function
increases the chance of an adverse maternal and fetal outcome. The underlying
cause of an acute coronary syndrome may be different from outside pregnancy.
The aetiology, pathophysiology and associated mortality as well as treatment
options are discussed.
2. Coronary artery disease diagnostics. The first chapter of this section deals with the
laboratory based biomarkers used to detect coronary artery disease. The challenge
has been the identification of a cardiospecific biomarker. The cardiovascular
biomarkers essentially fall into three categories. Those that identify patients at risk
atherosclerosis; those associated with plaque destabilisation and those which
indicate rupture of the plaque, necrosis and cardiac insufficiency. The use of
serum uric acid as a predictive biomarker in myocardial infarction is discussed in
the second chapter. A plethora of non-clinical, clinical and epidemiological studies
have accumulated over the decades that aimed to elucidate molecular and cellular
mechanisms of uric acid and its role as a diagnostic and prognostic aid or
importantly, as a therapeutic target. This stems from its antioxidant potential. The
role of serum uric acid on the cardiovascular system with respect to hypertension,
stroke, renal failure, heart failure and coronary heart disease are discussed. Being
able to identify patients with coronary artery disease early will help lower
hospital costs and decrease mortality and morbidity. Stress testing has emerged as
the sole non-invasive method for risk stratifying patients. Apart from highlighting
the advantages and disadvantages of various stress testing modalities, the chapter
reviews which patients should undergo stress testing based on appropriateness
criteria; managed separately based on their risk factors and identifying those who
may be at increased risk of acute myocardial infarction or death. The final chapter
of this section discusses the role of exercise electrocardiography in patients with
stable chest pain. A UK National Institute for Health and Clinical Excellence
(NICE) guideline on the diagnosis of discomfort of suspected cardiac origin
