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Chronic Care Programme
Treatment guidelines
Coronary Artery Disease
Chronic condition
Consultations protocols
Preferred treating provider
Notes
 preferred as indicated by option
 referral protocols apply
Option/plan
Provider
GMHPP
Gold Options
G1000, G500 and
G200.
Blue Options
B300 and B200.
GMISHPP
General Practitioner
Physician
Cardiology Paediatrician
Cardiologist
Pulmonologist
Thoracic Surgeon
Stable
New Patient
Maximum consultations per annum
 Initial consultation
 Follow-up consultation
Tariff codes
Recent acute coronary syndrome /
unstable
Existing patient
New & Existing
patient
1
1
3
1
0183; 0142; 0187; 0108
1
3
Investigations protocols
Type
Blood glucose
ECG without effort
ECG without and with effort
Multistage treadmill test
Cardiac examination (M mode)
Cardiac examination:
2 dimentional
Cardiac examination +
Doppler: Add
Chol / HDL / LDL / Trig
Haemoglobin estimation
Packed cell volume:
Haematocrit
Platelet count
Serum urea
Serum creatinine
Serum potassium
Serum sodium
CXR
ICD 10 coding
Provider
GP, Pathologist or
Specialist (see list)
GP, Pathologist or
Specialist (see list)
GP
Specialist
Specialist
Specialist
Maximum investigations per annum
Stable
Recent acute coronary
syndrome / unstable
Tariff code
New
Existing
New
Patient
Patient
Patient
4057;
1
1
1
4050
1232
2
1
2
1233
1235
3621
3622
2
2
1
1
1
1
0
0
2
2
1
1
Specialist
3625
1
0
1
Pathologist
GP, Pathologist or
Specialist (see list)
Pathologist
4025
3762
1
1
1
1
1
1
3791
1
1
1
Pathologist
Pathologist
Pathologist
Pathologist
Pathologist
Pathologist
3797
4151
4032
4113
4114
3445
1
1
1
2
2
0
1
0
0
2
2
0
1
2
2
2
2
1
I20.- I25.
General
Coronary artery disease (CAD), also called coronary heart disease (CHD), or atherosclerotic
heart disease, is the end result of the accumulation of atheromatous plaques within the walls of
the arteries that supply the myocardium (the muscle of the heart) with oxygen and nutrients. It is
the leading cause of death in the U.S. While the symptoms and signs of coronary heart disease are
noted in the advanced state of disease, most individuals with coronary heart disease show no
evidence of disease for decades as the disease progresses before the first onset of symptoms, often
a "sudden" heart attack, finally arise. After decades of progression, some of these atheromatous
plaques may rupture and (along with the activation of the blood clotting system) start limiting
blood flow to the heart muscle. The disease is the most common cause of sudden death[1], and is
also the most common reason for death of men and women over 20 years of age[2]. According to
present trends in the United States, half of healthy 40-year-old males will develop CHD in the
future, and one in three healthy 40-year-old women.[3] According to the Guinness Book of
Records, Northern Ireland is the country with the most occurrences of CHD. By contrast, the
Maasai of Africa have almost no heart disease.
As the degree of coronary artery disease progresses, there may be near-complete obstruction of
the lumen of the coronary artery, severely restricting the flow of oxygen-carrying blood to the
myocardium. Individuals with this degree of coronary heart disease typically have suffered from
one or more myocardial infarctions (heart attacks), and may have signs and symptoms of chronic
coronary ischemia, including symptoms of angina at rest and flash pulmonary edema.
A distinction should be made between myocardial ischemia and myocardial infarction. Ischemia
means that the amount of oxygen supplied to the tissue is inadequate to supply the needs of the
tissue. When the myocardium becomes ischemic, it does not function optimally. When large areas
of the myocardium becomes ischemic, there can be impairment in the relaxation and contraction
of the myocardium. If the blood flow to the tissue is improved, myocardial ischemia can be
reversed. Infarction means that the tissue has undergone irreversible death due to lack of
sufficient oxygen-rich blood.
An individual may develop a rupture of an atheromatous plaque at any stage of the spectrum of
coronary heart disease. The acute rupture of a plaque may lead to an acute myocardial infarction
(heart attack).
Signs and symptoms
Angina that occurs regularly with activity, upon awakening, or at other predictable times is
termed stable angina and is associated with high grade narrowings of the heart arteries. The
symptoms of angina are often treated with nitrate preparations such as nitroglycerin, which come
in short-acting and long-acting forms, and may be administered transdermally, sublingually or
orally. Many other more effective treatments, especially of the underlying atheromatous disease,
have been developed.
Angina that changes in intensity, character or frequency is termed unstable. Unstable angina may
precede myocardial infarction, and requires urgent medical attention. It is treated with morphine,
oxygen, intravenous nitroglycerin, and aspirin. Interventional procedures such as angioplasty may
be done.ishcmc rocks
There are often no typical symptoms as they are well known for coronary heart disease; Cardiac
Syndrome X often is a diagnosis of exclusion. However, the following list may be helpful in
diagnosing the disease:

