WordNet
- of or relating to the myocardium
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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/07/24 23:25:25」(JST)
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| Coronary artery disease | |
|---|---|
|
Illustration depicting atherosclerosis in a coronary artery.
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| Classification and external resources | |
| Specialty | Cardiology, cardiac surgery |
| ICD-10 | I20-I25 |
| ICD-9-CM | 410-414, 429.2 |
| MedlinePlus | 007115 |
| eMedicine | radio/192 |
| Patient UK | Coronary artery disease |
| MeSH | D003324 |
Coronary artery disease (CAD), also known as ischemic heart disease (IHD),[1] atherosclerotic heart disease,[2] atherosclerotic cardiovascular disease,[3] and coronary heart disease,[4] is a group of diseases that includes: stable angina, unstable angina, myocardial infarction, and sudden coronary death.[5] It is within the group of cardiovascular diseases of which it is the most common type.[6] A common symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck, or jaw.[7] Occasionally it may feel like heartburn.[7] Usually symptoms occur with exercise or emotional stress, last less than a few minutes, and gets better with rest.[7] Shortness of breath may also occur and sometimes no symptoms are present.[7] The first sign is occasionally a heart attack.[8] Other complications include heart failure or an irregular heartbeat.[8]
Risk factors include: high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol, poor diet, and excessive alcohol, among others.[9][10] Other risks include depression.[11] The underlying mechanism involves atherosclerosis of the arteries of the heart.[10] A number of tests may help with diagnoses including: electrocardiogram, cardiac stress testing, coronary computed tomographic angiography, and coronary angiogram, among others.[12]
Prevention is by eating a healthy diet, regular exercise, maintaining a healthy weight and not smoking.[13] Sometimes medication for diabetes, high cholesterol, or high blood pressure are also used.[13] There is limited evidence for screening people who are at low risk and do not have symptoms.[14] Treatment involves the same measures as prevention.[15][16] Additional medications such as aspirin, beta blockers, or nitroglycerin may be recommended.[16] Procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) may be used in severe disease.[16][17] In those with stable CAD it is unclear if PCI or CABG in addition to the other treatments improve life expectancy or decreases heart attack risk.[18]
In 2013 CAD was the most common cause of death globally, resulting in 8.14 million deaths (16.8%) up from 5.74 million deaths (12%) in 1990.[6] The risk of death from CAD for a given age has decreased between 1980 and 2010 especially in the developed world.[19] The number of cases of CAD for a given age has also decreased between 1990 and 2010.[20] In the United States in 2010 about 20% of those over 65 had CAD, while it was present in 7% of those 45 to 64, and 1.3% of those 18 to 45.[21] Rates are higher among men than women of a given age.[21]
Contents
- 1 Signs and symptoms
- 2 Risk factors
- 2.1 Blood fats
- 2.2 Other
- 3 Pathophysiology
- 4 Diagnosis
- 4.1 Stable angina
- 4.2 Acute coronary syndrome
- 4.3 Risk assessment
- 5 Prevention
- 5.1 Diet
- 5.2 Secondary prevention
- 6 Management
- 6.1 Medications
- 6.1.1 Aspirin
- 6.1.2 Anti-platelet therapy
- 6.2 Surgery
- 6.1 Medications
- 7 Epidemiology
- 8 Society and culture
- 9 Research
- 10 References
- 11 External links
Signs and symptoms
Chest pain that occurs regularly with activity, after eating, or at other predictable times is termed stable angina and is associated with narrowings of the arteries of the heart.
