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Coronary artery disease
Other Resources UpToDate PubMed

Coronary artery disease

Contributors: Scott Echternacht MD, Abdullah S. Abdullah MBBS, MRCP, MSc, David Peritz MD, Michael W. Winter MD, Ryan Hoefen MD, PhD
Other Resources UpToDate PubMed


Coronary artery disease (CAD) typically refers to progressive atherosclerosis within the coronary arteries, ultimately diminishing blood flow to the myocardium. Less common causes for coronary artery obstruction exist (eg, dissections, vasospasm, vasculitis) and result in variants of the disease. In the early stages, patients are asymptomatic, and CAD may be undetected or incidentally identified, such as by visualization of coronary artery calcification indicative of atherosclerosis on a chest CT. Symptoms (angina) ultimately develop due to ischemia, insufficient blood flow to meet metabolic demand of the myocardium, which may occur in an acute or chronic fashion. Acute ischemia due to plaque rupture and coronary thrombosis results in an acute coronary syndrome (ACS), which is classified as unstable angina, non ST-elevation myocardial infarction (NSTEMI), or ST-elevation myocardial infarction (STEMI), depending on severity and clinical features. These acute events are covered separately. Chronic, gradual progression generally results in stable angina, in which symptoms occur during periods of higher metabolic demand, such as physical exertion, and resolve with rest.

Inflammation is important in the pathogenesis of atherosclerosis. Endothelial cell dysfunction leads to macrophage and low-density lipoprotein (LDL) accumulations, causing foam cell formation and fatty streaks. This results in smooth muscle cell migration, proliferation, and extracellular matrix deposition, defined as a fibrous plaque. As the disease progresses, the fibrous plaque worsens and will eventually form a complex atheroma.

The hallmark symptom of ischemia is retrosternal chest pain / discomfort that may radiate to the neck, jaw, or left arm. Often, patients with this condition rest to ease the discomfort. The pain also generally improves with use of nitroglycerin. The pain is short-lived and starts gradually, rising to a maximum intensity within minutes, often described as "crescendo angina." Chest pain that reaches a peak within seconds should raise the possibility of an alternative diagnosis, notably aortic dissection. Other common symptoms include palpitations, nausea or heartburn-like symptoms, and hypotension. Atypical symptoms, such as dyspnea or syncope, are seen more often in women, elderly patients, and diabetic patients. Women tend to develop heart disease at a later age compared with men, with diabetes / insulin resistance, hypertension, obesity, and smoking being the strongest risk factors for early-onset CAD in women. There also appears to be an independent association between both hypertensive disorders during pregnancy and low birth weight with development of atherosclerotic cardiovascular disease.

Modifiable risk factors for development of CAD include smoking, hypertension, hyperlipidemia, type 2 diabetes mellitus, high glycemic index and glycemic load, obesity, and a sedentary lifestyle. Increased urinary sodium is associated with increased risk. Nonmodifiable risk factors include increasing age, male sex, postmenopausal status in women, and family history of CAD. Multiple forms of predominantly air pollution are risk factors for CAD.


I25.10 – Atherosclerotic heart disease of native coronary artery without angina pectoris

53741008 – Coronary arteriosclerosis

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

Cardiac causes of chest pain:
  • Acute coronary syndrome – New onset chest pain, pain of a new character, or pain of prolonged duration not relieved by rest; ECG is usually abnormal:
    • Acute coronary syndrome
    • Acute coronary syndrome
      • NSTEMI – no ST elevation on ECG but with acute elevations of cardiac markers
      • STEMI – ST or T wave changes across a vascular region with acute elevations of cardiac markers
  • Microvascular angina
  • Pericarditis – Sharp pain, positional (improved with leaning forward), recent illness or myocardial infarction (or other risk factors), pericardial friction rub, diffuse ST elevations on ECG.
  • Aortic dissection – Tearing chest pain that radiates to the back, hypotension, tachycardia, visible on CT.
  • Coronary vasospasm
  • Spontaneous coronary artery dissection
  • Takotsubo cardiomyopathy
  • Congestive heart failure
  • Mitral valve disease (eg, Mitral valve prolapse, Mitral regurgitation, or Mitral valve stenosis)
  • Substance related (eg, Cocaine-related cardiomyopathy)
  • Expanding aortic aneurysm – Positive risk factors (many are the same), visible on ultrasound or CT.
Pulmonary causes:
  • Pulmonary embolism – Pleuritic chest pain, tachycardia, shortness of breath, syncope, evidence of right heart strain on ECG, CT angiogram.
  • Pneumothorax
  • Streptococcus pneumoniae pneumonia – Pleuritic chest pain, cough, fever.
  • Malignancy
  • Pleurisy
  • Sarcoidosis
  • Acute chest syndrome
  • Pulmonary hypertension
Gastrointestinal causes:
  • Gastroesophageal reflux disease (GERD) – Burning pain, pain after eating large or spicy meals, pain on abdominal examination.
  • Peptic ulcer disease – Look for positive risk factors.
  • Esophageal motility disorder
  • Esophagitis
  • Eosinophilic esophagitis
  • Hiatal hernia
  • Spontaneous rupture of esophagus
  • Referred pain from abdominal viscera (eg, Acute cholecystitis, Acute pancreatitis) – Look for positive risk factors, liver function tests, pancreatic enzyme levels.
  • Sickle cell acute pain crisis
Musculoskeletal causes:
  • Costochondritis – Sharp, localized, reproducible pain; history of traumatic injury.
  • Rheumatic diseases (eg, Rheumatoid arthritis, Fibromyalgia)
  • Trauma
Psychiatric causes:
  • Panic disorder / Generalized anxiety disorder – History of psychiatric disease with admissions.
Infectious causes:
  • Herpes zoster (shingles) – Look for rash.

Best Tests

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Management Pearls

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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Last Reviewed:09/15/2020
Last Updated:07/24/2022
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Coronary artery disease
A medical illustration showing key findings of Coronary artery disease : Nausea, Dyspnea, Dyspepsia, Recurring episodes
Copyright © 2024 VisualDx®. All rights reserved.