Chest pain or Angina, quite often at rest; the pain may spread to the left arm or the neck,
back, throat, or jaw. There might be present a numbness (paresthesia) or a loss of feeling
in the arms, shoulders, or wrists. Patients with female-pattern coronary artery disease
often have chest pain after they exercise and a very variable duration of angina episodes.

Coronary angiography demonstrates “normal” coronary arteries, i. e. no blockages or
stenoses can be detected in the larger epicardial vessels.

No inducible coronary artery spasm present during cardiac catheterization.

Characteristic ischemic ECG changes during exercise testing.

ST segment depression and angina in the absence of left ventricular wall motion
abnormalities during pharmacological stress test.

Reduction of platelet aggregation after exercise (aggregation time 10 seconds).

Inconstant or partial response to sublingual nitrates.

Absence of cardiac or systemic diseases potentially associated with microvascular
dysfunction.

Postmenopausal or menopausal status.

Impaired quality of life.
Diagnosis
Diagnosis begins with a visit to the physician, who will take a medical history, discuss symptoms,
listen to the heart, and perform basic screening tests. These tests will measure weight, blood
pressure, blood lipid levels, and fasting blood glucose levels. Other diagnostic tests
include resting and exercise electrocardiogram, echocardiography, radionuclide scans, and
coronary angiography. The treadmill exercise (stress) test is an appropriate screening test for
those with high risk factors even when they feel well. An electrocardiogram (ECG) shows the
heart’s activity and may reveal a lack of oxygen (ischemia). Electrodes covered with conducting
jelly are placed on the patient’s chest, arms, and legs. They send impulses of the heart’s activity
through an oscilloscope (a monitor) to a recorder that traces them on paper. The test takes about
10 minutes and is performed in a physician’s office. A definite diagnosis cannot be made from
electrocardiography. About 50% of patients with significant coronary artery disease have
normal resting electrocardiograms. Another type of electrocardiogram, known as the exercise
stress test, measures how the heart and blood vessels respond to exertion when the patient is
exercising on a treadmill or a stationary bike. This test is performed in a physician’s office or an
exercise laboratory. It takes 15–30 minutes. It is not perfectly accurate. It sometimes
gives a normal reading when the patient has a heart problem or an abnormal reading when the
patient does not. If the electrocardiogram reveals a problem or is inconclusive, the next step is
exercise echocardiography or nuclear scanning (angiography). Echocardiography, cardiac
ultrasound, uses sound waves to create an image of the heart’s chambers and valves. A technician
applies gel to a hand-held transducer, then presses it against the patient’s chest. The heart’s sound
waves are converted into an image that can be displayed on a monitor. It does not reveal the
coronary arteries themselves, but can detect abnormalities in heart wall motion caused by
coronary disease. Performed in a cardiology outpatient diagnostic laboratory, the test takes 30–60
minutes. Radionuclide angiography enables physicians to see the blood flow of the coronary
arteries. Nuclear scans are performed by injecting a small amount of radiopharmaceutical
such as thallium into the bloodstream. A device that uses gamma rays to produce an image of the
radioactive material (gamma camera) records pictures of the heart. Radionuclide scans are not
dangerous. The radiation exposure is about the same as that in a chest x ray. The tiny amount of
radioactive material used disappears from the body in a few days. Radionuclide scans cost about
four times as much as exercise stress tests but provide more information. In radionuclide
angiography, a scanning camera passes back and forth over the patient who lies on a table.
Radionuclide angiography is usually performed in a hospital’s nuclear medicine department and
takes 30–60 minutes. Thallium scanning is usually done in conjunction with an exercise stress
test. When the stress test is finished, thallium or sestamibi is injected. The patient resumes
exercise for one minute to absorb the thallium. For patients who cannot exercise, cardiac blood
flow and heart rate may be increased by intravenous dipyridamole (Persantine) or adenosine.
Thallium scanning is done twice, immediately after injecting the radiopharmaceutical
and again four hours (and maybe 24 hours) later. It is usually performed in a hospital’s nuclear
medicine department. Each scan takes 30–60 minutes. Coronary angiography is the most accurate
method for making a diagnosis of coronary artery disease, but it is also the most invasive. It is a
form of cardiac catheterization that shows the heart’s chambers, great vessels, and coronary
arteries using x-ray technology. During coronary angiography the patient is awake but
sedated. ECG electrodes are placed on the patient’s chest and an intravenous line is inserted. A
local anesthetic is injected into the site where the catheter will be inserted. The cardiologist
inserts a catheter into a blood vessel and guides it into the heart. A contrast dye is injected to
make the heart visible on x-ray cinematography. Coronary angiography is performed in a cardiac
catheterization laboratory either in an outpatient or inpatient surgery unit. It takes from 30
minutes to two hours.
The diagnosis of “Cardiac Syndrome W” - female-pattern coronary artery disease often is, as
mentioned, an “exclusion” diagnosis. Therefore, usually the same tests are used as in any patient
with the suspicion of coronary heart disease:

