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Coronary artery disease

Changed by Joachim Feger, 8 Dec 2022
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Disclosures - updated 26 Nov 2022: Nothing to disclose

Updates to Article Attributes

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Coronary artery disease (CAD) is primarily due to the narrowing of the coronary arteries due to atherosclerosis, which results in myocardial ischaemia, and is the leading cause of mortality globally. 

Diagnosis

The diagnosis of coronary artery disease is based on typical imaging criteria either by cardiac CT or invasive coronary angiography.

Clinical presentation

Coronary artery disease is asymptomatic in most of the population. When severe enough it can cause angina or an acute coronary syndrome including myocardial infarction. CAD may also present with heart failure or sudden cardiac death.

Pathology

Coronary artery disease is primarily due to atherosclerosis, an inflammatory process that leads to atheroma development and remodelling/stenosis of the coronary arteries. ADiameter stenosis of >50% or a cross-sectional area reduction of diameter or >75% cross-section diameter reduction can lead to angina. Thrombus formation after plaque disruption can lead to acute coronary syndrome 1,2. 

Risk factors

Radiographic features

There are a variety of techniques to image coronary artery disease including both anatomical and functional modalities. Coronary angiography has been the mainstay for many years, but in certain patient groups, it is being replaced by non-invasive imaging such as coronary CT angiography (cCTA).

There are several appropriate clinical indications for the performance of coronary CTA 8: 

Haemodynamically-significant stenoses are those >70% for all coronary arteries, except the left main coronary artery where >50% stenosis is considered significant 7.

In a post-hocposthoc analysis of prospectiveprospectively acquired data, a cutoff value > -70 HU of the perivascular fat attenuation index (FAI) around the proximal right coronary artery was found to be predictive of increased all-cause mortality 10.

Severity assessment

The recently proposed SCCT grading scale for stenosis severity assesses the degree of luminal diameter stenosis 6:

