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Coronary Artery Disease

Philippine Heart Association

Clinical Practice Guidelines
Genecarlo Liwanag
Post-Graduate Intern, Manila Doctors
Hospital

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Coronary Artery Disease

CAD is commonly due to obstruction of the coronary

arteries, usually the epicardial arteries, by atheromatous
plaque.

Obstructive CAD also has many non- atherosclerotic

causes, including congenital abnormalities of the
coronary arteries; myocardial bridging; coronary arteritis
in association with the systemic vasculitides; and
radiation-induced coronary disease.

Myocardial ischemia may also occur in the absence of

obstructive CAD, as in the case of aortic valve disease,
hypertrophic cardiomyopathy, and idiopathic dilated
cardiomyopathy.

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Coronary Artery Disease

Independent risk factors:

family history of premature coronary artery disease,

cigarette smoking,

diabetes mellitus,

hypertension,

hyperlipidemia, a

sedentary lifestyle, and

obesity.

These risk factors accelerate or modify a complex and

chronic inflammatory process that ultimately manifests
as fibrous atherosclerotic plaque.

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Coronary Artery Disease

No uniform syndrome of signs and symptoms is initially

seen in patients with CAD.

Chest discomfort or angina pectoris is usually the

predominant symptom.

In other patients, the quality of the sensation is more

vague and described as a mild pressure-like discomfort,
an uncomfortable numb sensation, or a burning
sensation.

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Coronary Artery Disease

The site of the discomfort is usually retrosternal, but

radiation is common and usually occurs down the ulnar
surface of the left arm; the right arm and the outer
surfaces of both arms may also be involved.

Epigastric discomfort alone or in association with chest

pressure is not uncommon.

Anginal discomfort above the mandible, below the

epigastrium, or confined to the ear is rare.

2014 Philippine Heart

Association Clinical Practice
Guidelines for the Diagnosis
and Management of
Patients
with Stable Ischemic Heart
Disease

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Stable Ischemic Heart Disease

(PHA 2014), A careful history remains the cornerstone

of the diagnosis of stable angina, and it has been
repeatedly stated that it is possible to make a confident
diagnosis in the majority of patients based on the
history alone.

Emphasizes 5 components:
1.

Quality or Character of Chest pain

2.

Location

3.

Duration

4.

Factors that Precipitate the pain

5.

Factors the relieves pain

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Stable Ischemic Heart Disease

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Stable Ischemic Heart Disease

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Stable Ischemic Heart Disease
After

obtaining a detailed description of chest

pain, the presence of risk factors and comorbid conditions should be determined.

identify

conventional risk factors for the

development of CAD such as:

the presence of hypertension,

dyslipidemia,

cigarette smoking,

diabetes or impaired glucose tolerance,

obesity and sedentary lifestyle.

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Stable Ischemic Heart Disease
It

is also important to reliably identify comorbid conditions such as chronic heart

failure
(HF),
cerebrovascular
disease,
peripheral vascular disease, or chronic kidney
disease, as these conditions may have an
adverse influence on prognosis, presumably
through their effect on the progression of
atherosclerosis.

2014 Philippine Heart

Association Clinical Practice
Guidelines for the Diagnosis
and Management of
Patients with Non-ST
Elevation Acute Coronary
Syndrome

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Cardiovascular Disease

Cardiovascular disease (CVD) remains to be the

number one cause of mortality and a substantial
contributor to morbidity in the Philippines.

In the recent 2-year report of the Philippine Heart

Association (PHA) Acute Coronary Syndrome (ACS)
registry from November 2011 to November 2013,

the mortality rate for ACS was 7.8%.

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Cardiovascular Disease
predominantly

manifests as coronary
artery disease (CAD)
stable

ischemic heart disease (SIHD) or

ACS
ST

elevation ACS or
non-ST elevation ACS (NSTE-ACS).
NSTEMI
Unstable Angina

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Diagnosis And Risk Assessment

It IS RECOMMENDED that patients with the following

symptoms and signs undergo immediate assessment
for the diagnosis of ACS:

Chest pain or severe epigastric pain, non-traumatic in

origin, with component typical of myocardial ischemia
or myocardial infarction (MI): Central or substernal
compression or crushing chest pain pressure, tightness,
heaviness, cramping, burning, aching sensation;

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Diagnosis And Risk Assessment

Unexplained indigestion, belching, epigastric pain;

Radiating pain in neck, jaw, shoulders, back, or one or

both arms;

Unexplained syncope;

Palpitations;

Dyspnea;

Nausea and/or vomiting, or; 8. Diaphoresis.

