Are Patients Still at Risk?
Mechanism of Disease
The development of plaques in the coronary arteries, as a consequence of the systemic disease atherosclerosis, leads to CAD. Patients with CAD are at high risk of potentially fatal ischaemic events caused by atherothrombosis, such as MI and stroke. Therefore, the mortality and morbidity burden of CAD is high. CAD treatment involves lifestyle changes, drugs aimed at vascular protection and, in some instances, revascularization. Treatment aims to improve symptoms, control cardiovascular risk factors and prevent ischaemic events. However, even with optimal treatment, which includes an antiplatelet agent and a statin in all patients with CAD, there remains a high residual risk of ischaemic events.Read more on Thrombosisadviser.com
Almost all cases of coronary artery disease are attributed to atherosclerosis. A high apoB/apoAI ratio is one of the most potent risk factors for experiencing a myocardial infarction.
- Johns Hopkins Health Library. Anatomy and function of the coronary arteries. http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/anatomy_and_function_of_the_coronary_arteries_85,P00196/. Accessed July 2017.
Risk factors for poor outcomes in patients with stable CAD include hemoglobin levels, low blood pressure, and angina.
- Kalra PR, Greenlaw N, Ferrari R, et al; ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease (CLARIFY) Investigators. Hemoglobin and Change in Hemoglobin Status Predict Mortality, Cardiovascular Events, and Bleeding in Stable Coronary Artery Disease. Am J Med. 2017;130(6):720-730.
- Vidal-Petiot E, Ford I, Greenlaw N, et al; CLARIFY Investigators. Cardiovascular event rates and mortality according to achieved systolic and diastolic blood pressure in patients with stable coronary artery disease: an international cohort study. Lancet. 2016;388(10056):2142-2152.
- Steg PG, Greenlaw N, Tendera M, et al; Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease (CLARIFY) Investigators. Prevalence of anginal symptoms and myocardial ischemia and their effect on clinical outcomes in outpatients with stable coronary artery disease: data from the International Observational CLARIFY Registry. JAMA Intern Med Dis. 2014;174:1651–1659.
Approximately half of all patients who present with CAD have angina provoked by physical or emotional stress as the first manifestation.
- Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34:2949–3003.
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According guidelines issued by the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), patients with stable CAD may be candidates for revascularization (ie, restoration of oxygen/blood flow) with PCI or CABG to relieve symptoms or improve prognosis.
- Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014;35:2541–2619.
Reduction in the risk of secondary cardiac events can be provided by a comprehensive vascular protection strategy including the use of antithrombotic, lipid-lowering, antihypertensive, and/or glucose-lowering drugs.
- Cortes-Beringola A, et al. Eur J Prevent Cardiol 2017;24(3S);22–28.
Clinical trials DAPT with aspirin and a P2Y12 inhibitor have shown inconsistent effects on cardiovascular events and major bleeding.
- CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet. 1996;348:1329–1339.
- Yusuf S, Mehta SR, Zhao F, et al; Clopidogrel in Unstable angina to prevent Recurrent Events Trial Investigators. Early and late effects of clopidogrel in patients with acute coronary syndromes. Circulation. 2003;107:966–972.
- Bhatt DL, Fox KA, Werner Hacke ChB, et al; the CHARISMA Investigators. Clopidogrel and Aspirin versus Aspirin Alone for the Prevention of Atherothrombotic Events. N Engl J Med. 2006;354(16):1706-1717.
- Wiviott SD, Braunwald E, McCabe CH, et al; TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357:2001–2015.
- Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361:1045–1057.