  • 0% = no visible stenosis

  • 1-24% = minimal stenosis

  • 25-49% = mild stenosis

  • 50-69% = moderate stenosis

  • 70-99% = severe stenosis

  • 100% = occlusion

See also

  • -<p><strong>Coronary artery disease</strong> (<strong>CAD</strong>) is primarily due to narrowing of the <a href="/articles/coronary-arteries">coronary arteries</a> due to <a href="/articles/arteriosclerosis">atherosclerosis</a>, which results in <a title="Myocardial ischaemia" href="/articles/myocardial-ischaemia">myocardial ischaemia</a>, and is the leading cause of mortality globally. </p><h4>Clinical presentation</h4><p>Coronary artery disease is asymptomatic in most of the population. When severe enough it can cause angina or an <a href="/articles/acute-coronary-syndrome">acute coronary syndrome</a> including <a href="/articles/myocardial-infarction">myocardial infarction</a>. CAD may also present with <a href="/articles/heart-failure">heart failure</a> or sudden cardiac death. </p><h4>Pathology</h4><p>Coronary artery disease is primarily due to atherosclerosis, an inflammatory process that leads to atheroma development and remodelling/stenosis of the coronary arteries. A stenosis of &gt;50% of diameter or &gt;75% cross-section diameter reduction can lead to angina. Thrombus formation after plaque disruption can lead to acute coronary syndrome <sup>1,2</sup>. </p><h5>Risk factors</h5><ul>
  • -<li>non-modifiable: family history, age, male sex <sup>1</sup>
  • -</li>
  • -<li>modifiable: <a href="/articles/hyperlipidaemia">hypercholesterolaemia</a>, <a href="/articles/left-ventricular-hypertrophy">left ventricular hypertrophy</a>, <a href="/articles/obesity">obesity</a>, <a href="/articles/hypertension">hypertension</a>, <a href="/articles/diabetes-mellitus">diabetes</a>, sedentary lifestyle, smoking, alcohol <sup>1</sup>
  • -</li>
  • -</ul><h4>Radiographic features</h4><p>There are a variety of techniques to image coronary artery disease including both anatomical and functional modalities. Coronary angiography has been the mainstay for many years, but in certain patient groups is being replaced by non-invasive imaging such as <a href="/articles/cardiac-ct-1">coronary CT angiography (cCTA)</a>.</p><p>There are several appropriate clinical indications for the performance of coronary CTA <sup>8</sup>: </p><ul>
  • -<li>acute chest pain in patients with a low-to-intermediate pretest probability of coronary artery disease</li>
  • -<li>evaluation of <a href="/articles/coronary-arteries">coronary artery anatomy</a> and <a href="/articles/coronary-artery-bypass-graft">bypass grafts</a>
  • -</li>
  • -<li>assessment of <a href="/articles/congenital-cardiovascular-anomalies">congenital heart disease</a>
  • -</li>
  • -<li>
  • -<a href="/articles/coronary-artery-calcification">coronary artery calcium</a> scoring</li>
  • -<li>patients with technically limited images from echocardiography or <a href="/articles/cardiac-mri">MRI</a>
  • -</li>
  • -</ul><p>Haemodynamically-significant stenoses are those &gt;70% for all coronary arteries, except the left main coronary artery where &gt;50% stenosis is considered significant <sup>7</sup>.</p><p>In a post-hoc analysis of prospective acquired data, a cutoff value &gt; -70 <a href="/articles/hounsfield-unit">HU</a> of the <a href="/articles/perivascular-fat-attenuation-index">perivascular fat attenuation index (FAI)</a> around the proximal right coronary artery was found to be predictive of increased all-cause mortality <sup>10</sup>.</p><h5>Severity assessment</h5><p>The recently proposed SCCT grading scale for stenosis severity assesses the degree of luminal diameter stenosis <sup>6</sup>:</p><ul>
  • -<li>0% = no visible stenosis</li>
  • -<li>1-24% = minimal stenosis</li>
  • -<li>25-49% = mild stenosis</li>
  • -<li>50-69% = moderate stenosis</li>
  • -<li>70-99% = severe stenosis</li>
  • -<li>100% = occlusion</li>
