Coronary Heart Disease

Coronary heart disease

Coronary heart disease (CHD) is a narrowing of the small blood vessels that supply blood and oxygen to the heart. CHD is also called coronary artery disease.

Symptoms

Symptoms may be very noticeable, but sometimes you can have the disease and not have any symptoms.
Chest pain or discomfort (angina) is the most common symptom. You feel this pain when the heart is not getting enough blood or oxygen. How bad the pain is varies from person to person.

• It may feel heavy or like someone is squeezing your heart. You feel it under your breast bone (sternum), but also in your neck, arms, stomach, or upper back.
• The pain usually occurs with activity or emotion, and goes away with rest or a medicine called nitroglycerin.
• Other symptoms include shortness of breath and fatigue with activity (exertion).

Causes

Coronary heart disease is usually caused by a condition called atherosclerosis, which occurs when fatty material and a substance called plaque build up on the walls of your arteries. This causes them to get narrow. As the coronary arteries narrow, blood flow to the heart can slow down or stop. This can cause chest pain (stable angina), shortness of breath, heart attack, and other symptoms.
Coronary heart disease (CHD) is the leading cause of death in the United States for men and women.
Many things increase your risk for heart disease:

• Men in their 40s have a higher risk of CHD than women. But as women get older (especially after they reach menopause), their risk increases to almost equal that of a man’s risk. See: Heart disease and women
• Bad genes (heredity) can increase your risk. You are more likely to develop the condition if someone in your family has had a history of heart disease — especially if they had it before age 50. Your risk for CHD goes up the older you get.
• Diabetes is a strong risk factor for heart disease.
• High blood pressure increases your risk of coronary artery disease and heart failure.
• Abnormal cholesterol levels: your LDL (“bad”) cholesterol should be as low as possible, and your HDL (“good”) cholesterol should be as high as possible.
• Metabolic syndrome refers to high triglyceride levels, high blood pressure, excess body fat around the waist, and increased insulin levels. People with this group of problems have an increased chance of getting heart disease.
• Smokers have a much higher risk of heart disease than nonsmokers.
• Chronic kidney disease can increase your risk.
• Already having atherosclerosis or hardening of the arteries in another part of your body (examples are stroke and abdominal aortic aneurysm) increases your risk of having coronary heart disease.
• Other risk factors including alcohol abuse, not getting enough exercise, and excessive amounts of stress.

Higher-than-normal levels of inflammation-related substances, such as C-reactive protein and fibrinogen are being studied as possible indicators of an increased risk for heart disease.
Increased levels of a chemical called homocysteine, an amino acid, are also linked to an increased risk of a heart attack

Tests & diagnosis

Many tests help diagnose CHD. Usually, your doctor will order more than one test before making a definite diagnosis.
Tests may include:

• Electrocardiogram (ECG)
• Exercise stress test
• Echocardiogram
• Nuclear scan
• Electron-beam computed tomography (EBCT) to look for calcium in the lining of the arteries — the more calcium, the higher your chance for CHD
• CT angiography — a noninvasive way to perform coronary angiography
• Magnetic resonance angiography

Coronary angiography/arteriography — an invasive procedure designed to evaluate the heart arteries under x-ray.

Treatment

You may be asked to take one or more medicines to treat blood pressure, diabetes, or high cholesterol levels. Follow your doctor’s directions closely to help prevent coronary artery disease from getting worse. Goals for treating these conditions in those who have coronary artery disease are:

• LDL cholesterol level less than or equal to 100 mg/dL
• Glycosylated hemoglobin (HbA1c) levels less than or equal to 7%
• Blood pressure less than or equal to 120/80 mmHg

Taking aspirin with or without clopidogrel (Plavix) helps prevent blood clots from forming in your arteries and reduces your risk of having a heart attack. Ask your doctor if you should be taking these.

Treatment depends on your symptoms and how severe the disease is. Your doctor may give you one or more medicines to treat CHD, including:

• ACE inhibitors to lower blood pressure and protect your heart
• Beta-blockers to lower heart rate, blood pressure, and oxygen use by the heart
• Calcium channel blockers to relax arteries, lowering blood pressure and reducing strain on the heart
• Diuretics to lower blood pressure and treat congestive heart failure
• Nitrates (such as nitroglycerin) to stop chest pain and improve blood supply to the heart
• Statins to lower cholesterol

NEVER ABRUPTLY STOP TAKING ANY OF THESE DRUGS. Always talk to your doctor first. Stopping these drugs suddenly can make your angina worse or cause a heart attack.

Procedures and surgeries used to treat CHD include:

• Angioplasty and stent placement, called percutaneous coronary interventions (PCIs)
• Coronary artery bypass surgery
• Minimally invasive heart surgery

Lifestyle changes are very important. Your doctor may tell you to:

• Avoid or reduce the amount of salt (sodium) you eat
• Eat a heart healthy diet — one that is low in saturated fats, cholesterol, and trans fat
• Get regular exercise and maintain a healthy weight
• Keep your blood sugar strictly under control if you have diabetes
• Stop smoking

Prognosis
Everyone recovers differently. Some people can maintain a healthy life by changing their diet, stopping smoking, and taking medications exactly as the doctor prescribes. Others may need medical procedures such as angioplasty or surgery.
Although everyone is different, early detection of CHD generally results in a better outcome.

Prevention 
See your health care provider regularly.
Tips for preventing CHD or lowering your risk of the disease:

• Avoid or reduce stress as best as you can.
• Don’t smoke.
• Eat well-balanced meals that are low in fat and cholesterol and include several daily servings of fruits and vegetables.
• Get regular exercise. If your weight is considered normal, get at least 30 minutes of exercise every day. If you are overweight or obese, experts say you should get 60 – 90 minutes of exercise every day.
• Keep your blood pressure below 130/80 mmHg if you have diabetes or chronic kidney disease, and below 140/90 otherwise
• Keep your cholesterol and blood sugar under control.

Moderate amounts of alcohol (one glass a day for women, two for men) may reduce your risk of cardiovascular problems. However, drinking larger amounts does more harm than good.

If you have one or more risk factors for coronary heart disease, talk to your doctor about possibly taking an aspirin a day to help prevent a heart attack or stroke. You may be prescribed low-dose aspirin therapy if the benefit is likely to outweigh the risk of gastrointestinal side effects.

New guidelines no longer recommend hormone replacement therapy, vitamins E or C, antioxidants, or folic acid to prevent heart disease. The use of hormone replacement therapy in women who are close to menopause or who have finished menopause is controversial at this time.

Complications

• Heart attack
• Heart failure
• Unstable angina
• Sudden death

When to contact a doctor 
If you have any of the risk factors for CHD, contact your doctor to discuss prevention and possible treatment.
Immediately contact your health care provider, call the local emergency number (such as 911), or go to the emergency room if you have:

• Angina
• Shortness of breath
• Symptoms of a heart attack
• This information is for you only.
• Always follow your healthcare provider’s instructions for taking medicines or other changes.
• Ask your provider about nonprescription medicines and supplements before you take them.

c@American Accreditation HealthCare Commission
Coronary artery disease

Your coronary arteries are the major blood vessels that supply your heart with blood, oxygen and nutrients. When these arteries become damaged or diseased — usually due to a buildup of fatty deposits called plaques — it’s known as coronary artery disease. 
These deposits can slowly narrow your coronary arteries, causing your heart to receive less blood. Eventually, diminished blood flow may cause chest pain (angina), shortness of breath or other symptoms. A complete blockage, caused either by accumulated plaques or a ruptured plaque, can cause a heart attack. 
Because coronary artery disease often develops over decades, it can go virtually unnoticed until it produces a heart attack. But there’s plenty you can do to prevent and treat coronary artery disease. Start by committing to a healthy lifestyle. 