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Diagnosis And Risk Assessment
The

character of angina in ACS may possess all

the descriptive qualities of those seen in stable
ischemic disease

except for some characteristic features. The

traditional clinical presentations of ACS include:
prolonged anginal pain (more than 20 minutes)
at rest

Atypical

symptoms are more common in

certain populations such as the elderly,
women, diabetics, or chronic kidney disease
(CKD) patients.

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Diagnosis And Risk Assessment
The

presence of diabetes, renal deficiency

and atherosclerosis of non-coronary vessels
may strengthen the diagnosis of ACS.

In

patients with no known atherosclerotic

disease, age is the most important factor.

Males older than 55 years, and females older

than 65 years, have the highest risk for coronary
disease.

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Diagnosis And Risk Assessment
IS

STRONGLY RECOMMENDED that a 12-lead

electrocardiogram (ECG) be obtained
immediately within 10 minutes of
emergency room (ER) presentation in
patients with ongoing chest discomfort.

Patients

who present with ST-segment

depression are initially considered to have
either UA or NSTEMI;

the distinction between the two diagnoses is

based ultimately on the detection in the blood of
markers of myocardial necrosis.

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Diagnosis And Risk Assessment
ECGs

may be repeated after 3 hours, 6 to 9

hours, and 24 hours after the initial event. It
should also be done anytime during
recurrence of symptoms and prior to
discharge.

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Diagnosis And Risk Assessment
It

IS RECOMMENDED that quantitative

troponin be measured in all patients with
chest discomfort consistent with ACS.

In

patients with initially negative cardiac

markers, a repeat determination within 3
hours of presentation increases the sensitivity
for MI diagnosis to almost 100%.

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Diagnosis And Risk Assessment
It

IS NOT RECOMMENDED to request for total

creatine kinase (CK) (without MB isotype),
aspartate aminotransferase, betahydroxybutyrate dehydrogenase, and/or
lactate dehydrogenase as markers for the
detection of cardiac injury.

High

sensitivity troponin I or T (cTNI or cTNT)

are the preferred markers of myocardial injury
because they are more specific and more
sensitive than the traditional cardiac enzymes
such as CK or its isoenzyme MB (CKMB).

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Diagnosis And Risk Assessment
It

IS RECOMMENDED that an echocardiogram

be done in all patients suspected to have ACS
for evaluation of global and regional left
ventricular (LV) function, for ruling in or out
differential diagnoses and for prognostic
information.

It

MAY BE RECOMMENDED to perform

coronary computerized tomography
angiography (CTA) to exclude ACS in those
with non diagnostic ECG and troponin, and
have a low to intermediate likelihood of CAD.

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Hospital Care

Patients with NTSE-ACS and hemodynamically Stable:

Admission to CCU/ICU

Continuous ECG Monitoring with VS and NVS monitoring

Supplemental O2 Given for patients with cyanosis or

respiratory distress

Hook to Pulse Oximeter

Nitrates for immediate relief of ischemic symptoms.

It IS NOT RECOMMENDED to administer nitroglycerine

(NTG) or other nitrates within 24 hours of sildenafil use or
within 48 hours of tadalafil use. The suitable time for nitrate
administration after vardenafil use is not determined.

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Hospital Care

It IS RECOMMENDED to initiate a beta blocker by oral

route for all patients within the first 24 hours unless
contraindications are present. Use of IV beta
blockers should be considered with caution.

Beta blockers should be started early in the absence of

contraindications

hemodynamic compromise including hypotension, with

or without shock;

active bronchospasm;

severe bradycardia or heart block greater than 1st

degree unless with pacemaker;

myocardial infarction precipitated by cocaine use; and

overt heart failure including pulmonary edema

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Hospital Care

It MAY BE RECOMMENDED to use oral long-acting

calcium antagonists for recurrent ischemia in the
absence of contraindication and when beta
blockers and nitrates are maximally used.