  • +<p><strong>Coronary artery disease</strong> (<strong>CAD</strong>) is primarily due to the narrowing of the <a href="/articles/coronary-arteries">coronary arteries</a> due to <a href="/articles/arteriosclerosis">atherosclerosis</a>, which results in <a href="/articles/myocardial-ischaemia" title="Myocardial ischaemia">myocardial ischaemia</a>, and is the leading cause of mortality globally. </p><h4>Diagnosis</h4><p>The diagnosis of coronary artery disease is based on typical imaging criteria either by cardiac CT or invasive coronary angiography.</p><h4>Clinical presentation</h4><p>Coronary artery disease is asymptomatic in most of the population. When severe enough it can cause angina or an <a href="/articles/acute-coronary-syndrome">acute coronary syndrome</a> including <a href="/articles/myocardial-infarction">myocardial infarction</a>. CAD may also present with <a href="/articles/heart-failure">heart failure</a> or sudden cardiac death.</p><h4>Pathology</h4><p>Coronary artery disease is primarily due to atherosclerosis, an inflammatory process that leads to atheroma development and remodelling/stenosis of the coronary arteries. Diameter stenosis of &gt;50% or a cross-sectional area reduction of &gt;75% can lead to angina. Thrombus formation after plaque disruption can lead to <a href="/articles/acute-coronary-syndrome" title="Acute coronary syndrome">acute coronary syndrome</a> <sup>1,2</sup>. </p><h5>Risk factors</h5><ul>
  • +<li><p>non-modifiable: family history, age, male sex <sup>1</sup></p></li>
  • +<li><p>modifiable: <a href="/articles/hyperlipidaemia">hypercholesterolaemia</a>, <a href="/articles/left-ventricular-hypertrophy">left ventricular hypertrophy</a>, <a href="/articles/obesity">obesity</a>, <a href="/articles/hypertension">hypertension</a>, <a href="/articles/diabetes-mellitus">diabetes</a>, sedentary lifestyle, smoking, alcohol <sup>1</sup></p></li>
  • +</ul><h4>Radiographic features</h4><p>There are a variety of techniques to image coronary artery disease including both anatomical and functional modalities. Coronary angiography has been the mainstay for many years, but in certain patient groups, it is being replaced by non-invasive imaging such as <a href="/articles/cardiac-ct-1">coronary CT angiography (cCTA)</a>.</p><p>There are several appropriate clinical indications for the performance of coronary CTA <sup>8</sup>: </p><ul>
  • +<li><p>acute chest pain in patients with a low-to-intermediate pretest probability of coronary artery disease</p></li>
  • +<li><p>evaluation of <a href="/articles/coronary-arteries">coronary artery anatomy</a> and <a href="/articles/coronary-artery-bypass-graft">bypass grafts</a></p></li>
  • +<li><p>assessment of <a href="/articles/congenital-cardiovascular-anomalies">congenital heart disease</a></p></li>
  • +<li><p><a href="/articles/coronary-artery-calcification">coronary artery calcium</a> scoring</p></li>
  • +<li><p>patients with technically limited images from echocardiography or <a href="/articles/cardiac-mri">MRI</a></p></li>
  • +</ul><p>Haemodynamically-significant stenoses are those &gt;70% for all coronary arteries, except the left main coronary artery where &gt;50% stenosis is considered significant <sup>7</sup>.</p><p>In a posthoc analysis of prospectively acquired data, a cutoff value &gt; -70 <a href="/articles/hounsfield-unit">HU</a> of the <a href="/articles/perivascular-fat-attenuation-index">perivascular fat attenuation index (FAI)</a> around the proximal right coronary artery was found to be predictive of increased all-cause mortality <sup>10</sup>.</p><h5>Severity assessment</h5><p>The recently proposed SCCT grading scale for stenosis severity assesses the degree of luminal diameter stenosis <sup>6</sup>:</p><ul>
  • +<li><p>0% = no visible stenosis</p></li>
  • +<li><p>1-24% = minimal stenosis</p></li>
  • +<li><p>25-49% = mild stenosis</p></li>
  • +<li><p>50-69% = moderate stenosis</p></li>
  • +<li><p>70-99% = severe stenosis</p></li>
  • +<li><p>100% = occlusion</p></li>
  • -<li><a href="/articles/accaha-classification-of-coronary-lesions">ACC/AHA classification of coronary lesions</a></li>
  • -<li><a href="/articles/coronary-artery-disease-reporting-and-data-system-3">Coronary Artery Disease - Reporting and Data System (CAD-RADS)</a></li>
  • +<li><p><a href="/articles/accaha-classification-of-coronary-lesions">ACC/AHA classification of coronary lesions</a></p></li>
  • +<li><p><a href="/articles/coronary-artery-disease-reporting-and-data-system-3">Coronary Artery Disease - Reporting and Data System (CAD-RADS)</a></p></li>

