Coronary artery disease

Overview

Coronary artery disease (CAD) is a common type of heart disease. It affects the main blood vessels
that supply blood to the heart, called the coronary arteries. In CAD, there is reduced blood flow to
the heart muscle. A buildup of fats, cholesterol and other substances in and on the artery walls, a
condition called atherosclerosis, usually causes coronary artery disease. The buildup, called plaque,
makes the arteries narrow.

Coronary artery disease often develops over many years. Symptoms are from the lack of blood flow
to the heart. They may include chest pain and shortness of breath. A complete blockage of blood
flow can cause a heart attack.

Treatment for coronary artery disease may include medicines and surgery. Eating a nutritious diet,
getting regular exercise and not smoking can help prevent coronary artery disease and the conditions
that can cause it.

Coronary artery disease also may be called coronary heart disease.

Symptoms

Symptoms of coronary artery disease happen when the heart doesn't get enough oxygen-rich blood.
Coronary artery disease symptoms may include:

 Chest pain, called angina. You may feel squeezing, pressure, heaviness, tightness or pain in
the chest. It may feel like somebody is standing on your chest. The chest pain usually affects
the middle or left side of the chest. Activity or strong emotions can trigger angina. There are
different types of angina. The type depends on the cause and whether rest or medicine
makes symptoms better. In some people, especially women, the pain may be brief or sharp
and felt in the neck, arm or back.

 Shortness of breath. You may feel like you can't catch your breath.

 Fatigue. If the heart can't pump enough blood to meet your body's needs, you may feel
unusually tired.

Symptoms of coronary artery disease may not be noticed at first. Sometimes symptoms only happen
when the heart is beating hard, such as during exercise. As the coronary arteries continue to narrow,
symptoms can get more severe or frequent.

A completely blocked coronary artery will cause a heart attack. Common heart attack symptoms
include:

 Chest pain that may feel like pressure, tightness, squeezing or aching.

 Pain or discomfort that spreads to the shoulder, arm, back, neck, jaw, teeth or sometimes the
upper belly.

 Cold sweats.

 Fatigue.

 Heartburn.
  Nausea.

 Shortness of breath.

 Lightheadedness or sudden dizziness.

Chest pain is usually the most common symptom of heart attack. But for some people, such as
women, the elderly and those with diabetes, symptoms may seem unrelated to a heart attack. For
example, they may have nausea or a very brief pain in the neck or back. Some people having a heart
attack don't notice symptoms.

When to see a doctor

If you think you're having a heart attack, immediately call 911 or your local emergency number. If you
don't have access to emergency medical services, have someone drive you to the nearest hospital.
Drive yourself only as a last option.

Smoking or having high blood pressure, high cholesterol, diabetes, obesity or a strong family history
of heart disease makes you more likely to get coronary artery disease. If you're at high risk of
coronary artery disease, talk to your healthcare professional. You may need tests to check for
narrowed arteries and coronary artery disease.

Causes
Development of atherosclerosisEnlarge image

Coronary artery disease is caused by the buildup of fats, cholesterol and other substances in and on
the walls of the heart arteries. This condition is called atherosclerosis. The buildup is called plaque.
Plaque can cause the arteries to narrow, blocking blood flow. The plaque also can burst, causing a
blood clot.

Some causes of atherosclerosis and coronary artery disease are:

 Diabetes or insulin resistance.

 High blood pressure.

 Lack of exercise.
  Smoking or tobacco use.

Risk factors

Coronary artery disease is common.

Coronary artery disease risk factors you can't control include:

 Age. Getting older increases the risk of damaged and narrowed arteries.

 Birth sex. Men are generally at greater risk of coronary artery disease. However, the risk for
women increases after menopause.

 Family history. A family history of heart disease makes you more likely to get coronary artery
disease. This is especially true if a parent, brother, sister or child got heart disease at an early
age. The risk is highest if your father or a brother had heart disease before age 55 or if your
mother or a sister developed it before age 65.

Coronary artery disease risk factors you can control are:

 Smoking. If you smoke, quit. Smoking is bad for heart health. People who smoke have a
much greater risk of heart disease. Breathing in secondhand smoke also increases the risk.

 High blood pressure. Uncontrolled high blood pressure can make arteries hard and stiff. This
can lead to atherosclerosis, which causes coronary artery disease.

