Coronary Artery Disease: Diagnosis and Treatment – A Comprehensive Modern Review

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I. Overview Coronary artery disease (CAD) is a chronic, progressive condition characterized by the formation of atherosclerotic plaques along the inner walls of the coronary arteries—vessels that supply oxygen and nutrients to the heart muscle. These plaques can narrow or completely block the arteries, reducing blood flow to the heart (myocardial ischemia) and, in severe cases, causing a heart attack (myocardial infarction).

CAD is a leading cause of illness and death worldwide, especially in developed countries—including the United States—where around 800,000 people experience a heart attack each year. The disease also contributes significantly to healthcare costs and lost productivity.

II. Causes and Risk Factors The primary cause of CAD is atherosclerosis—buildup of fats, cholesterol, calcium, and cellular debris inside the arterial walls, forming plaques that narrow the artery’s opening.

Modifiable risk factors include:

• High blood pressure (hypertension): Directly linked to the risk of cardiac events.

• High levels of LDL cholesterol ("bad" cholesterol) and low levels of HDL ("good" cholesterol): Increase the likelihood of plaque buildup.

• Diabetes: Accelerates atherosclerotic changes.

• Obesity and lack of physical activity: Raise risk by negatively affecting metabolism.

• Smoking: One of the strongest reversible risk factors.

Non-modifiable risk factors include:

• Age: Risk increases progressively after age 40, especially in men.

• Gender: Men are at higher risk at younger ages, but after menopause, women’s risk matches or surpasses that of men.

• Family history: A family history of early-onset CAD significantly increases risk.

Social and behavioral factors: Poor dietary habits, social isolation, stress, poverty, and limited access to healthcare all contribute to the development of CAD.

III. Key Symptoms The classic symptom is angina—a squeezing, pressing, or burning chest pain that may radiate to the arms, neck, jaw, or back. It’s often triggered by physical exertion or emotional stress and typically eases with rest or nitroglycerin.

Other common symptoms include:

• Shortness of breath during exertion (dyspnea)

• Weakness and fatigue

• Nausea, sweating, dizziness

Important note: In older adults, women, and people with diabetes, symptoms can be atypical—presenting as weakness, indigestion, abdominal pain, or even no pain at all (known as “silent ischemia”).

IV. Diagnosis (Expert Opinions) Diagnosis begins with:

• A detailed medical history and assessment of risk factors

• A physical exam

Key diagnostic tests include:

• Electrocardiogram (ECG): Can show signs of ischemia or previous heart attacks.

• Stress tests: Help detect ischemia when resting ECG results are inconclusive.

Modern imaging techniques:

• Coronary CT angiography (CCTA): Offers direct visualization of plaques and helps determine the degree of narrowing.

• Positron Emission Tomography (PET): Provides highly sensitive imaging to assess heart muscle blood flow and is increasingly recommended for selected patients.

The gold standard: Invasive coronary angiography offers the most comprehensive information about coronary artery anatomy and allows for immediate intervention if necessary.

Expert consensus: The diagnostic approach should be individualized, combining clinical evaluation with appropriate imaging methods to achieve accurate risk stratification and timely treatment.

V. Treatment and Recommendations (Official Guidelines)

1. Risk Factor Modification – The Foundation of Therapy

• Healthy Diet: Emphasize fruits, vegetables, whole grains, and fish.

• Physical Activity: At least 150 minutes of moderate-intensity exercise per week.

• Smoking Cessation and Alcohol Moderation: Stop smoking and limit alcohol intake.

• Control of Blood Pressure, Cholesterol, and Blood Sugar: Essential for reducing risk and slowing disease progression.

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2. Medication Therapy

• Statins: Lower LDL (“bad”) cholesterol and slow plaque buildup.

• Beta-blockers, ACE inhibitors, Calcium Channel Blockers: Help manage blood pressure and reduce the heart’s workload.

• Antithrombotic Medications (e.g., Aspirin): Decrease the risk of blood clot formation.

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3. Invasive Procedures

• Angioplasty and Stenting (PCI): Recommended for severe narrowing or symptoms that don’t respond to medication.

• Coronary Artery Bypass Grafting (CABG): Used in cases of multi-vessel disease or when other therapies are ineffective.

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The clinical guidelines of the ACC/AHA (American College of Cardiology / American Heart Association) emphasize the importance of an individualized approach and shared decision-making between the doctor and patient.

VI. Latest Scientific Advances

• Advanced Imaging Techniques: Coronary CT angiography (CCTA) and Coronary Artery Calcium (CAC) scoring improve risk prediction and help tailor treatment, especially for patients at intermediate risk.

• New Medications: PCSK9 inhibitors (e.g., inclisiran) show significant reductions in LDL cholesterol and plaque progression—even in patients already on maximally tolerated statin therapy.

• Genetics and Personalized Risk: Polygenic risk scores and gene-specific testing are becoming part of personalized risk assessment and care planning.

• Focus on Inflammation: New treatments targeting inflammation in arterial plaques (e.g., anti-IL-6 and anti-IL-1β agents) are being studied as potential additions to standard therapy.

VII. Expert Consensus

Experts from leading American organizations—including the AHA, ACC, NIH, and CDC—agree on the following key points:

• Prevention and early diagnosis are critical to reducing the burden of coronary artery disease.

• Treatment should be multidisciplinary, personalized, and patient-centered.

• Lifestyle modification remains the cornerstone of disease management, with medications and invasive therapies added as needed based on the latest clinical guidelines.

• Equal access to modern treatment, follow-up care, and rehabilitation is essential for successful coronary disease management strategies.

 Primary sources:

1. Duggan JP et al. Epidemiology of Coronary Artery Disease. Surgical Clinics of North America (2022). https://doi.org/10.1016/j.suc.2022.01.007

2. Jia S et al. Evidence in Guidelines for Treatment of Coronary Artery Disease. Advances in Experimental Medicine and Biology (2020). https://doi.org/10.1007/978-981-15-2517-9_2

3. Damluji AA et al. Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association. Circulation (2023). https://doi.org/10.1161/cir.0000000000001112

4. Martin SS et al. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation (2024). https://doi.org/10.1161/cir.0000000000001209

5. Clinical Trial NCT01347710 – PET Imaging in CAD; Maddahi J et al. JACC (2020).

6. Arnett D et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. JACC (2019). https://doi.org/10.1016/j.jacc.2019.03.009

7. Clinical Trial NCT05360446 – Inclisiran in CAD progression (2022).

8. McClellan M et al. Call to Action: Urgent Challenges in Cardiovascular Disease: A Presidential Advisory From the American Heart Association. Circulation (2019). https://doi.org/10.1161/cir.0000000000000652

9. Tamis-Holland JE et al. Contemporary Diagnosis and Management of Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association. Circulation (2019). https://doi.org/10.1161/cir.0000000000000670