Angina that changes in intensity, character or frequency is termed unstable. Unstable angina may precede myocardial infarction. In adults who go to the emergency with an unclear cause of pain, about 30% have pain due to coronary artery disease.[22]
Risk factors
Coronary artery disease has a number of well determined risk factors. The most common risk factors include smoking, family history, hypertension, obesity, diabetes, lack of exercise, stress, and high blood lipids.[23] Smoking is associated with about 36% of cases and obesity 20%.[24] Lack of exercise has been linked to 7–12% of cases.[24][25] Exposure to the herbicide Agent orange may increase risk.[26]
Job stress appears to play a minor role accounting for about 3% of cases.[24] In one study, women who were free of stress from work life saw an increase in the diameter of their blood vessels, leading to decreased progression of atherosclerosis.[27] Contrastingly, women who had high levels of work-related stress experienced a decrease in the diameter of their blood vessels and significantly increased disease progression.[27] Also, having a type A behavior pattern, a group of personality characteristics including time urgency, competitiveness, hostility, and impatience[28] is linked to an increased risk of coronary disease.[29]
Risk factors can be classified as: fixed (such as age, sex, family history) and modifiable (such as smoking, hypertension, diabetes mellitus, obesity, etc.)
Blood fats
- High blood cholesterol (specifically, serum LDL concentrations) HDL(high density lipoprotein)has a protective effect over development of coronary artery disease.[30]
- High blood triglycerides may play a role.[31]
- High levels of lipoprotein(a),[32][33][34] a compound formed when LDL cholesterol combines with a protein known as apolipoprotein(a).
Dietary cholesterol does not appear to have a significant effect on blood cholesterol and thus recommendations about its consumption may not be needed.[35]
Other
- Type A personality.Type A behaviour is associated with competitive drive, restlessness,hostility & a sense of impatience. Added in 1981 as an independent risk factor after a majority of research into the field discovered that TABP's were twice as likely to exhibit CAD as any other personality type (very controversial due to tobacco industry funding of these researches).[citation needed]
- The number of categories of adverse childhood experiences (psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill, suicidal, or incarcerated) showed a graded relationship to the presence of adult diseases including coronary artery (ischemic heart) disease. [36]
- Hemostatic factors:[37] High levels of fibrinogen and coagulation factor VII are associated with an increased risk of CAD. Factor VII levels are higher in individuals with a high intake of dietary fat[citation needed]. Decreased fibrinolytic activity has been reported in patients with coronary atherosclerosis.
- Low hemoglobin[38]
- Men over 45; Women over 55[39]
Pathophysiology
Micrograph of a coronary artery with the most common form of coronary artery disease (atherosclerosis) and marked luminal narrowing. Masson's trichrome.
Illustration depicting coronary artery disease
Limitation of blood flow to the heart causes ischemia (cell starvation secondary to a lack of oxygen) of the myocardial cells. Myocardial cells may die from lack of oxygen and this is called a myocardial infarction (commonly called a heart attack). It leads to heart muscle damage, heart muscle death and later myocardial scarring without heart muscle regrowth. Chronic high-grade stenosis of the coronary arteries can induce transient ischemia which leads to the induction of a ventricular arrhythmia, which may terminate into ventricular fibrillation leading to death.
Typically, coronary artery disease occurs when part of the smooth, elastic lining inside a coronary artery (the arteries that supply blood to the heart muscle) develops atherosclerosis. With atherosclerosis, the artery's lining becomes hardened, stiffened, and swollen with all sorts of "gunge" - including calcium deposits, fatty deposits, and abnormal inflammatory cells - to form a plaque. Deposits of calcium phosphates (hydroxyapatites) in the muscular layer of the blood vessels appear to play not only a significant role in stiffening arteries but also for the induction of an early phase of coronary arteriosclerosis. This can be seen in a so-called metastatic mechanism of calciphylaxis as it occurs in chronic kidney disease and haemodialysis (Rainer Liedtke 2008). Although these patients suffer from a kidney dysfunction, almost fifty percent of them die due to coronary artery disease. Plaques can be thought of as large "pimples" that protrude into the channel of an artery, causing a partial obstruction to blood flow. Patients with coronary artery disease might have just one or two plaques, or might have dozens distributed throughout their coronary arteries. A more severe form is chronic total occlusion (CTO), when a coronary artery is completely obstructed for more than 3 months.[40]