Symptoms
If your coronary arteries become narrowed, they can’t supply enough oxygenated blood to your heart — especially when it’s beating hard, such as during physical activity. At first, the restricted blood flow may not cause any coronary artery disease symptoms. As the fatty deposits continue to accumulate in your coronary arteries, however, you may develop coronary artery disease symptoms, including:

• Chest pain (angina). You may feel pressure or tightness in your chest, as if someone were standing on your chest. The pain, referred to as angina, is usually triggered by physical or emotional stress. It typically goes away within minutes after stopping the stressful activity. In some people, especially women, this pain may be fleeting or sharp and noticed in the abdomen, back or arm.
• Shortness of breath. If your heart can’t pump enough blood to meet your body’s needs, you may develop shortness of breath or extreme fatigue with exertion.
• Heart attack. If a coronary artery becomes completely blocked, you may have a heart attack. The classic symptoms of a heart attack include crushing pressure in your chest and pain in your shoulder or arm, sometimes with shortness of breath and sweating. Women are somewhat more likely than men are to experience less typical signs of a heart attack, including nausea and back or jaw pain. Sometimes a heart attack occurs without any apparent signs or symptoms.

When to see a doctor 

If you suspect 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 resort. 
If you have risk factors for coronary artery disease — such as high blood pressure, high cholesterol, diabetes or obesity — talk to your doctor. He or she may want to test you for the condition, especially if you have signs or symptoms of narrowed arteries. Even if you don’t have evidence of coronary artery disease, your doctor may recommend aggressive treatment of your risk factors. Early diagnosis and treatment may stop progression of coronary artery disease and help prevent a heart attack. 

Causes
Coronary artery disease is thought to begin with damage or injury to the inner layer of a coronary artery, sometimes as early as childhood. The damage may be caused by various factors, including:

• Smoking
• High blood pressure
• High cholesterol
• Diabetes
• Radiation therapy to the chest, as used for certain types of cancer

Once the inner wall of an artery is damaged, fatty deposits (plaques) made of cholesterol and other cellular waste products tend to accumulate at the site of injury in a process called atherosclerosis. If the surface of these fatty deposits breaks or ruptures, blood cells called platelets will clump at the site to try to repair the artery. This clump can block the artery, leading to a heart attack. 

Risk factors
Risk factors for coronary artery disease include:

• Age. Simply getting older increases your risk of damaged and narrowed arteries.
• Gender. Men are generally at greater risk of coronary artery disease than are women. However, the risk for women increases after menopause.
• Family history. A family history of heart disease is associated with a higher risk of coronary artery disease, especially if a parent developed it at an early age (before age 60).
• Smoking. Nicotine constricts your blood vessels, and carbon monoxide can damage their inner lining, making them more susceptible to atherosclerosis. The incidence of heart attack in women who smoke at least 20 cigarettes a day is six times that of women who’ve never smoked. For men who smoke, the incidence triples compared with nonsmokers.
• High blood pressure. Uncontrolled high blood pressure can result in hardening and thickening of your arteries, narrowing the channel through which blood can flow.
• High blood cholesterol levels. High levels of cholesterol in your blood can increase the risk of formation of plaques and atherosclerosis. High cholesterol can be caused by a high level of low-density lipoproteins (LDLs), known as “bad” cholesterol, or a low level of high-density lipoproteins (HDLs), known as “good” cholesterol.
• Diabetes. Diabetes is associated with an increased risk of coronary artery disease. Both conditions share similar risk factors, such as obesity and high blood pressure.
• Obesity. Excess weight typically worsens other risk factors.
• Physical inactivity. Lack of exercise also is associated with coronary artery disease and some of its risk factors, as well.
• High stress. Unrelieved stress in your life may damage your arteries as well as worsen other risk factors for coronary artery disease.

Risk factors often occur in clusters and may build on one another, such as obesity leading to diabetes and high blood pressure. When grouped together, certain risk factors put you at an ever greater risk of coronary artery disease. For example, metabolic syndrome — a cluster of conditions that includes elevated blood pressure, high triglycerides, elevated insulin levels and excess body fat around the waist — increases the risk of coronary artery disease. 
Sometimes coronary artery disease develops without any classic risk factors. Researchers are studying other possible factors, including:

• C-reactive protein. Your liver produces C-reactive protein (CRP) in response to injury or infection. CRP is also produced by muscle cells within the coronary arteries. CRP is a general sign of inflammation, which plays a central role in atherosclerosis.
• Homocysteine. Homocysteine is an amino acid your body uses to make protein and to build and maintain tissue. But excessive levels of homocysteine may increase your risk of coronary artery disease and other cardiovascular conditions.
• Fibrinogen. Fibrinogen is a protein in your blood that plays a central role in blood clotting. But too much may promote excessive clumping of platelets, the type of blood cell largely responsible for clotting. That can cause a clot to form in an artery, leading to a heart attack or stroke. Fibrinogen may also be an indicator of the inflammation that accompanies atherosclerosis.
• Lipoprotein (a). This substance forms when a low-density lipoprotein (LDL) particle attaches to a specific protein. Lipoprotein (a) may disrupt your body’s ability to dissolve blood clots. High levels of lipoprotein (a) may be associated with an increased risk of cardiovascular disease, including coronary artery disease and heart attack.

Coronary artery disease can lead to:

• Chest pain (angina). When your coronary arteries narrow, your heart may not receive enough blood when demand is greatest — particularly during physical activity. This can cause chest pain (angina) or shortness of breath.
• Heart attack. If a cholesterol plaque ruptures, stimulating platelet clumping, complete blockage of your heart artery may trigger a heart attack. The lack of blood flow to your heart during a heart attack leads to irreversible damage to your heart muscle. The amount of damage depends in part on how quickly you receive treatment.
• Heart failure. If some areas of your heart are chronically deprived of oxygen and nutrients because of reduced blood flow, or if your heart has been damaged by a heart attack, your heart may become too weak to pump enough blood to meet your body’s needs. This condition is known as heart failure.
• Abnormal heart rhythms (arrhythmia). Inadequate blood supply to the heart or damage to heart tissue can interfere with your heart’s electrical impulses, causing abnormal heart rhythms.

Complications
Coronary artery disease can lead to:

• Chest pain (angina). When your coronary arteries narrow, your heart may not receive enough blood when demand is greatest — particularly during physical activity. This can cause chest pain (angina) or shortness of breath.
• Heart attack. If a cholesterol plaque ruptures, stimulating platelet clumping, complete blockage of your heart artery may trigger a heart attack. The lack of blood flow to your heart during a heart attack leads to irreversible damage to your heart muscle. The amount of damage depends in part on how quickly you receive treatment.
• Heart failure. If some areas of your heart are chronically deprived of oxygen and nutrients because of reduced blood flow, or if your heart has been damaged by a heart attack, your heart may become too weak to pump enough blood to meet your body’s needs. This condition is known as heart failure.
• Abnormal heart rhythms (arrhythmia). Inadequate blood supply to the heart or damage to heart tissue can interfere with your heart’s electrical impulses, causing abnormal heart rhythms.
  