References changed:

  • 1. Grech E. Pathophysiology and Investigation of Coronary Artery Disease. BMJ. 2003;326(7397):1027-30. <a href="https://doi.org/10.1136/bmj.326.7397.1027">doi:10.1136/bmj.326.7397.1027</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/12742929">Pubmed</a>
  • 2. Libby P & Theroux P. Pathophysiology of Coronary Artery Disease. Circulation. 2005;111(25):3481-8. <a href="https://doi.org/10.1161/CIRCULATIONAHA.105.537878">doi:10.1161/CIRCULATIONAHA.105.537878</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15983262">Pubmed</a>
  • 3. Schoepf U, Becker C, Ohnesorge B, Yucel E. CT of Coronary Artery Disease. Radiology. 2004;232(1):18-37. <a href="https://doi.org/10.1148/radiol.2321030636">doi:10.1148/radiol.2321030636</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15220491">Pubmed</a>
  • 4. Bluemke D, Achenbach S, Budoff M et al. Noninvasive Coronary Artery Imaging: Magnetic Resonance Angiography and Multidetector Computed Tomography Angiography: A Scientific Statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention of the Council on Cardiovascular Radiology and Intervention, and the Councils on Clinical Cardiology and Cardiovascular Disease in the Young. Circulation. 2008;118(5):586-606. <a href="https://doi.org/10.1161/CIRCULATIONAHA.108.189695">doi:10.1161/CIRCULATIONAHA.108.189695</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/18586979">Pubmed</a>
  • 5. Attili A & Cascade P. CT and MRI of Coronary Artery Disease: Evidence-Based Review. AJR Am J Roentgenol. 2006;187(6 Suppl):S483-99. <a href="https://doi.org/10.2214/AJR.06.0309">doi:10.2214/AJR.06.0309</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/17114564">Pubmed</a>
  • 6. Sayols-Baixeras S, Lluís-Ganella C, Lucas G, Elosua R. Pathogenesis of Coronary Artery Disease: Focus on Genetic Risk Factors and Identification of Genetic Variants. Appl Clin Genet. 2014;7:15-32. <a href="https://doi.org/10.2147/TACG.S35301">doi:10.2147/TACG.S35301</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24520200">Pubmed</a>
  • 7. Abbara S, Miller SW. Cardiac Imaging: The Requisites. (2009) - <a href="http://books.google.com/books?vid=ISBN">Google Books</a>
  • 8. Schroeder S, Achenbach S, Bengel F et al. Cardiac Computed Tomography: Indications, Applications, Limitations, and Training Requirements: Report of a Writing Group Deployed by the Working Group Nuclear Cardiology and Cardiac CT of the European Society of Cardiology and the European Council of Nuclear Cardiology. Eur Heart J. 2008;29(4):531-56. <a href="https://doi.org/10.1093/eurheartj/ehm544">doi:10.1093/eurheartj/ehm544</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/18084017">Pubmed</a>
  • 9. Cury R, Abbara S, Achenbach S et al. CAD-RADS(TM) Coronary Artery Disease - Reporting and Data System. An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology. J Cardiovasc Comput Tomogr. 2016;10(4):269-81. <a href="https://doi.org/10.1016/j.jcct.2016.04.005">doi:10.1016/j.jcct.2016.04.005</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/27318587">Pubmed</a>
  • 10. Oikonomou E, Marwan M, Desai M et al. Non-Invasive Detection of Coronary Inflammation Using Computed Tomography and Prediction of Residual Cardiovascular Risk (The CRISP CT Study): A Post-Hoc Analysis of Prospective Outcome Data. Lancet. 2018;392(10151):929-39. <a href="https://doi.org/10.1016/S0140-6736(18)31114-0">doi:10.1016/S0140-6736(18)31114-0</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30170852">Pubmed</a>
  • 1. Grech ED. Pathophysiology and investigation of coronary artery disease. BMJ. 2003;326 (7397): 1027-30. <a href="http://dx.doi.org/10.1136/bmj.326.7397.1027">doi:10.1136/bmj.326.7397.1027</a> - <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1125933">Free text at pubmed</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/12742929">Pubmed citation</a><span class="auto"></span>
  • 2. Libby P, Theroux P. Pathophysiology of coronary artery disease. Circulation. 2005;111 (25): 3481-8. <a href="http://dx.doi.org/10.1161/CIRCULATIONAHA.105.537878">doi:10.1161/CIRCULATIONAHA.105.537878</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/15983262">Pubmed citation</a><span class="auto"></span>
