Department of Cardiology, Marshfield Clinic Health System, Marshfield, Wisconsin; Adjunct Professor of Medicine, University of Wisconsin, School of Medicine, Madison, Wisconsin
Chief Science Officer, Scientific Director of Cardiovascular Research Institute, Huntington Medical Research Institutes, Pasadena, California; Professor of Medicine (Clinical Scholar), Cardiovascular Division, Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California.
Clin Med Res. 2023 Jun;21(2):95-104. doi: 10.3121/cmr.2023.1806.
In patients with ST-elevation myocardial infarction, immediate coronary angiography and intervention is the best practice, if an experienced laboratory is available. In non-Q-wave infarction most, but not all, studies suggest that early invasive strategy is superior to conservative management. Complete revascularization is preferred. A literature search regarding management of coronary artery disease was conducted in PubMed between January 1985 to January 2021. Articles published in English were reviewed, and those relevant were selected by both authors. Special focus was on the ISCHEMIA trial and related articles. The utility of coronary angiography in patients with stable coronary artery disease is challenging. All patients should undergo optimal medical therapy. Patients with angina should not only receive approved anti-anginal agents but should also receive lifestyle modifications and pharmacologic therapy to control risk factors such as diabetes, hypertension, dyslipidemia, and smoking; and should consider organized physical activity programs. Low density lipoprotein should be reduced to 70 mg/dL or less. Non-invasive studies such as coronary computed tomography angiography (CCTA) are preferred. If expert CCTA is not available, then stress test, preferably with imaging, is recommended. If the results of CCTA show high risk, then coronary angiography and intervention are usually indicated. In patients with left main disease, left ventricular dysfunction, or symptoms of congestive heart failure, early invasive strategy is recommended. If none of these conditions exist, then initial medical therapy may be initiated, and invasive therapy should be utilized only if clinically indicated. In patients with chronic stable angina, continue with medical therapy and risk factor modification. If the frequency or severity of angina episodes change, coronary angiography and revascularization should be considered, as appropriate. In patients with significant renal dysfunction, angiogram may be indicated only if there is complete failure of medical therapy. Optimal medical therapy should be initially utilized in all patients. Early invasive management and revascularization should be utilized in patients with left ventricular dysfunction, congestive heart failure, and failure of medical therapy. A shared decision-making process should always be utilized.
在有 ST 段抬高的心肌梗死患者中，如果有经验的实验室可用，立即进行冠状动脉造影和介入治疗是最佳实践。在非 Q 波心肌梗死中，大多数（但不是全部）研究表明，早期侵入性策略优于保守治疗。首选完全血运重建。在 1985 年 1 月至 2021 年 1 月期间，在 PubMed 中进行了有关冠心病管理的文献检索。审查了发表的英文文章，并由两位作者选择了相关文章。特别关注 ISCHEMIA 试验和相关文章。在稳定性冠状动脉疾病患者中进行冠状动脉造影的实用性具有挑战性。所有患者都应接受最佳的药物治疗。心绞痛患者不仅应接受批准的抗心绞痛药物治疗，还应接受生活方式改变和药物治疗来控制糖尿病、高血压、血脂异常和吸烟等危险因素，并应考虑有组织的体育活动方案。应将低密度脂蛋白降低到 70mg/dL 或更低。首选冠状动脉计算机断层扫描血管造影（CCTA）等非侵入性研究。如果没有专家 CCTA，则建议进行压力测试，最好是有影像学检查的压力测试。如果 CCTA 结果显示高危，则通常需要进行冠状动脉造影和介入治疗。对于左主干病变、左心室功能障碍或充血性心力衰竭症状的患者，建议采用早期侵入性策略。如果不存在这些情况，则可以开始初始药物治疗，如果临床上需要，则应进行侵入性治疗。对于慢性稳定性心绞痛患者，继续进行药物治疗和危险因素改变。如果心绞痛发作的频率或严重程度发生变化，则应考虑进行冠状动脉造影和血运重建。对于有严重肾功能障碍的患者，只有在药物治疗完全失败的情况下才需要进行血管造影。所有患者都应首先利用最佳药物治疗。对于左心室功能障碍、充血性心力衰竭和药物治疗失败的患者，应采用早期侵入性管理和血运重建。应始终利用共同决策过程。