Preparing for your appointment
Early-stage coronary artery disease often produces no symptoms, so you may not discover you’re at risk of the condition until a routine checkup reveals you have high cholesterol or high blood pressure. So it’s important to have regular checkups. 

If you’re seeing your doctor because you’re having symptoms or you have risk factors for coronary artery disease, you’re likely to start by first seeing your primary care doctor or a general practitioner. Eventually, however, you may be referred to a heart specialist (cardiologist). 

Because appointments can be brief, and because there’s often a lot of ground to cover, it’s a good idea to be prepared for your appointment. Here’s some information to help you get ready for your appointment, and what to expect from your doctor. 

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there’s anything you need to do in advance, such as restrict your diet. For a cholesterol test, for example, you may need to fast for a period of time beforehand.
• Write down any symptoms you’re experiencing, including any that may seem unrelated to coronary artery disease.
• Write down key personal information, including a family history of heart disease, stroke, high blood pressure or diabetes, and any major stresses or recent life changes.
• Make a list of all medications, as well as any vitamins or supplements, that you’re taking.
• Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For coronary artery disease, some basic questions to ask your doctor include:

• What is likely causing my symptoms or condition?
• What are other possible causes for my symptoms or condition?
• What kinds of tests will I need?
• What is the best course of action?
• What are the alternatives to the primary approach that you’re suggesting?
• I have other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Should I see a specialist? What will that cost, and will my insurance cover seeing a specialist? (You may need to ask your insurance provider directly for information about coverage.)
• Is there a generic alternative to the medicine you’re prescribing me?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you’ve prepared to ask your doctor, don’t hesitate to ask questions during your appointment at any time that you don’t understand something. 

What to expect from your doctor 
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous, or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?

What you can do in the meantime 
It’s never too early to make healthy lifestyle changes, such as quitting smoking, eating healthy foods and becoming more physically active. These are primary lines of defense against coronary artery disease and its complications, including heart attack and stroke. 

Test and Diagnosis
The doctor will ask questions about your medical history, do a physical exam and order routine blood tests. He or she may suggest one or more diagnostic tests as well, including:

• Electrocardiogram (ECG). An electrocardiogram records electrical signals as they travel through your heart. An ECG can often reveal evidence of a previous heart attack or one that’s in progress. In other cases, Holter monitoring may be recommended. With this type of ECG, you wear a portable monitor for 24 hours as you go about your normal activities. Certain abnormalities may indicate inadequate blood flow to your heart.
• Echocardiogram. An echocardiogram uses sound waves to produce images of your heart. During an echocardiogram, your doctor can determine whether all parts of the heart wall are contributing normally to your heart’s pumping activity. Parts that move weakly may have been damaged during a heart attack or be receiving too little oxygen. This may indicate coronary artery disease or various other conditions.
• Stress test. If your signs and symptoms occur most often during exercise, your doctor may ask you to walk on a treadmill or ride a stationary bike during an ECG. This is known as an exercise stress test. In other cases, medication to stimulate your heart may be used instead of exercise.

Some stress tests are done using an echocardiogram. These are known as stress echos. For example, your doctor may do an ultrasound before and after you exercise on a treadmill or bike. Or your doctor may use medication to stimulate your heart during an echocardiogram. 
Another stress test known as a nuclear stress test helps measure blood flow to your heart muscle at rest and during stress. It’s similar to a routine exercise stress test but with images in addition to an ECG. Trace amounts of radioactive material — such as thallium or a compound known as sestamibi (Cardiolite) — are injected into your bloodstream. Special cameras can detect areas in your heart that receive less blood flow.

• Coronary catheterization. To view blood flow through your heart, your doctor may inject a special dye into your arteries (intravenously). This is known as an angiogram. The dye is injected into the arteries of the heart through a long, thin, flexible tube (catheter) that is threaded through an artery, usually in the leg, to the arteries in the heart. This procedure is called cardiac catheterization. The dye outlines narrow spots and blockages on the X-ray images. If you have a blockage that requires treatment, a balloon can be pushed through the catheter and inflated to improve the blood flow in your heart. A stent may then be used to keep the dilated artery open.
• CT scan. Computerized tomography (CT) technologies, such as electron beam computerized tomography (EBCT) or a CT coronary angiogram, can help your doctor visualize your arteries. EBCT, also called an ultrafast CT scan, can detect calcium within fatty deposits that narrow coronary arteries. If a substantial amount of calcium is discovered, coronary artery disease is likely. A CT coronary angiogram, in which you receive a contrast dye injected intravenously during a CT scan, also can generate images of your heart arteries.
• Magnetic resonance angiogram (MRA). This procedure uses MRI technology, often combined with an injected contrast dye, to check for areas of narrowing or blockages — although the details may not be as clear as those provided by coronary catheterization.

Treatment
Treatment for coronary artery disease usually involves lifestyle changes and, if necessary, drugs and certain medical procedures. 

Lifestyle changes 
Making a commitment to the following healthy lifestyle changes can go a long way toward promoting healthier arteries:

• Quit smoking.
• Eat healthy foods.
• Exercise regularly.
• Lose excess weight.
• Reduce stress.

Drugs 
Various drugs can be used to treat coronary artery disease, including:

• Cholesterol-modifying medications. By decreasing the amount of cholesterol in the blood, especially low-density lipoprotein (LDL) or “bad” cholesterol, these drugs decrease the primary material that deposits on the coronary arteries. Boosting your high-density lipoprotein (HDL), or “good” cholesterol, may help, too. Your doctor can choose from a range of medications, including statins, niacin, fibrates and bile acid sequestrants.
• Aspirin. Your doctor may recommend taking a daily aspirin or other blood thinner. This can reduce the tendency of your blood to clot, which may help prevent obstruction of your coronary arteries. If you’ve had a heart attack, aspirin can help prevent future attacks. There are some cases where aspirin isn’t appropriate, such as if you have a bleeding disorder of you’re already taking another blood thinner, so ask your doctor before starting to take aspirin.
• Beta blockers. These drugs slow your heart rate and decrease your blood pressure, which decreases your heart’s demand for oxygen. If you’ve had a heart attack, beta blockers reduce the risk of future attacks.
• Nitroglycerin. Nitroglycerin tablets, sprays and patches can control chest pain by opening up your coronary arteries and reducing your heart’s demand for blood.
• Angiotensin-converting enzyme (ACE) inhibitors. These drugs decrease blood pressure and may help prevent progression of coronary artery disease. If you’ve had a heart attack, ACE inhibitors reduce the risk of future attacks.
• Calcium channel blockers. These medications relax the muscles that surround your coronary arteries and cause the vessels to open, increasing blood flow to your heart. They also control high blood pressure.

Procedures to restore and improve blood flow 
Sometimes more aggressive treatment is needed. Here are a few options:

• Angioplasty and stent placement (percutaneous coronary revascularization). In this procedure, your doctor inserts a long, thin tube (catheter) into the narrowed part of your artery. A wire with a deflated balloon is passed through the catheter to the narrowed area. The balloon is then inflated, compressing the deposits against your artery walls. A mesh tube (stent) is often left in the artery to help keep the artery open. Some stents slowly release medication to help keep the artery open.
• Coronary artery bypass surgery. A surgeon creates a graft to bypass blocked coronary arteries using a vessel from another part of your body. This allows blood to flow around the blocked or narrowed coronary artery. Because this requires open-heart surgery, it’s most often reserved for cases of multiple narrowed coronary arteries.

