Cambridge Medicine Journal [CMJ]

Abstract

Introduction: Coronary artery disease (CAD) is the accumulation of atherosclerotic plaque in the coronary arteries; resulting in limited myocardial perfusion. CAD has high levels of global morbidity and mortality and is well researched. Asymptomatic coronary artery disease (ACAD) is the precursor subclinical state and is inadequately detected and researched. The aim of this article was to cross-examine the current research on ACAD. Emphasis was placed on methods of assessment and screening of ACAD.

Materials and Methods: A review of the literature was completed following a structured protocol; search engines, inclusion and exclusion criteria were defined a priori.

Results: Forty-eight articles met all inclusion criteria and were retrieved for detailed analysis. Outcome-based evidence suggested that cardiovascular disease risk stratification followed by imaging based assessments in low-to-moderate risk candidates were shown to be of clinical value in ACAD. A ‘treat all’ primary preventative approach was shown to be of most benefit; however the social and financial implications of this remain unclear.

Conclusions: Effective management of ACAD is essential to lower the worldwide incidence, morbidity and mortality of CAD. Further outcome-based evidence highlighting the benefits of identification, screening and early primary prevention of ACAD is urgently needed.

Keywords: Asymptomatic coronary artery disease, asymptomatic coronary atherosclerosis, subclinical coronary artery disease, subclinical coronary atherosclerosis, asymptomatic coronary artery disease screening, asymptomatic coronary artery disease investigations, asymptomatic coronary artery disease management

Introduction

Quand tu sauras mon crime et le sort qui m’accable,
Je n’en mourrai pas moins, j’en mourrai plus coupable.

Jean Racine (1639–1699), Phèdre¹

Phèdre is a tragedy which explores the relationship between moral culpability and responsibility for one’s actions by examining the incestuous love of a queen for her step-son, a passion that is apparently imputed to her by a vengeful deity. What is fascinating for the purposes of our discussion is the dynamic interplay between the portrayals of Phèdre’s infatuation both as an illness and simultaneously as a crime, for this is essentially the same question we must consider in deciding to what extent a malady excuses behaviour that contravenes society’s judicial expectations. While this was doubtless an intriguing consideration for a seventeenth century French dramatist, it is all the more pertinent for us today given the extent of medicalisation that has occurred in recent decades across many spheres of society. In terms of psychiatry, this may be illustrated merely with reference to the DSM, which between its first edition in 1952 and the fourth revision fifty-two years later has more than tripled the number of conditions it identifies, taking the total from 112 to more than 370 today [1]. This inexorable rise has led certain commentators to question the extent to which this phenomenon is justified, particularly where it impinges on the realm of moral accountability. This is exemplified in an article by the sociologist Frank Furedi entitled The seven deadly personality disorders, in which he describes how all of those vices that the Catholic Church once taught to be mortal sins are now considered by Western culture to be addictive illnesses, with the sole exception of pride, which is thought to be a virtue, the helpful antidote to low self-esteem [2]. This issue is one of eminent importance to the forensic psychiatrist, who may be obliged to stand as an expert witness and give evidence on a defendant’s mental state, potentially obviating the accusation that they had the mens rea for a crime. This is particularly the case in homicide, where mental illness can reduce a verdict from murder to manslaughter, but it is of more general significance in the verdict of ‘not guilty by reason of insanity’. Thus, this essay shall concern itself with a consideration of the current theories on which medico-legal practice seems to be predicated, before examining a possible alternative to this model and the congruence of this with a broader philosophical perspective, concluding with some speculation as to the implications of this concept for clinical practice and for society.