There is a term in medicine called cardiac syndrome X, which describes chest pain (Angina pectoris) and chest discomfort in people who do not show signs of blockages in the larger coronary arteries of their hearts when an angiogram (coronary angiogram) is being performed.[41] No one knows exactly what causes cardiac syndrome X. One explanation is microvascular dysfunction.[42] It is not completely clear why women are more likely than men to have it; however, hormones and other risk factors unique to women may play a role.[43]
Diagnosis
Coronary angiogram of a man
Coronary angiogram of a woman
For symptomatic patients, stress echocardiography can be used to make a diagnosis for obstructive coronary artery disease.[44] The use of echocardiography, stress cardiac imaging, and/or advanced non-invasive imaging is not recommended on individuals who are exhibiting no symptoms and are otherwise at low risk for developing coronary disease.[44][45]
CAD has always been a tough disease to diagnose without the use of invasive or stressful activities. The development of the Multifunction Cardiogram (MCG) has changed the way CAD is diagnosed. The MCG consists of a 2 lead resting EKG signal is transformed into a mathematical model and compared against tens of thousands of clinical trials to diagnose a patient with an objective severity score, as well as secondary and tertiary results about the patient's condition. The results from MCG tests have been validated in 8 clinical trials[citation needed] which resulted in a database of over 50,000 patients where the system has demonstrated accuracy comparable to coronary angiography (90% overall sensitivity, 85% specificity). This level of accuracy comes from the application of advanced techniques in signal processing and systems analysis combined with a large scale clinical database which allows MCG to provide quantitative, evidence-based results to assist physicians in reaching a diagnosis. The MCG has also been awarded a Category III CPT code by the American Medical Association in the July 2009 CPT update[citation needed].
The diagnosis of "Cardiac Syndrome X" - the rare coronary artery disease that is more common in women, as mentioned, an "exclusion" diagnosis. Therefore, usually the same tests are used as in any patient with the suspicion of coronary artery disease:
- Baseline electrocardiography (ECG)
- Exercise ECG – Stress test
- Exercise radioisotope test (nuclear stress test, myocardial scintigraphy)
- Echocardiography (including stress echocardiography)
- Coronary angiography
- Intravascular ultrasound
- Magnetic resonance imaging (MRI)
The diagnosis of coronary disease underlying particular symptoms depends largely on the nature of the symptoms. The first investigation is an electrocardiogram (ECG/EKG), both for "stable" angina and acute coronary syndrome. An X-ray of the chest and blood tests may be performed.
Stable angina
Main article: Angina pectoris
In "stable" angina, chest pain with typical features occurring at predictable levels of exertion, various forms of cardiac stress tests may be used to induce both symptoms and detect changes by way of electrocardiography (using an ECG), echocardiography (using ultrasound of the heart) or scintigraphy (using uptake of radionuclide by the heart muscle). If part of the heart seems to receive an insufficient blood supply, coronary angiography may be used to identify stenosis of the coronary arteries and suitability for angioplasty or bypass surgery.
Acute coronary syndrome
Main article: Acute coronary syndrome
Diagnosis of acute coronary syndrome generally takes place in the emergency department, where ECGs may be performed sequentially to identify "evolving changes" (indicating ongoing damage to the heart muscle). Diagnosis is clear-cut if ECGs show elevation of the "ST segment", which in the context of severe typical chest pain is strongly indicative of an acute myocardial infarction (MI); this is termed a STEMI (ST-elevation MI), and is treated as an emergency with either urgent coronary angiography and percutaneous coronary intervention (angioplasty with or without stent insertion) or with thrombolysis ("clot buster" medication), whichever is available. In the absence of ST-segment elevation, heart damage is detected by cardiac markers (blood tests that identify heart muscle damage). If there is evidence of damage (infarction), the chest pain is attributed to a "non-ST elevation MI" (NSTEMI). If there is no evidence of damage, the term "unstable angina" is used. This process usually necessitates admission to hospital, and close observation on a coronary care unit for possible complications (such as cardiac arrhythmias – irregularities in the heart rate).