Lifestyle modification and prevention
Lifestyle changes can help you prevent or slow the progression of coronary artery disease.

• Stop smoking. Smoking is a major risk factor for coronary artery disease. Nicotine constricts blood vessels and forces your heart to work harder, and carbon monoxide reduces oxygen in your blood and damages the lining of your blood vessels. If you smoke, quitting is the best way to reduce your risk of a heart attack.
• Control your blood pressure. Ask your doctor for a blood pressure measurement at least every two years. He or she may recommend more frequent measurements if your blood pressure is higher than normal or you have a history of heart disease. Optimal blood pressure is below 120 systolic and 80 diastolic, as measured in millimeters of mercury (mm Hg).
• Check your cholesterol. Ask your doctor for a baseline cholesterol test when you’re in your 20s and then at least every five years. If your test results aren’t within desirable ranges, your doctor may recommend more frequent measurements. Most people should aim for an LDL level below 130 milligrams per deciliter (mg/dL), or 3.4 millimoles per liter (mmol/L). If you have other risk factors for heart disease, your target LDL may be below 100 mg/dL (2.6 mmol/L). If you’re at very high risk of heart disease — if you’ve already had a heart attack or have diabetes, for example — your target LDL level is below 70 mg/dL (1.8 mmol/L).
• Keep diabetes under control. If you have diabetes, tight blood sugar control can help reduce the risk of heart disease.
• Get moving. Exercise helps you achieve and maintain a healthy weight and control diabetes, elevated cholesterol and high blood pressure — all risk factors for coronary artery disease. With your doctor’s OK, aim for 30 to 60 minutes of physical activity most days of the week.
• Eat healthy foods. A heart-healthy diet based on fruits, vegetables and whole grains — and low in saturated fat, cholesterol and sodium — can help you control your weight, blood pressure and cholesterol. Eating one or two servings of fish a week also is beneficial.
• Maintain a healthy weight. Being overweight increases your risk of coronary artery disease. Weight loss is especially important for people who have large waist measurements — more than 40 inches for men and more than 35 inches for women — because people with this body shape are more likely to develop diabetes and heart disease.
• Manage stress. Reduce stress as much as possible. Practice healthy techniques for managing stress, such as muscle relaxation and deep breathing.

In addition to healthy lifestyle changes, remember the importance of regular medical checkups. Some of the main risk factors for coronary artery disease — high cholesterol, high blood pressure and diabetes — have no symptoms in the early stages. Early detection and treatment can set the stage for a lifetime of better heart health. 

Also ask your doctor about a yearly flu vaccine. Coronary artery disease and other cardiovascular disorders increase the risk of complications from the flu. 
The same lifestyle habits that can help treat coronary artery disease can also help prevent it from developing in the first place. Leading a healthy lifestyle can help keep your arteries strong, elastic and smooth, and allow for maximum blood flow. Heart-healthy habits include:

• Not smoking
• Controlling conditions such as high blood pressure, high cholesterol and diabetes
• Staying physically active
• Eating healthy foods
• Maintaining a healthy weight
• Reducing and managing stress

Remember this article is for your information only. Dr. Ben-Zur recommends consulting your physician prior to making any changes in your diet, exercise or medical program. 

By Mayo Clinic staff 

Coronary artery disease

Coronary heart disease (CHD) is a narrowing of the small blood vessels that supply blood and oxygen to the heart. CHD is also called coronary artery disease.

Causes
Coronary heart disease is usually caused by a condition called atherosclerosis, which occurs when fatty material and a substance called plaque build up on the walls of your arteries. This causes them to get narrow. As the coronary arteries narrow, blood flow to the heart can slow down or stop. This can cause chest pain (stable angina), shortness of breath, heart attack, and other symptoms.

Coronary heart disease (CHD) is the leading cause of death in the United States for men and women.
Many things increase your risk for heart disease:

• Men in their 40s have a higher risk of CHD than women. But as women get older (especially after they reach menopause), their risk increases to almost equal that of a man’s risk. See: Heart disease and women
• Bad genes (heredity) can increase your risk. You are more likely to develop the condition if someone in your family has had a history of heart disease — especially if they had it before age 50. Your risk for CHD goes up the older you get.
• Diabetes is a strong risk factor for heart disease.
• High blood pressure increases your risk of coronary artery disease and heart failure.
• Abnormal cholesterol levels: your LDL (“bad”) cholesterol should be as low as possible, and your HDL (“good”) cholesterol should be as high as possible.
• Metabolic syndrome refers to high triglyceride levels, high blood pressure, excess body fat around the waist, and increased insulin levels. People with this group of problems have an increased chance of getting heart disease.
• Smokers have a much higher risk of heart disease than nonsmokers.
• Chronic kidney disease can increase your risk.
• Already having atherosclerosis or hardening of the arteries in another part of your body (examples are stroke and abdominal aortic aneurysm) increases your risk of having coronary heart disease.
• Other risk factors including alcohol abuse, not getting enough exercise, and excessive amounts of stress.

Higher-than-normal levels of inflammation-related substances, such as C-reactive protein and fibrinogen are being studied as possible indicators of an increased risk for heart disease.
Increased levels of a chemical called homocysteine, an amino acid, are also linked to an increased risk of a heart attack.

Symptoms
Symptoms may be very noticeable, but sometimes you can have the disease and not have any symptoms.
Chest pain or discomfort (angina) is the most common symptom. You feel this pain when the heart is not getting enough blood or oxygen. How bad the pain is varies from person to person.

• It may feel heavy or like someone is squeezing your heart. You feel it under your breast bone (sternum), but also in your neck, arms, stomach, or upper back.
• The pain usually occurs with activity or emotion, and goes away with rest or a medicine called nitroglycerin.
• Other symptoms include shortness of breath and fatigue with activity (exertion).

Work-up
Many tests help diagnose CHD. Usually, your doctor will order more than one test before making a definite diagnosis.
Tests may include:

• Electrocardiogram (ECG)
• Exercise stress test
• Echocardiogram
• Nuclear scan
• Electron-beam computed tomography (EBCT) to look for calcium in the lining of the arteries — the more calcium, the higher your chance for CHD
• CT angiography — a noninvasive way to perform coronary angiography
• Magnetic resonance angiography
• Coronary angiography/arteriography — an invasive procedure designed to evaluate the heart arteries under x-ray

Treatment

You may be asked to take one or more medicines to treat blood pressure, diabetes, or high cholesterol levels. Follow your doctor’s directions closely to help prevent coronary artery disease from getting worse. Goals for treating these conditions in those who have coronary artery disease are:

• LDL cholesterol level less than or equal to 100 mg/dL
• Glycosylated hemoglobin (HbA1c) levels less than or equal to 7%
• Blood pressure less than or equal to 120/80 mmHg

Taking aspirin with or without clopidogrel (Plavix) helps prevent blood clots from forming in your arteries and reduces your risk of having a heart attack. Ask your doctor if you should be taking these.
Treatment depends on your symptoms and how severe the disease is. Your doctor may give you one or more medicines to treat CHD, including:

• ACE inhibitors to lower blood pressure and protect your heart
• Beta-blockers to lower heart rate, blood pressure, and oxygen use by the heart
• Calcium channel blockers to relax arteries, lowering blood pressure and reducing strain on the heart
• Diuretics to lower blood pressure and treat congestive heart failure
• Nitrates (such as nitroglycerin) to stop chest pain and improve blood supply to the heart
• Statins to lower cholesterol

NEVER ABRUPTLY STOP TAKING ANY OF THESE DRUGS. Always talk to your doctor first. Stopping these drugs suddenly can make your angina worse or cause a heart attack.
Procedures and surgeries used to treat CHD include:

• Angioplasty and stent placement, called percutaneous coronary interventions (PCIs)
• Coronary artery bypass surgery
• Minimally invasive heart surgery

Lifestyle changes are very important. Your doctor may tell you to:

• Avoid or reduce the amount of salt (sodium) you eat
• Eat a heart healthy diet — one that is low in saturated fats, cholesterol, and trans fat
• Get regular exercise and maintain a healthy weight
• Keep your blood sugar strictly under control if you have diabetes
• Stop smoking

Outlook

Everyone recovers differently. Some people can maintain a healthy life by changing their diet, stopping smoking, and taking medications exactly as the doctor prescribes. Others may need medical procedures such as angioplasty or surgery.
Although everyone is different, early detection of CHD generally results in a better outcome.

Possible complications

• Heart attack
• Heart failure
• Unstable angina
• Sudden death

Contact your doctor

If you have any of the risk factors for CHD, contact your doctor to discuss prevention and possible treatment.
Immediately contact your health care provider, call the local emergency number (such as 911), or go to the emergency room if you have:

• Angina
• Shortness of breath
• Symptoms of a heart attack

Prevention

See your health care provider regularly.
Tips for preventing CHD or lowering your risk of the disease:

• Avoid or reduce stress as best as you can.
• Don’t smoke.
• Eat well-balanced meals that are low in fat and cholesterol and include several daily servings of fruits and vegetables.
• Get regular exercise. If your weight is considered normal, get at least 30 minutes of exercise every day. If you are overweight or obese, experts say you should get 60 – 90 minutes of exercise every day.
• Keep your blood pressure below 130/80 mmHg if you have diabetes or chronic kidney disease, and below 140/90 otherwise
• Keep your cholesterol and blood sugar under control.

Moderate amounts of alcohol (one glass a day for women, two for men) may reduce your risk of cardiovascular problems. However, drinking larger amounts does more harm than good.

If you have one or more risk factors for coronary heart disease, talk to your doctor about possibly taking an aspirin a day to help prevent a heart attack or stroke. You may be prescribed low-dose aspirin therapy if the benefit is likely to outweigh the risk of gastrointestinal side effects.

New guidelines no longer recommend hormone replacement therapy, vitamins E or C, antioxidants, or folic acid to prevent heart disease. The use of hormone replacement therapy in women who are close to menopause or who have finished menopause is controversial at this time.

**

This article is for your information only.  Always consult your physician prior to making any changes in your diet, exercise or medical program.

Ref//
Mosca L, Banka CL, Benjamin EJ, et al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update. Circulation. 2007; Published online before print February 19, 2007.

Smith SC Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006 May 16;113(19):2363-72. Erratum in: Circulation. 2006 Jun 6;113(22):e847.

Morrow DA, Gersh BJ. Chronic coronary artery disease. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: Saunders Elsevier;2007: chap 54.

Boden WE, O’rourke RA, Teo KK, et al. Optimal Medical Therapy with or without PCI for Stable Coronary Disease. N Engl J Med. 2007 Mar 26; [Epub ahead of print].

U.S. Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement.Ann Intern Med. 2009;150:396-404.

Update Date: 4/23/2009

Coronary artery disease

Coronary artery disease (CAD), also called coronary heart disease, is a condition in which plaque (plak) builds up inside the coronary arteries. These arteries supply your heart muscle with oxygen-rich blood.
Plaque is made up of fat, cholesterol (ko-LES-ter-ol), calcium, and other substances found in the blood. When plaque builds up in the arteries, the condition is called atherosclerosis (ATH-er-o-skler-O-sis).

Plaque narrows the arteries and reduces blood flow to your heart muscle. It also makes it more likely that blood clots will form in your arteries. Blood clots can partially or completely block blood flow.

Causes
Research suggests that coronary artery disease (CAD) starts when certain factors damage the inner layers of the coronary arteries. These factors include:

• Smoking
• High amounts of certain fats and cholesterol in the blood
• High blood pressure
• High amounts of sugar in the blood due to insulin resistance or diabetes

When damage occurs, your body starts a healing process. Excess fatty tissues release compounds that promote this process. This healing causes plaque to build up where the arteries are damaged. 
The buildup of plaque in the coronary arteries may start in childhood. Over time, plaque can narrow or completely block some of your coronary arteries. This reduces the flow of oxygen-rich blood to your heart muscle. 
Plaque also can crack, which causes blood cells called platelets (PLATE-lets) to clump together and form blood clots at the site of the cracks. This narrows the arteries more and worsens angina or causes a heart attack.

Who Is At Risk for Coronary Artery Disease?

Coronary artery disease (CAD) is the leading cause of death in the United States for both men and women. Each year, more than half a million Americans die from CAD.
Certain traits, conditions, or habits may raise your chance of developing CAD. These conditions are known as risk factors. 
You can control most risk factors and help prevent or delay CAD. Other risk factors can’t be controlled.

Major Risk Factors

Many factors raise the risk of developing CAD. The more risk factors you have, the greater chance you have of developing CAD.

• Unhealthy blood cholesterol levels. This includes high LDL cholesterol (sometimes called bad cholesterol) and low HDL cholesterol (sometimes called good cholesterol).
• High blood pressure. Blood pressure is considered high if it stays at or above 140/90 mmHg over a period of time.
• Smoking. This can damage and tighten blood vessels, raise cholesterol levels, and raise blood pressure. Smoking also doesn’t allow enough oxygen to reach the body’s tissues.
• Insulin resistance. This condition occurs when the body can’t use its own insulin properly. Insulin is a hormone that helps move blood sugar into cells where it’s used.
• Diabetes. This is a disease in which the body’s blood sugar level is high because the body doesn’t make enough insulin or doesn’t use its insulin properly.
• Overweight or obesity. Overweight is having extra body weight from muscle, bone, fat, and/or water. Obesity is having a high amount of extra body fat.
• Metabolic syndrome. Metabolic syndrome is the name for a group of risk factors linked to overweight and obesity that raise your chance for heart disease and other health problems, such as diabetes and stroke.
• Lack of physical activity. Lack of activity can worsen other risk factors for CAD.
• Age. As you get older, your risk for CAD increases. Genetic or lifestyle factors cause plaque to build in your arteries as you age. By the time you’re middle-aged or older, enough plaque has built up to cause signs or symptoms.
• • In men, the risk for CAD increases after age 45.
  • In women, the risk for CAD risk increases after age 55.
• Family history of early heart disease. Your risk increases if your father or a brother was diagnosed with CAD before 55 years of age, or if your mother or a sister was diagnosed with CAD before 65 years of age.