 Cholesterol. Too much "bad" cholesterol in the blood can increase the risk of atherosclerosis.
"Bad" cholesterol is called low-density lipoprotein (LDL) cholesterol. Not enough "good"
cholesterol, called high-density lipoprotein (HDL) cholesterol, also leads to atherosclerosis.

 Diabetes. Diabetes increases the risk of coronary artery disease. Type 2 diabetes and
coronary artery disease share some risk factors, such as obesity and high blood pressure.

 Obesity. Too much body fat is bad for overall health. Obesity can lead to type 2 diabetes and
high blood pressure. Ask your healthcare team what a healthy weight is for you.

 Chronic kidney disease. Having long-term kidney disease increases the risk of coronary
artery disease.

 Not getting enough exercise. Physical activity is important for good health. A lack of exercise
is linked to coronary artery disease and some of its risk factors.

 A lot of stress. Emotional stress may damage the arteries and worsen other risk factors for
coronary artery disease.

 Unhealthy diet. Eating foods with a lot of saturated fat, trans fat, salt and sugar can increase
the risk of coronary artery disease.

 Alcohol use. Heavy alcohol use can lead to heart muscle damage. It also can worsen other
risk factors of coronary artery disease.

 Amount of sleep. Too little sleep and too much sleep both have been linked to an increased
risk of heart disease.

Risk factors often happen together. One risk factor may trigger another. When grouped together,
some risk factors make you even more likely to develop coronary artery disease. For example,
metabolic syndrome is a group of conditions that includes high blood pressure, high blood sugar, too
much body fat around the waist and high triglyceride levels. Metabolic syndrome increases the risk
of coronary artery disease.

Other possible risk factors for coronary artery disease may include:

 Breathing pauses during sleep, called obstructive sleep apnea. This condition causes
breathing to stop and start during sleep. It can cause sudden drops in blood oxygen levels.
The heart must work harder to pump blood. Blood pressure goes up.

 Increased high-sensitivity C-reactive protein (hs-CRP). This protein appears in higher than
usual amounts when there's inflammation somewhere in the body. High hs-CRP levels may
be a risk factor for heart disease. It's thought that as coronary arteries narrow, the level of
hs-CRP in the blood goes up.

 High triglycerides. This is a type of fat in the blood. High levels may raise the risk of coronary
artery disease, especially for women.

 High levels of homocysteine. Homocysteine is a substance that the body uses to make
protein and to build and maintain tissue. But high levels of homocysteine may raise the risk
of coronary artery disease.

 Preeclampsia. This pregnancy complication causes high blood pressure and increased
protein in the urine. It can lead to a higher risk of heart disease later in life.

 Other pregnancy complications. Diabetes or high blood pressure during pregnancy are
known risk factors for coronary artery disease.

 Certain autoimmune diseases. People who have conditions such as rheumatoid arthritis and
lupus have an increased risk of atherosclerosis.

Complications

Complications of coronary artery disease may include:

 Chest pain, also called angina. This is a symptom of coronary artery disease. But it also can
be a complication of worsening CAD. The chest pain happens when arteries narrow and the
heart doesn't get enough blood.

 Heart attack. A heart attack can happen if atherosclerosis causes a blood clot. A clot can
block blood flow. The lack of blood can damage the heart muscle. The amount of damage
depends in part on how quickly you are treated.

 Heart failure.Narrowed arteries in the heart or high blood pressure can slowly make the
heart weak or stiff. This can make it harder for the heart to pump blood.

 Irregular heart rhythms, called arrhythmias. If the heart doesn't get enough blood, changes
in heart signaling can happen. This can cause irregular heartbeats.
Angina treatment: Stents, drugs, lifestyle changes — What's best?

Blocked heart arteries can cause a type of chest pain called angina. Angina pain is a symptom that
means the heart isn't getting enough oxygen. It's important to treat blockages that cause angina to
avoid a heart attack and other complications.

The type of treatment your doctor recommends depends on the type of angina you have.

Types of angina

The most common types of angina are chronic stable angina and unstable angina.

 Chronic stable angina. This chest pain occurs when your heart is working hard enough to
need more oxygen, such as during moderate or vigorous exercise or mental stress. The pain
can go away when you rest. The pattern of pain — how long it lasts, how often it occurs,
what triggers it, and how it responds to rest or treatment — remains stable for at least two
months.