Verapamil and diltiazem should be avoided in patients with

pulmonary edema or evidence of severe LV dysfunction

Amlodipine and felodipine appear to be well tolerated by

patients with chronic LV dysfunction, but have not been
tested extensively in NSTE-ACS.

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Hospital Care

It IS STRONGLY RECOMMENDED that an ACEI

should be administered within 24 hours of
admission to NSTE-ACS patients with pulmonary
congestion, with LVEF less than 40% in the
absence of hypotension and other
contraindications.

ACEIs have been shown to reduce mortality rate in patients

with acute MI or who recently had an MI and have LV
systolic dysfunction, in diabetic patients with LV
dysfunction, and in a broad spectrum of patients with highrisk chronic CAD, including patients with normal LV
function.

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Hospital Care

It is recommended that morphine sulfate be

administered IV when symptoms are not
immediately relieved with NTG, or when acute
pulmonary congestion and/or severe agitation is
present.

Morphine sulfate 1 to 5 mg IV is recommended for patients

whose symptoms are not relieved after three serial
sublingual NTG tablets, or whose symptoms recur despite
adequate anti-ischemic therapy.

may be repeated every 5 to 30 minutes as needed to

relieve symptoms and maintain patient comfort.

Meperidine hydrochloride can be substituted in patients

who are allergic to morphine.

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Hospital Care

It is STRONGLY RECOMMENDED that non-enteric coated

aspirin be chewed by patients as soon as possible at initial
presentation at an initial dose of 160 to 320 mg followed
by 80 to 160 mg daily indefinitely.

It IS STRONGLY RECOMMENDED to start a P2Y12

inhibitor (ticagrelor, prasugrel or clopidogrel) in addition to
aspirin for a period of 12 months unless there are
contraindications such as excessive risk of bleeding.

It IS STRONGLY RECOMMENDED to discontinue

ticagrelor and clopidogrel at least 5 days prior to elective
CABG, and 7 days for prasugrel, unless CABG or the need
for a P2Y12 inhibitor outweighs the risk of bleeding.

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Hospital Care

It IS STRONGLY RECOMMENDED to start

unfractionated heparin (UFH), enoxaparin or
fondaparinux in addition to antiplatelet therapy.

UFH should be given for 48 hours. A single bolus of UFH (85

IU/kg or 60 IU/kg with glycoprotein (GP) IIb/IIIa inhibitors)
should be added to fondaparinux at the time of PCI.

Enoxaparin or fondaparinux should be given for 5 to 8 days

Conservative (Medical)
versus Early Invasive
(Coronary Angiography and
Revascularization)
Strategies

+ It IS RECOMMENDED that an early invasive strategy (as

early as possible up to 72 hours) followed by
revascularization (PCI or CABG) be used in patients with
any of the following high-risk indicators:

Recurrent angina/ischemia at rest or with low-level activities despite intensive antiischemic therapy;

Elevated cardiac biomarkers (Troponin T or Troponin I); or new or presumably new

ST-segment depression;

Signs or symptoms of HF, or new or worsening mitral regurgitation;

High-risk findings from non-invasive testing ;

Hemodynamic instability;

Sustained ventricular tachycardia;

PCI within 6 months;

Prior CABG;

High-risk score (e.g., using GRACE), and;

10.Reduced LV systolic function (LVEF less than 40%).

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Hospital Care

PCI IS RECOMMENDED for NSTE-ACS patients with 1- to

2-vessel CAD, with or without significant proximal left
anterior descending CAD, but with a large area of
viable myocardium and high-risk criteria on noninvasive testing.

CABG IS RECOMMENDED for patients with significant

left main disease, and is the preferred revascularization
strategy for patients with multi-vessel coronary
disease; vessels with lesions not favorable for PCI;
depressed systolic function (LVEF lower than 50%); and
diabetes.

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Hospital Care

It IS STRONGLY RECOMMENDED to maintain patients who

were treated medically with aspirin indefinitely, and
ticagrelor 90 mg twice daily or clopidogrel 75 mg daily, for 12
months.

It IS STRONGLY RECOMMENDED to maintain patients who

underwent stenting, with aspirin indefinitely, plus ticagrelor
90 mg twice daily or prasugrel 10 mg daily or clopidogrel 75
mg daily, for 12 months in patients with drug-eluting stents,
and 6 months in patients with bare metal stents.