Although age and a family history of early heart disease are risk factors, it doesn’t mean that you will develop CAD if you have one or both. 
Making lifestyle changes and/or taking medicines to treat other risk factors can often lessen genetic influences and prevent CAD from developing, even in older adults.

Emerging Risk Factors

Scientists continue to study other possible risk factors for CAD.
High levels of a protein called C-reactive protein (CRP) in the blood may raise the risk for CAD and heart attack. High levels of CRP are proof of inflammation in the body. Inflammation is the body’s response to injury or infection. Damage to the arteries’ inner walls seems to trigger inflammation and help plaque grow. 
Research is under way to find out whether reducing inflammation and lowering CRP levels also can reduce the risk of developing CAD and having a heart attack.
High levels of fats called triglycerides in the blood also may raise the risk of CAD, particularly in women.

Other Factors That Affect Coronary Artery Disease

Other factors also may contribute to CAD. These include:

• Sleep apnea. Sleep apnea is a disorder in which your breathing stops or gets very shallow while you’re sleeping. Untreated sleep apnea can raise your chances of having high blood pressure, diabetes, and even a heart attack or stroke.
• Stress. Research shows that the most commonly reported “trigger” for a heart attack is an emotionally upsetting event—particularly one involving anger.
• Alcohol. Heavy drinking can damage the heart muscle and worsen other risk factors for heart disease. Men should have no more than two drinks containing alcohol a day. Women should have no more than one drink containing alcohol a day.

What Are the Signs and Symptoms of Coronary Artery Disease?

A common symptom of coronary artery disease (CAD) is angina. Angina is chest pain or discomfort that occurs when your heart muscle doesn’t get enough oxygen-rich blood. 
Angina may feel like pressure or a squeezing pain in your chest. You also may feel it in your shoulders, arms, neck, jaw, or back. This pain tends to get worse with activity and go away when you rest. Emotional stress also can trigger the pain. 
Another common symptom of CAD is shortness of breath. This symptom happens if CAD causes heart failure. When you have heart failure, your heart can’t pump enough blood throughout your body. Fluid builds up in your lungs, making it hard to breathe. 
The severity of these symptoms varies. The symptoms may get more severe as the buildup of plaque continues to narrow the coronary arteries.

Signs and Symptoms of Heart Problems Linked to Coronary Artery Disease

Some people who have CAD have no signs or symptoms. This is called silent CAD. It may not be diagnosed until a person show signs and symptoms of a heart attack, heart failure, or an arrhythmia (an irregular heartbeat). 

Heart Attack

A heart attack happens when an area of plaque in a coronary artery breaks apart, causing a blood clot to form. 
The blood clot cuts off most or all blood to the part of the heart muscle that’s fed by that artery. Cells in the heart muscle die because they don’t receive enough oxygen-rich blood. This can cause lasting damage to your heart.
The most common symptom of heart attack is chest pain or discomfort. Most heart attacks involve discomfort in the center of the chest that lasts for more than a few minutes or goes away and comes back. The discomfort can feel like pressure, squeezing, fullness, or pain. It can be mild or severe. Heart attack pain can sometimes feel like indigestion or heartburn. 

Heart attacks also can cause upper body discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath or fatigue (tiredness) often may occur with or before chest discomfort. Other symptoms of heart attack are nausea (feeling sick to your stomach), vomiting, lightheadedness or fainting, and breaking out in a cold sweat.

Heart Failure

Heart failure is a condition in which your heart can’t pump enough blood to your body. Heart failure doesn’t mean that your heart has stopped or is about to stop working. It means that your heart can’t fill with enough blood or pump with enough force, or both. 
This causes you to have shortness of breath and fatigue that tends to increase with activity. Heart failure also can cause swelling in your feet, ankles, legs, and abdomen.

Arrhythmia

An arrhythmia is a problem with the speed or rhythm of the heartbeat. When you have an arrhythmia, you may notice that your heart is skipping beats or beating too fast. Some people describe arrhythmias as a fluttering feeling in their chests. These feelings are called palpitations. 
Some arrhythmias can cause your heart to suddenly stop beating. This condition is called sudden cardiac arrest (SCA).  SCA can make you faint and it can cause death if it’s not treated right away. 

How Is Coronary Artery Disease Diagnosed?

Your doctor will diagnose coronary artery disease (CAD) based on:

• Your medical and family histories
• Your risk factors
• The results of a physical exam and diagnostic tests and procedures

Diagnostic Tests and Procedures

No single test can diagnose CAD. If your doctor thinks you have CAD, he or she will probably do one or more of the following tests.

EKG (Electrocardiogram)

An EKG is a simple test that detects and records the electrical activity of your heart. An EKG shows how fast your heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of your heart. 
Certain electrical patterns that the EKG detects can suggest whether CAD is likely. An EKG also can show signs of a previous or current heart attack.

Stress Testing

During stress testing, you exercise to make your heart work hard and beat fast while heart tests are performed. If you can’t exercise, you’re given medicine to speed up your heart rate. 
When your heart is beating fast and working hard, it needs more blood and oxygen. Arteries narrowed by plaque can’t supply enough oxygen-rich blood to meet your heart’s needs. A stress test can show possible signs of CAD, such as:

• Abnormal changes in your heart rate or blood pressure
• Symptoms such as shortness of breath or chest pain
• Abnormal changes in your heart rhythm or your heart’s electrical activity

During the stress test, if you can’t exercise for as long as what’s considered normal for someone your age, it may be a sign that not enough blood is flowing to your heart. But other factors besides CAD can prevent you from exercising long enough (for example, lung diseases, anemia, or poor general fitness). 
Some stress tests use a radioactive dye, sound waves, positron emission tomography (PET), or cardiac magnetic resonance imaging (MRI) to take pictures of your heart when it’s working hard and when it’s at rest. 
These imaging stress tests can show how well blood is flowing in the different parts of your heart. They also can show how well your heart pumps blood when it beats.

Echocardiography

This test uses sound waves to create a moving picture of your heart. Echocardiography provides information about the size and shape of your heart and how well your heart chambers and valves are working. 
The test also can identify areas of poor blood flow to the heart, areas of heart muscle that aren’t contracting normally, and previous injury to the heart muscle caused by poor blood flow.

Chest X Ray

A chest x ray takes a picture of the organs and structures inside the chest, including your heart, lungs, and blood vessels. 
A chest x ray can reveal signs of heart failure, as well as lung disorders and other causes of symptoms that aren’t due to CAD.

Blood Tests

Blood tests check the levels of certain fats, cholesterol, sugar, and proteins in your blood. Abnormal levels may show that you have risk factors for CAD.

Electron-Beam Computed Tomography

Your doctor may recommend electron-beam computed tomography (EBCT). This test finds and measures calcium deposits (called calcifications) in and around the coronary arteries. The more calcium detected, the more likely you are to have CAD. 
EBCT isn’t used routinely to diagnose CAD, because its accuracy isn’t yet known.

Coronary Angiography and Cardiac Catheterization

Your doctor may ask you to have coronary angiography (an-jee-OG-ra-fee) if other tests or factors show that you’re likely to have CAD. This test uses dye and special x rays to show the insides of your coronary arteries. 