Depending on the risk assessment, stress testing or angiography may be used to identify and treat coronary artery disease in patients who have had an NSTEMI or unstable angina.
Risk assessment
There are various risk assessment systems for determining the risk of coronary artery disease, with various emphasis on different variables above. A notable example is Framingham Score, used in the Framingham Heart Study. It is mainly based on age, gender, diabetes, total cholesterol, HDL cholesterol, tobacco smoking and systolic blood pressure.[46]
Prevention
Prevention involves: exercise, decreasing obesity, treating hypertension, a healthy diet, decreasing cholesterol levels, and stopping smoking. Medications and exercise are roughly equally effective.[47]
In diabetes mellitus, there is little evidence that very tight blood sugar control improves cardiac risk although improved sugar control appears to decrease other problems like kidney failure and blindness. The World Health Organization (WHO) recommends "low to moderate alcohol intake" to reduce risk of coronary artery disease although this remains without scientific cause and effect proof.[48]
Diet
Main article: Diet and heart disease
A diet high in fruits and vegetables decreases the risk of cardiovascular disease and death.[49] Vegetarians have a lower risk of heart disease,[50][51] possibly due to their greater consumption of fruits and vegetables.[52] Evidence also suggests that the Mediterranean diet[53] and a high fiber diet lower the risk.[54]
The consumption of trans fat (commonly found in hydrogenated products such as margarine) has been shown to cause a precursor to atherosclerosis[55] and increase the risk of coronary artery disease.[56]
Evidence does not support a beneficial role for omega-3 fatty acid supplementation in preventing cardiovascular disease (including myocardial infarction and sudden cardiac death).[57][58] There is tentative evidence that menaquinone (Vitamin K2), but not phylloquinone (Vitamin K1), intake may reduce the risk of CAD mortality.[59]
Secondary prevention
Secondary prevention is preventing further sequelae of already established disease. Lifestyle changes that have been shown to be effective to this goal include:
- Weight control
- Smoking cessation
- Avoiding the consumption of trans fats (in partially hydrogenated oils)
- Exercise. In people with coronary artery disease, aerobic exercise, like walking, jogging, or swimming, can reduce the risk of mortality.[60] Aerobic exercise can help decrease blood pressure and the amount of blood cholesterol (LDL) over time. It also increases HDL cholesterol which is considered as "good cholesterol".[61][62] Separate to the question of the benefits of exercise; it is unclear whether doctors should spend time counseling patients to exercise. The U.S. Preventive Services Task Force, found "insufficient evidence" to recommend that doctors counsel patients on exercise, but "it did not review the evidence for the effectiveness of physical activity to reduce chronic disease, morbidity and mortality", it only examined the effectiveness of the counseling itself.[63] The American Heart Association, based on a non-systematic review, recommends that doctors counsel patients on exercise.[64]
- Decrease psychosocial stress.[65]
Management
There are a number of treatment options for coronary artery disease:[66]
- Lifestyle changes
- Medical treatment - drugs (e.g. cholesterol lowering medications, beta-blockers, nitroglycerin, calcium antagonists, etc.);
- Coronary interventions as angioplasty and coronary stent;
- Coronary artery bypass grafting (CABG)
Medications
- Statins, which reduce cholesterol, reduce risk of coronary disease[67]
- Nitroglycerin
- ACE inhibitors, which treat hypertension and may lower the risk of recurrent myocardial infarction[citation needed]
- Calcium channel blockers and/or beta-blockers
- Aspirin
It is recommended that blood pressure typically be reduced to less than 140/90 mmHg.[68] The diastolic blood pressure however should not be lower than 60 mmHg. Beta blockers are recommended first line for this use.[68]
Aspirin
In those with no other heart problems aspirin decreases the risk of a myocardial infarction in men but not women and increases the risk of bleeding, most of which is from the stomach. It does not affect the overall risk of death in either men or women.[69] It is thus only recommended in adults who are at increased risk for coronary artery disease[70] where increased risk is defined as 'men older than 90 years of age, postmenopausal women, and younger persons with risk factors for coronary artery disease (for example, hypertension, diabetes, or smoking) are at increased risk for heart disease and may wish to consider aspirin therapy'. More specifically, high-risk persons are 'those with a 5-year risk ≥ 3%'.[citation needed]