It IS STRONGLY RECOMMENDED that beta blockers be

continued indefinitely for all NSTE-ACS patients unless
contraindicated. In those with moderate or severe systolic
dysfunction, the dosing regimen must be titrated slowly.

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Hospital Care

It IS STRONGLY RECOMMENDED to continue ACE

inhibition indefinitely in all NSTE-ACS patients who have
a LVEF less than 40%, hypertension, diabetes mellitus
or HF. In the absence of these aggravating factors, use
of ACEIs may still be RECOMMENDED. An ARB may be
prescribed if an ACEI cannot be tolerated.

It IS RECOMMENDED to continue nitrates for ischemic

relief.

It IS RECOMMENDED to continue CCBs as add-on

therapy to beta blockers or if the latter are not
tolerated for ischemic control.

2014 Philippine Heart

Association Clinical Practice
Guidelines for the Diagnosis
and Management of
Patients with
ST Segment Elevation
Myocardial Infarction

It IS STRONGLY RECOMMENDED that patients presenting with

chest discomfort and ECG finding of at least 0.1 mV ST
segment elevation in two contiguous leads should receive
reperfusion therapy (e.g., primary PCI or thrombolytics), if not
contraindicated.

It IS RECOMMENDED to observe for ECG tracings that make

the diagnosis of acute myocardial infarction (AMI) difficult,
such as left bundle branch block (LBBB), ventricular paced
rhythm, patients without diagnostic ST segment elevation but
with persistent ischemic symptoms, isolated posterior
myocardial infarction (MI) and ST segment elevation in lead
aVR. In these situations, certain ECG changes are seen such as
marked ST elevation and hyperacute T waves, and these
require immediate reperfusion therapy.

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Initial ER Management
Aspirin

160 to 320 mg tablet (non-enteric

coated, chewed);

Clopidogrel

300 to 600 mg whether or not

fibrinolysis will be given; Clopidgrel 600 mg
or prasugrel 60 mg or ticagrelor 180 mg when
a patient will undergo PCI;

Nitrates,

Morphine 2 to 4 mg IV for relief of

chest pain, and;

Supplemental

oxygen MAY BE RECOMMENDED

during the first 6 hours to patients with
arterial oxygen saturation of less than 90%.

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In Hospital Treatment

Reperfusion therapy IS RECOMMENDED to all eligible

patients with STEMI with symptom onset within the
prior 12 hours.

It IS STRONGLY RECOMMENDED to undergo immediate

thrombolysis (unless contraindicated), with a door-toneedle time of less than 60 minutes as a goal.

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Indications for PCI

patients with STEMI and ischemic symptoms of less than

12 hours duration.

patients with STEMI and ischemic symptoms of less than

12 hours duration who have contraindications to
fibrinolytic therapy, irrespective of the time delay from
first medical contact.

patients with STEMI and cardiogenic shock or acute severe

heart failure (HF), irrespective of time delay from MI onset

MAY BE RECOMMENDED in patients with STEMI if there is

clinical and/or ECG evidence of ongoing ischemia between
12 and 24 hours after symptom onset

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Therapeutic Hypothermia

Therapeutic hypothermia IS RECOMMENDED as soon as

possible in comatose or post-arrest patients with STEMI
and out-of-hospital cardiac arrest caused by ventricular
fibrillation (VF) or pulseless ventricular tachycardia
(VT), including patients who underwent primary PCI.

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Indications for CABG

failed PCI with persistent pain or hemodynamic

instability in patients with coronary anatomy suitable
for surgery.

persistent or recurrent ischemia refractory to medical

therapy in patients who have coronary anatomy
suitable for surgery

not candidates for PCI or fibronolytic therapy.

patients with STEMI at the time of operative repair of

mechanical defects.

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Indications for CABG

Emergency CABG within 6 hours of symptom onset MAY

BE RECOMMENDED in patients with STEMI who do not
have cardiogenic shock and are not candidates for PCI
or fibrinolytic therapy.

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CABG and Antiplatelet Agents

Clopidogrel should be withheld for 5 days prior to CABG

Ticagrelor 3 to 5 days

Prasugrel 7 days

For Emergency CABG: Clopidogrel and Ticagrelor d/c

within 24 hours