To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization (KATH-e-ter-i-ZA-shun). A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. The tube is then threaded into your coronary arteries, and the dye is released into your bloodstream. Special x rays are taken while the dye is flowing through your coronary arteries.

Cardiac catheterization is usually done in a hospital. You’re awake during the procedure. It usually causes little to no pain, although you may feel some soreness in the blood vessel where your doctor put the catheter.

How Is Coronary Artery Disease Treated?

Treatment for coronary artery disease (CAD) may include lifestyle changes, medicines, and medical procedures. The goals of treatments are to:

• Relieve symptoms
• Reduce risk factors in an effort to slow, stop, or reverse the buildup of plaque
• Lower the risk of blood clots forming, which can cause a heart attack
• Widen or bypass clogged arteries
• Prevent complications of CAD

Lifestyle Changes

Making lifestyle changes can often help prevent or treat CAD. For some people, these changes may be the only treatment needed:

• Follow a heart healthy eating plan to prevent or reduce high blood pressure and high blood cholesterol and to maintain a healthy weight
• Increase your physical activity. Check with your doctor first to find out how much and what kinds of activity are safe for you.
• Lose weight, if you’re overweight or obese.
• Quit smoking, if you smoke. Avoid exposure to secondhand smoke.
• Learn to cope with and reduce stress.

Follow a Heart Healthy Eating Plan

Recommend healthy eating, physical activity, and controlling your weight. 
Therapeutic Lifestyle Changes (TLC). Your doctor may recommend TLC if you have high cholesterol. TLC is a three-part program that includes a healthy diet, physical activity, and weight management. 
With the TLC diet, less than 7 percent of your daily calories should come from saturated fat. This kind of fat is mainly found in meat and poultry, including dairy products. No more than 25 to 35 percent of your daily calories should come from all fats, including saturated, trans, monounsaturated, and polyunsaturated fats. 
You also should have less than 200 mg a day of cholesterol. The amounts of cholesterol and the different kinds of fat in prepared foods can be found on the Nutrition Facts label.
Foods high in soluble fiber also are part of a healthy eating plan. They help block the digestive track from absorbing cholesterol. These foods include:

• Whole grain cereals such as oatmeal and oat bran
• Fruits such as apples, bananas, oranges, pears, and prunes
• Legumes such as kidney beans, lentils, chick peas, black-eyed peas, and lima beans

A diet high in fruits and vegetables can increase important cholesterol-lowering compounds in your diet. These compounds, called plant stanols or sterols, work like soluble fiber. 
Fish are an important part of a heart healthy diet. They’re a good source of omega-3 fatty acids, which may help protect the heart from blood clots and inflammation and reduce the risk for heart attack. Try to have about two fish meals every week. Fish high in omega-3 fats are salmon, tuna (canned or fresh), and mackerel.
You also should try to limit the amount of sodium (salt) that you eat. This means choosing low-sodium and low-salt foods and “no added salt” foods and seasonings at the table or when cooking. The Nutrition Facts label on food packaging shows the amount of sodium in the item.
Try to limit alcoholic drinks. Too much alcohol will raise your blood pressure and triglyceride level. (Triglycerides are a type of fat found in the blood.) Alcohol also adds extra calories, which will cause weight gain. Men should have no more than two alcoholic drinks a day. Women should have no more than one alcoholic drink a day.
Dietary Approaches to Stop Hypertension (DASH) eating plan. Your doctor may recommend the DASH eating plan if you have high blood pressure. The DASH eating plan focuses on fruits, vegetables, whole grains, and other foods that are heart healthy and lower in salt/sodium. 
This eating plan is low in fat and cholesterol. It also focuses on fat-free or low-fat milk and dairy products, fish, poultry, and nuts. The DASH eating plan is reduced in red meat (including lean red meat), sweets, added sugars, and sugar-containing beverages. It’s rich in nutrients, protein, and fiber.
The DASH eating plan is a good heart healthy eating plan, even for those who don’t have high blood pressure.

Increase Physical Activity

Regular physical activity can lower many CAD risk factors, including LDL (“bad”) cholesterol, high blood pressure, and excess weight. Physical activity also can lower your risk for diabetes and raise your levels of HDL cholesterol (the “good” cholesterol that helps prevent CAD).
Check with your doctor about how much and what kinds of physical activity are safe for you. Unless your doctor tells you otherwise, try to get at least 30 minutes of moderate-intensity activity on most or all days of the week. You can do the activity all at once or break it up into shorter periods of at least 10 minutes each. 
Moderate-intensity activities include brisk walking, dancing, bowling, bicycling, gardening, and housecleaning. 
More intense activities, such as jogging, swimming, and various sports, also may be appropriate for shorter periods.

Maintain a Healthy Weight

Maintaining a healthy weight can decrease risk factors for CAD. If you’re overweight, aim to reduce your weight by 7 to 10 percent during your first year of treatment. This amount of weight loss can lower your risk for CAD and other health problems.
After the first year, you may have to continue to lose weight so you can lower your body mass index (BMI) to less than 25. 
BMI measures your weight in relation to your height and gives an estimate of your total body fat. A BMI between 25 and 29 is considered overweight. A BMI of 30 or more is considered obese. A BMI of less than 25 is the goal for preventing and treating CAD.

Quit Smoking

If you smoke or use tobacco, quit. Smoking can damage and tighten blood vessels and raise your risk for CAD. 
You also should avoid exposure to secondhand smoke.

Reduce Stress

Research shows that the most commonly reported “trigger” for a heart attack is an emotionally upsetting event—particularly one involving anger. Also, some of the ways people cope with stress, such as drinking, smoking, or overeating, aren’t heart healthy. 
Physical activity can help relieve stress and reduce other CAD risk factors. Many people also find that meditation or relaxation therapy helps them reduce stress.

Medicines

You may need medicines to treat CAD if lifestyle changes aren’t enough. Medicines can:

• Decrease the workload on your heart and relieve CAD symptoms
• Decrease your chance of having a heart attack or dying suddenly
• Lower your cholesterol and blood pressure
• Prevent blood clots
• Prevent or delay the need for a special procedure (for example, angioplasty or coronary artery bypass grafting (CABG))

Medicines used to treat CAD include anticoagulants (AN-te-ko-AG-u-lants), aspirin and other antiplatelet (an-ty-PLAYT-lit) medicines, ACE inhibitors, beta blockers, calcium channel blockers, nitroglycerin, glycoprotein IIb-IIIa, statins, and fish oil and other supplements high in omega-3 fatty acids.

Medical Procedures

You may need a medical procedure to treat CAD. Both angioplasty and CABG are used as treatments.
Angioplasty opens blocked or narrowed coronary arteries. During angioplasty, a thin tube with a balloon or other device on the end is threaded through a blood vessel to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque outward against the wall of the artery. This widens the artery and restores the flow of blood. 

Angioplasty can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. Sometimes a small mesh tube called a stent is placed in the artery to keep it open after the procedure. 

In CABG, arteries or veins from other areas in your body are used to bypass (that is, go around) your narrowed coronary arteries. CABG can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. 
You and your doctor can discuss which treatment is right for you.