Baseline ECG

Exercise ECG – Stress test

Exercise radioisotope test (nuclear stress test, myocardial scintigraphy).

Echocardiography (including stress echocardiography).

Coronary angiography.

Intravascular ultrasound.

MRI scan
Treatment
Therapeutic options for coronary heart disease today are based on three principles: 1. Medical
treatment - drugs (e.g. nitroglycerin, beta-blockers, calcium antagonists, etc.); 2. Coronary
interventions as angioplasty and stent-implantation; 3. Coronary artery bypass grafting (CABG coronary artery bypass surgery). Recent research efforts focus on new angiogenic treatment
modalities (angiogenesis) and various (adult) stem cell therapies.
A variety of drugs are used in the attempt to treat the female-pattern coronary artery disease: beta
blockers, nitrates, calcium channel antagonists, ACE-inhibitors, statins, imipramin (analgesia),
aminophylline, hormone replacement therapy (oestrogen), even electrical spinal cord stimulation
are tried to overcome the symptomatology -all with mixed results. Quite often the quality of life
for these women remains poor.
While not enough is known about female-pattern coronary artery disease to list specific
prevention techniques, adopting heart-healthy habits can be a good start. These include
monitoring cholesterol and blood pressure levels, maintaining a low-fat diet, exercising regularly,
quitting smoking, avoiding recreational drugs, and moderating alcohol intake. However, there
might be a new option for women suffering from “Cardiac Syndrome X”: Protein based
Angiogenesis. This new protein-based angiogenic therapy - using fibroblast growth factor 1
(FGF-1) - might be used as sole therapy as well as adjunct to bypass surgery – thus overcoming
the limitations of conventional bypass surgery.
Neo-angiogenesis in a woman's heart after FGF-1 treatment
Beyond drug therapy, interventional procedures, and coronary artery bypass grafting,
angiogenesis now offers a new, specific and – so far as we know from three human clinical trials
– effective treatment targeted for women’s coronary heart disease.
Medicine formularies
Plan or option
Link to appropriate Mediscor formulary
GMHPP
Gold Options
G1000, G500 and
G200
Blue Options
B300 and B200
GMISHPP
Blue Option B100
[Core]
n/a
Epidemiology
Coronary artery disease, also called coronary heart disease or heart disease, is the leading cause of
death for both men and women in the United States. According to the American Heart
Association, in 1995 one in every 4.8 deaths in the United States was caused by coronary artery
disease. About every 29 seconds, one American will have a heart attack; about every minute, one
American will die from a heart attack. Fourteen million Americans have active symptoms of
coronary artery disease (heart attack or chest pains). Many millions more have silent coronary
disease, the first indication of which can be sudden death
Prognosis
In many cases, coronary artery disease can be successfully treated. Advances in medicine and
healthier lifestyles have caused a substantial decline in death rates from coronary artery disease
since the mid-1980s. New diagnostic techniques enable doctors to identify and treat coronary
artery disease in its earliest stages. New technologies and surgical procedures have extended the
lives of many patients who would otherwise have died. Research on coronary artery disease
continues.
Prevention
A healthy lifestyle can help prevent coronary artery disease and help keep it from progressing. A
heart healthy lifestyle includes eating right, regular exercise, maintaining a healthy weight, no
smoking, moderate drinking, no recreational drugs, controlling hypertension, and managing
stress. Cardiac rehabilitation programs are excellent to help prevent recurring coronary
problems for people who are at risk and who have had coronary events and procedures.
Eat right
A healthy diet includes a variety of foods that are low in fat, especially saturated fat, low in
cholesterol, and high in fiber. It includes plenty of fruits and limited sodium. Some foods are low
in fat but high in cholesterol and some are low in cholesterol but high in fat. Saturated fat raises
cholesterol and, in excessive amounts, increases the amount of the clot-forming proteins in blood.
Polyunsaturated and monounsaturated fats are good for the heart. Fat should comprise no more
than 30% of total daily calories. Cholesterol, a waxy substance containing fats, is found in foods
such as meat, eggs, and other animal products. It is also produced in the liver. Soluble fiber
can help lower cholesterol. Dietary cholesterol should be limited to about 300 milligrams per day.
Many popular lipid-lowering drugs can reduce LDL cholesterol by an average of 25–30% when
used with a low-fat, low-cholesterol diet.
