Regarding code 4i3.

9:

EpidemiologSr

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Predominant age: Most common in middle age and older men, postmenopausal women
Predominant sex: Male > Female

Incidence

-500,000 new cases of stable anqina occur vearlv in the United States.
Prevalence

More than 10 million peoole in the United States suffer from angina.
Risk Factors
Risk factors for coronary artery disease include:

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Family history of premature CAD in lst-degree relatives (in male relatives <55 yrs old or
female relatives <65 yrs old)
Obesity
Hypercholesterolemia
Elevated blood pressure
Cigarette smoking
Diabetes mellitus
Male gender
Advanced age

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Predictable and reproducible anginal symptoms lasting 3-15 minutes brought on by

exertion, emotional stress, meals, cold air, or smoking; symptoms relieved by rest or
nitrates
Careful history is important in eliciting symptoms of angina as listed above.
Dyspnea on exertion may present as the only symptom. (SHORTNESS OF BREATH)
Atypical symptoms more likely in women, elderly, and diabetic patients.
Canadian Cardiovascular Society grading of chronic stable angina severity:
o Class 1: Ordinary physical activity does not cause angina; angina with strenuous
or rapid or prolonged exertion

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Class 2: Slight limitation of ordinary activity (walking rapidly or >2 blocks,

climbing >1 flight of stairs, emotional stress)
Class 3: Marked limitation of ordinary physical activity.
Class 4: Inability to carry on any physical activity without discomfort. Angina
may occur at rest.

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WIIT{T THESE PATIENTS MAY BE ON THAT YOU CAN KEF'PTHE PI{YSICIAN

***r(Ask the physician how many patients are on medications that are bolded/underlined
below (also see risk factors from above that trigger this chest tightness/discomfort feeling).
The predominance of these patients have felt chest discomfort that could benefit from this
code 413.9 and would authorize the 2c19 testing. 'srt*'r*
Medication

First Line
Anti-ischemic (anti-anginal) medications:
o Beta blockers decrease heart rate, blood pressure, and myocardial contractility:
. Atenolol (25-100 mg/d), metoprolol (25-100 mg b.i.d.)
. Adjust doses according to clinical response. Aim to maintain resting heart
rate of 50-60 beats per minute.
, Side effects may include fatigue, exercise intolerance, erectile
dysfunction, bradycardi4 or heart block.
. Contraindications include decompensated CHF, severe bradycardi4
advanced AV block, or severe lung disease.
dilate systemic veins and arteries (including coronary vessels) and cause
" Nitrates
decreased afterload and increased myocardial flow:
. Sublingual nitroelvcerin 0.4 mg SL. For acute anginal episodes. Repeat
2-3 times over a 10-15 minute period; if no relief, immediate medical
attention must be sought.
. Long-acting nitrates: Should be used with a drug-free interval of 8-12
hours to prevent tolerance. Side effects such as headaches and hypotension
tend to clear with continued usage.

o Calcium

channel hlockers (CCB) cause artenal vasodilation,

decrease

myocardial oxygen demand, and improve coronary blood flow. Only long-acting
CCBs should be used:

Dihydropyridine CCBs such as nifedipine (30-90 mg/d), amlodipine (510 mgld), or felodipine (2.5-lA mgld) cause more vasodilation.
Nondihydropyridine ccBs such as diltiazem (120-480 mgld) or
verapamil (120450 mgld).Amlodipine preferred in patients with low
ejection fraction.

Vasculoprotective theraPies :
o Antiplatelet therapy is indicated in all patients:
. Aspirin (81-325 mg/d) is preferred
. Clopidogrel (75 mgld) may be used in patients with contraindications to
asPirin.
. Combination of aspirin and clopidogrel is indicated for those with stent
placement to reduce rate of stent thrombosis (1 month for bare metal stents
and>12 months for drug eluting stents)

o Statins (e.g.,
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simvastatin, atorvastatin, pravastatin, lovastatin) for

hypercholesterolemia:
ACE inhibitors have been shown to reduce both cardiovascular death and MI.
I"al*teO in patlents with CAD or other vascular disease (lXB], particularly in
those with diabetes or left ventricular (LV) systolic dysfirnction (1)[A]:
. Angiotensin receptor blockers may be used in patients intolerant of ACE
inhibitors.