 Unstable angina. This is either new or changed chest pain. The pain is believed to be coming
from the heart muscle. If you have a history of stable angina, the pain is different than usual.
For example, the pain may feel worse, or it may last longer than usual. The pain might occur
during lighter levels of activity, or it doesn't get better with rest or medicine.

Unstable angina is dangerous and a warning sign of a heart attack. If you have new or changed chest
pain, seek medical care right away.

Other types of angina include variant angina, also called Prinzmetal angina. This rare type is caused
by a spasm in the coronary arteries. Another type, called microvascular angina, can be a symptom of
disease in the small coronary artery blood vessels.

Treatment options
 Enlarge image

Coronary artery stent

If your angina is stable, you might be able to control it with lifestyle changes and medicines. Unstable
angina requires treatment right away in a hospital. This may involve medicines or a procedure.

Medicines

Several medicines can improve angina symptoms, including:

 Aspirin. Aspirin and other anti-platelet medicines prevent blood clotting. This makes it easier
for blood to flow through narrowed heart arteries.
  Nitroglycerin. This medicine widens the heart arteries. It can help control or relieve chest
pain. Nitroglycerin is available as a pill, spray or patch.

 Beta blockers. These medicines help the heart beat more slowly and with less force. This
eases angina pain.

 Statins. Statins are often prescribed to treat high cholesterol. They also might help prevent
fatty deposits called plaque from clogging heart arteries.

 Calcium channel blockers. These medicines relax and widen blood vessels, increasing blood
flow to the heart.

 Ranolazine. This medicine might be given with or instead of beta blockers for angina. It's
typically used if angina symptoms don't improve with other medicines.

Angioplasty and stent placement

Angioplasty, also called percutaneous coronary intervention, increases blood flow through a blocked
artery and decreases angina.

During an angioplasty, a doctor inserts a thin, flexible tube called a catheter into a blood vessel,
usually in the groin or wrist. A tiny balloon is on the end of the tube. The doctor inflates the balloon
to widen the artery. A small metal mesh tube called a stent may be placed to keep the artery open.

This process can take 30 minutes to several hours. You usually stay in the hospital at least overnight.
Your health care team tells you when you can return to your daily activities.

Sometimes the blockage returns after an angioplasty. Using a stent coated with medicine can help
prevent this.

If unstable angina or stable angina affects some of the main heart arteries and does not improve
with stenting and other treatments, heart bypass surgery may be needed. Heart bypass surgery is
open-heart surgery. It's also called coronary artery bypass grafting or CABG — pronounced
"cabbage."

Enhanced external counterpulsation (EECP) therapy

EECP therapy might be recommended for some people whose angina doesn't improve with other
treatments. For this therapy, large cuffs are wrapped around your legs. Air pressure causes the cuffs
to inflate and deflate in time to your heartbeat. You typically need five one-hour treatments a week
for seven weeks.

Lifestyle changes

Making lifestyle changes to keep the heart healthy is an important part of angina treatment. Try
these tips:

 Quit smoking. If you smoke, stop. If you need help quitting, talk to your health care team
about therapies that can help.

 Eat a healthy diet. Eat a healthy diet with limited amounts of saturated fat, trans fat, salt and
sugar. Include a variety of fruits and vegetables, whole grains, lean meats, and low-fat dairy
products in your diet.
  Stay active. Regular exercise and activity help control diabetes, high cholesterol and high
blood pressure &mdash all risk factors for heart disease. Talk to your health care team about
starting a safe exercise plan. If your angina occurs with activity, pace yourself and take rest
breaks.

 Manage weight. Ask your doctor what a healthy weight is for you and how to achieve it.

 Treat medical conditions. Get treatment for health conditions that can increase your risk of
angina, such as diabetes, high blood pressure and high blood cholesterol.

 Reduce stress. Find ways to help reduce emotional stress. Getting more exercise, practicing
mindfulness and connecting with others in support groups are some ways to reduce and
manage stress.

How to choose

You and your care team should discuss the pros and cons of each treatment to decide which is best
for you. For most people, first steps include medicines and lifestyle changes. If those don't work for
you, angioplasty and stenting can be another option.

Talk to your doctor if you think your treatment isn't controlling your angina well enough.