  • 3. Schoepf UJ, Becker CR, Ohnesorge BM et-al. CT of coronary artery disease. Radiology. 2004;232 (1): 18-37. <a href="http://dx.doi.org/10.1148/radiol.2321030636">doi:10.1148/radiol.2321030636</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/15220491">Pubmed citation</a><span class="auto"></span>
  • 4. Bluemke DA, Achenbach S, Budoff M et-al. Noninvasive coronary artery imaging: magnetic resonance angiography and multidetector computed tomography angiography: a scientific statement from the american heart association committee on cardiovascular imaging and intervention of the council on cardiovascular radiology and intervention, and the councils on clinical cardiology and cardiovascular disease in the young. Circulation. 2008;118 (5): 586-606. <a href="http://dx.doi.org/10.1161/CIRCULATIONAHA.108.189695">doi:10.1161/CIRCULATIONAHA.108.189695</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/18586979">Pubmed citation</a><span class="auto"></span>
  • 5. Attili AK, Cascade PN. CT and MRI of coronary artery disease: evidence-based review. AJR Am J Roentgenol. 2006;187 (6_supplement): S483-99. <a href="http://dx.doi.org/10.2214/AJR.06.0309">doi:10.2214/AJR.06.0309</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/17114564">Pubmed citation</a><span class="auto"></span>
  • 6. Sayols-Baixeras S, Lluís-Ganella C, Lucas G et-al. Pathogenesis of coronary artery disease: focus on genetic risk factors and identification of genetic variants. Appl Clin Genet. 2014;7: 15-32. <a href="http://dx.doi.org/10.2147/TACG.S35301">doi:10.2147/TACG.S35301</a> - <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3920464">Free text at pubmed</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/24520200">Pubmed citation</a><span class="auto"></span>
  • 7. Abbara S, Miller SW. Cardiac Imaging: The Requisites. Mosby. ISBN:0323055273. <a href="http://books.google.com/books?vid=ISBN0323055273">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/0323055273">Find it at Amazon</a><span class="auto"></span>
  • 8. Schroeder S, Achenbach S, Bengel F, Burgstahler C, Cademartiri F, de Feyter P, George R, Kaufmann P, Kopp AF, Knuuti J, Ropers D, Schuijf J, Tops LF, Bax JJ; Working Group Nuclear Cardiology and Cardiac CT; European Society of Cardiology; European Council of Nuclear Cardiology. Cardiac computed tomography: indications, applications, limitations, and training requirements: report of a Writing Group deployed by the Working Group Nuclear Cardiology and Cardiac CT of the European Society of Cardiology and the European Council of Nuclear Cardiology. Eur Heart J. 2008 Feb;29(4):531-56. Epub 2007 Dec 15. DOI: 10.1093/eurheartj/ehm544
  • 9. Cury RC, Abbara S, Achenbach S, Agatston A, Berman DS, Budoff MJ, Dill KE, Jacobs JE, Maroules CD, Rubin GD, Rybicki FJ, Schoepf UJ, Shaw LJ, Stillman AE, White CS, Woodard PK, Leipsic JA. CAD-RADS(TM) Coronary Artery Disease - Reporting and Data System. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology. Journal of cardiovascular computed tomography. 10 (4): 269-81. <a href="https://doi.org/10.1016/j.jcct.2016.04.005">doi:10.1016/j.jcct.2016.04.005</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/27318587">Pubmed</a> <span class="ref_v4"></span>
  • 10. Oikonomou EK, Marwan M, Desai MY, Mancio J, Alashi A, Hutt Centeno E, Thomas S, Herdman L, Kotanidis CP, Thomas KE, Griffin BP, Flamm SD, Antonopoulos AS, Shirodaria C, Sabharwal N, Deanfield J, Neubauer S, Hopewell JC, Channon KM, Achenbach S, Antoniades C. Non-invasive detection of coronary inflammation using computed tomography and prediction of residual cardiovascular risk (the CRISP CT study): a post-hoc analysis of prospective outcome data. (2018) Lancet (London, England). 392 (10151): 929-939. <a href="https://doi.org/10.1016/S0140-6736(18)31114-0">doi:10.1016/S0140-6736(18)31114-0</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30170852">Pubmed</a> <span class="ref_v4"></span>
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