Fruits and vegetables are rich in fiber, vitamins, and minerals. They are low-calorie and nearly
fat free. Vitamin C and beta-carotene, found in many fruits and vegetables, keep LDL-cholesterol
from turning into a form that damages coronary arteries.
Excess sodium can increase the risk of high blood pressure. Many processed foods contain large
amounts of sodium. Limit daily intake to about 2,400 milligrams, about the amount in a teaspoon
of salt.
The “Food Guide” Pyramid developed by the U.S. Departments of Agriculture and Health and
Human Services provides easy-to-follow guidelines for daily heart healthy eating. It recommends
six to 11 servings of bread, cereal, rice, and pasta; three to five servings of vegetables; two to four
servings of fruit; two to three servings of milk, yogurt, and cheese; and two to three servings of
meat, poultry, fish, dry beans, eggs, and nuts. Fats, oils, and sweets should be used sparingly.
Canola and olive oil are better for the heart than other cooking oils. Coronary patients should be
on a strict diet.
Exercise regularly
Aerobic exercise can lower blood pressure, help control weight, and increase HDL (“good”)
cholesterol. It may keep the blood vessels more flexible. The Centers for Disease Control and
Prevention and the American College of Sports Medicine recommend moderate to intense aerobic
exercise lasting about 30 minutes four or more times per week for maximum heart health. Three
10-minute exercise periods are also beneficial. Aerobic exercise—activities such as walking,
jogging, and cycling—uses the large muscle groups and forces the body to use oxygen more
efficiently. It can also include everyday activities such as active gardening, climbing stairs, or
brisk housework. People with coronary artery disease or risk factors should consult a doctor
before beginning an exercise program.
Maintain a desirable body weight
About one quarter of all Americans are overweight and nearly one-tenth are obese, according to
the Surgeon General’s Report on Nutrition and Health. People who are 20% or more over their
ideal body weight have an increased risk of developing coronary artery disease. Losing weight
can help reduce total and LDL cholesterol, reduce triglycerides, and boost HDL cholesterol. It
may also reduce blood pressure. Eating right and exercising are two key components of losing
weight.
Avoid recreational drugs
Do not smoke or use tobacco. Smoking has many adverse effects on the heart. It increases the
heart rate, constricts major arteries, and can create irregular heartbeats. It raises blood pressure,
contributes to the development of plaque, increases the formation of blood clots, and causes blood
platelets to cluster and impede blood flow. Heart damage caused by smoking can be repaired
by quitting. Even heavy smokers can return to heart health. Several studies have shown that exsmokers face the same risk of heart disease as non-smokers within five to 10 years after they quit.
Drink in moderation. Modest consumption of alcohol may actually protect against coronary artery
disease because alcohol appears to raise levels of HDL (“good”) cholesterol. The American Heart
Association defines moderate consumption as one ounce of alcohol per day, roughly one cocktail,
one 8-ounce glass of wine, or two 12-ounce glasses of beer. However, even moderate drinking
can increase risk factors for heart disease for some people (by raising blood pressure, for
example). Excessive drinking is always bad for the heart. It usually raises blood pressure and can
poison the heart and cause abnormal heart rhythms or even heart failure.
Do not use other recreational drugs. Commonly used recreational drugs, particularly cocaine and
“crack,” can seriously harm the heart and should never be used.
Seek treatment for hypertension
High blood pressure, one of the most common and serious risk factors for coronary artery disease,
can be completely controlled through lifestyle changes and medication. Moderate hypertension
can be controlled by reducing dietary intake of sodium and fat, exercising regularly, managing
stress, abstaining from smoking, and drinking alcohol in moderation. People for whom these
changes do not work or people with severe hypertension may be helped by many categories of
medication.
Manage stress
Everyone experiences stress, the mental and physical reaction to life’s irritations and challenges.
Stress can sometimes be avoided and when it is inevitable, it can be controlled. Techniques for
controlling stress include: taking life more slowly, spending more time with family and
friends, thinking positively, getting enough sleep, exercising, and practicing relaxation
techniques.
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ab
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