Anti-platelet therapy
Clopidogrel plus aspirin reduces cardiovascular events more than aspirin alone in those with an STEMI. In others at high risk but not having an acute event the evidence is weak.[71] In those who have had a stent more than 12 months of clopidogrel plus aspirin does not affect the risk of death.[72]
Surgery
Revascularization for acute coronary syndrome has a mortality benefit.[73] Revascularization for stable ischaemic heart disease does not appear to have benefits over medical therapy alone.[74] In those with disease in more than one artery coronary artery bypass grafts appear better than percutaneous coronary interventions.[75][76]
Epidemiology
Disability-adjusted life year for ischaemic heart disease per 100,000 inhabitants in 2004.[77]
no data
<350
350–700
700–1050
1050–1400
1400–1750
1750–2100
2100–2450
2450–2800
2800–3150
3150–3500
3500–4000
>4000
CAD as of 2010 was the leading cause of death globally resulting in over 7 million deaths.[78] This is up from 5.2 million deaths in 1990.[78] It may affect individuals at any age but becomes dramatically more common at progressively older ages, with approximately a tripling with each decade of life.[79] Males are affected more often than females.[79]
It is estimated that 60% of the world's cardiovascular disease burden will occur in the South Asian subcontinent despite only accounting for 20% of the world's population. This may be secondary to a combination of genetic predisposition and environmental factors. Organizations such as the Indian Heart Association are working with the World Heart Federation to raise awareness about this issue.[80]
Coronary heart disease (CHD) is the leading cause of death for both men and women and accounts for approximately 600,000 deaths in the United States every year.[81] According to present trends in the United States, half of healthy 40-year-old men will develop CAD in the future, and one in three healthy 40-year-old women.[82] It is the most common reason for death of men and women over 20 years of age in the United States.[83] The Maasai of Africa have almost no heart disease.
Society and culture
Other terms sometimes used for this condition are "hardening of the arteries" and "narrowing of the arteries".[84]
Research
Further information: atheroma and atherosclerosis
Recent research efforts focus on new angiogenic treatment modalities (angiogenesis) and various (adult) stem cell therapies.
A region on Chromosome 17 was confined to families with multiple cases of myocardial infarction.[85]
A more controversial link is that between Chlamydophila pneumoniae infection and atherosclerosis.[86] While this intracellular organism has been demonstrated in atherosclerotic plaques, evidence is inconclusive as to whether it can be considered a causative factor.[citation needed] Treatment with antibiotics in patients with proven atherosclerosis has not demonstrated a decreased risk of heart attacks or other coronary vascular diseases.[87]
Since the 1990s the search for new treatment options for coronary artery disease patients, particularly for so called "no-option" coronary patients, focused on usage of angiogenesis[88] and (adult) stem cell therapies. Numerous clinical trials were performed, either applying protein (angiogenic growth factor) therapies, such as FGF-1 or VEGF, or cell therapies using different kinds of adult stem cell populations. Research is still going on - with first promising results particularly for FGF-1[89][90] and utilization of endothelial progenitor cells.
Myeloperoxidase has been proposed as a biomarker.[91]
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External links
- Risk Assessment of having a heart attack or dying of coronary artery disease, from the American Heart Association.
- Risk Assessment Tool for Estimating 10-year Risk of Developing Hard CHD using Framingham score
- The InVision Guide to a Healthy Heart An interactive website on the development and function of the cardiovascular system and cardiovascular diseases and consequences. The website also features treatment options and preventative measures for maintaining a healthy heart.
- A Mechanism of a Metabolic Induction of Coronary Artery Disease in Chronic Kidney Disease, Rainer K. Liedtke, MD
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UpToDate Contents
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- 1. 狭心症：心筋虚血による胸痛 angina pectoris chest pain caused by myocardial ischemia
- 2. Silent myocardial ischemia: Epidemiology, pathophysiology, and diagnosis
- 3. 無症候性心筋虚血：予後および治療 silent myocardial ischemia prognosis and therapy
- 4. 心筋虚血および心筋梗塞の診断における心電図 electrocardiogram in the diagnosis of myocardial ischemia and infarction
- 5. 心電図チュートリアル：心筋虚血および心筋梗塞 ecg tutorial myocardial ischemia and infarction
English Journal
- Antioxidant Activity of Heracleum persicum Fruit Extract: Evidence from a Randomized Controlled Trial.
- Panahi Y1, Dadjou Y2, Pishgoo B2, Akbari A2, Sahebkar A3,4.
- Journal of dietary supplements.J Diet Suppl.2016 Sep 2;13(5):530-7. doi: 10.3109/19390211.2015.1120842. Epub 2016 Jan 28.
- Oxidative stress is a unifying feature of several cardiometabolic risk factors, and has been suggested to be implicated in atherogenesis. This study aimed to investigate the efficacy of supplementation with Heracleum persicum fruit-a common dietary spice-in modulating systemic biomarkers of oxidativ
- PMID 26820395
- Evaluation of the Usability of Selected Questionnaires Assessing Physical Activity in the Prophylaxis of Cardiovascular Diseases.
- Czeczelewska E1, Czeczelewski J2, Wasiluk A3, Saczuk J3.
- Advances in clinical and experimental medicine : official organ Wroclaw Medical University.Adv Clin Exp Med.2016 Jul-Aug;25(1):59-67. doi: 10.17219/acem/39157.
- BACKGROUND: The main health problem of the Polish population is posed by cardiovascular diseases (CDVD), coronary artery disease (CAD) in particular. Respectively higher physical activity linked with energy expenditure of at least 1000 kcal/week may significantly reduce the risk of CAD development.
- PMID 26935499
- Detailed analysis of association between common single nucleotide polymorphisms and subclinical atherosclerosis: The Multi-ethnic Study of Atherosclerosis.
- Vargas JD1, Manichaikul A2, Wang XQ3, Rich SS4, Rotter JI5, Post WS6, Polak JF7, Budoff MJ8, Bluemke DA9.
- Data in brief.Data Brief.2016 Feb 15;7:229-42. doi: 10.1016/j.dib.2016.01.048. eCollection 2016.
- Previously identified single nucleotide polymorphisms (SNPs) in genome wide association studies (GWAS) of cardiovascular disease (CVD) in participants of mostly European descent were tested for association with subclinical cardiovascular disease (sCVD), coronary artery calcium score (CAC) and caroti
- PMID 26958643
Japanese Journal
- An isolated single L-II type coronary artery anomaly: A rare coronary anomaly
- Intractable & Rare Diseases Research 4(4), 203-206, 2015
- NAID 130005109598
- An isolated single L-II type coronary artery anomaly: A rare coronary anomaly
- Intractable & Rare Diseases Research advpub(0), 2015
- NAID 130005100377
- Exercise Preconditioning-Induced Early and Late Phase of Cardioprotection Is Associated With Protein Kinase C Epsilon Translocation
- Circulation Journal 78(7), 1636-1645, 2014
- NAID 130003391144
Related Links
- A review of the ECG features of myocardial ischaemia ... Wellens’ Syndrome Wellens’ syndrome is a pattern of inverted or biphasic T waves in V2-4 (in patients presenting with ischaemic chest pain) that is highly specific for critical ...
- ischemia [is-ke´me-ah] deficiency of blood in a part, due to functional constriction or actual obstruction of a blood vessel. adj., adj ische´mic. myocardial ischemia deficiency of blood supply to the heart muscle. my·o·car·di·al is·che·mi ...
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★リンクテーブル★
| リンク元 | 「心筋虚血」 |
| 関連記事 | 「myocardial」「myocardia」「ischaemia」 |
「心筋虚血」
「myocardial」
- adj.
- 心筋の
「myocardia」
- np.