Cardiac Rehabilitation

Your doctor may prescribe cardiac rehabilitation (rehab) for angina or after CABG, angioplasty, or a heart attack. Cardiac rehab, when combined with medicine and surgical treatments, can help you recover faster, feel better, and develop a healthier lifestyle. Almost everyone with CAD can benefit from cardiac rehab.
The cardiac rehab team may include doctors, nurses, exercise specialists, physical and occupational therapists, dietitians, and psychologists or other behavioral therapists.
Rehab has two parts:

• Exercise training. This part helps you learn how to exercise safely, strengthen your muscles, and improve your stamina. Your exercise plan will be based on your individual abilities, needs, and interests.
• Education, counseling, and training. This part of rehab helps you understand your heart condition and find ways to reduce your risk for future heart problems. The cardiac rehab team will help you learn how to cope with the stress of adjusting to a new lifestyle and with your fears about the future.

How Can Coronary Artery Disease Be Prevented or Delayed?

Taking action to control your risk factors can help prevent or delay coronary artery disease (CAD). Your chance of developing CAD goes up with the number of risk factors you have.
Know your family history of health problems related to CAD. If you or someone in your family has CAD, be sure to tell your doctor. Also, let your doctor know if you smoke.

Living With Coronary Artery Disease

Coronary artery disease (CAD) can cause serious complications. However, if you follow your doctor’s advice and change your habits, you can prevent or reduce the chances of:

• Dying suddenly from heart problems
• Having a heart attack and permanently damaging your heart muscle
• Damaging your heart because of reduced oxygen supply
• Having arrhythmias (irregular heartbeats)

Ongoing Health Care Needs

Doing physical activity regularly, taking prescribed medicines, following a heart healthy eating plan, and watching your weight can help control CAD. 
See your doctor regularly to keep track of your blood pressure and blood cholesterol and blood sugar levels. A cholesterol blood test will show your levels of LDL (“bad”) cholesterol, HDL (“good”) cholesterol, and triglycerides. A fasting blood glucose test will check your blood sugar level and show if you’re at risk for or have diabetes. These tests will show whether you need more treatments for your CAD. 

Talk to your doctor about how often you should schedule office visits or blood tests. Between those visits, call your doctor if you develop any new symptoms or if your symptoms worsen.
CAD raises your risk for heart attack.  Learn the symptoms of heart attack and arrhythmia.  Call 9–1–1 if you have any of these symptoms for more than 5 minutes:

• Chest discomfort or pain—uncomfortable pressure, squeezing, fullness, or pain in the center of the chest that can be mild or strong. This discomfort or pain lasts more than a few minutes or goes away and comes back.
• Upper body discomfort in one or both arms, the back, neck, jaw, or stomach.
• Shortness of breath, which may occur with or before chest discomfort.

It’s important to know the difference between angina and a heart attack. During a heart attack, the pain is usually more severe than angina, and it doesn’t go away when you rest or take medicine. If you don’t know whether your chest pain is angina or a heart attack, call 9–1–1.
Let the people you see regularly know you’re at risk for a heart attack. They can seek emergency care if you suddenly faint, collapse, or develop other severe symptoms.
You may feel depressed or anxious if you’ve been diagnosed with CAD and/or had a heart attack. You may worry about heart problems or making lifestyle changes that are necessary for your health. Your doctor may recommend medicine, professional counseling, or relaxation therapy if you have depression or anxiety. 
Physical activity can improve mental well-being, but you should talk to your doctor before starting any fitness activities. It’s important to treat any anxiety or depression that develops because it raises your risk of having a heart attack

Key Points

• Coronary artery disease (CAD), also called coronary heart disease, is a condition in which plaque builds up inside the coronary arteries. These arteries supply your heart muscle with oxygen-rich blood.
• Plaque narrows the coronary arteries and reduces blood flow to your heart muscle. It also makes it more likely that blood clots will form in your arteries. Blood clots can partially or completely block blood flow.
• CAD can lead to angina, heart attack, heart failure, and arrhythmias (irregular heartbeats).
• CAD is the most common type of heart disease. It’s the leading cause of death in the United States for both men and women.
• Research suggests that CAD starts when certain factors damage the inner layers of the coronary arteries. When damage occurs, your body starts a healing process. This healing causes plaque to build up where the artery is damaged. Over time, the plaque may crack and causes blood clots to form in the arteries. This can worsen angina or cause a heart attack.
• Many factors raise the risk of developing CAD.  Major risk factors include unhealthy blood cholesterol levels, high blood pressure, smoking, insulin resistance, diabetes, overweight or obesity, metabolic syndrome, lack of physical activity, age, and a family history of early heart disease.
• Common symptoms of CAD are angina and shortness of breath. However, some people have no signs or symptoms. This is called silent CAD. It may not be diagnosed until a person shows signs and symptoms of a heart attack, heart failure, or an arrhythmia.
• Your doctor will diagnose CAD based on your medical and family histories, your risk factors, and the results of diagnostic tests.
• Treatment for CAD may include lifestyle changes, medicines, and medical procedures. Lifestyle changes include following a heart healthy eating plan, increasing physical activity, maintaining a healthy weight, quitting smoking, and reducing stress.
• Taking action to control your risk factors can help prevent or delay CAD. You can take action by making lifestyle changes and/or taking medicines as prescribed by your doctor.
• If you’ve been diagnosed with CAD, you can control the disease with lifestyle changes and medicines. See your doctor regularly, and call him or her if you develop any new symptoms or your symptoms become more severe.

 ** Remember this article is for your information only. Dr. Ben-Zur recommends consulting your physician prior to making any changes in your diet, exercise or medical program.

© 2009 nhlbi.nih.gov/health/dci

Coronary Artery Disease

Coronary artery disease, also called coronary heart disease, or simply, heart disease, is the No. 1 killer in America, affecting more than 13 million Americans.
What Is Coronary Artery Disease?
Coronary artery disease is atherosclerosis of the coronary arteries, producing blockages in the vessels which nourish the heart itself. Atherosclerosis occurs when the arteries become clogged and narrowed, restricting blood flow. Without adequate blood flow from the coronary arteries, the heart becomes starved of oxygen and vital nutrients it needs to work properly.

How Does Coronary Artery Disease Develop?
Your coronary arteries are blood vessels on the heart. They are smooth and elastic, allowing blood to flow freely.
Before your teen years, fat can start to deposit in the blood vessel walls. As you get older, the fat builds up. This causes injury to your blood vessel walls. In an attempt to heal itself, the fatty tissues release chemicals that promote the process of healing but make the inner walls of the blood vessel sticky.

Then, other substances, such as inflammatory cells, proteins, and calcium that travel in your bloodstream start sticking to the inside of the vessel walls. The fat and other substances combine to form a material called plaque, which can narrow the flow of blood in the artery (atherosclerosis). 

Some plaque deposits are hard on the outside and soft and mushy on the inside. Some plaque is fragile, cracking or tearing, exposing the soft, fatty inside. When this happens, platelets (disc-shaped particles in the blood that aid clotting) come to the area, and blood clots accumulate on the injured vessel wall. This causes the artery to narrow even more. Sometimes, the blood clot breaks apart by itself, and blood supply is restored. 
Over time, the inside of the arteries develop plaques of different sizes. 

Eventually, a narrowed coronary artery may develop new blood vessels that go around the blockage to get blood to the heart. However, during times of increased exertion or stress, the new arteries may not be able to supply enough oxygen-rich blood to the heart muscle. 
In other cases, the blood clot may totally block the blood supply to the heart muscle, causing what is called an acute coronary syndrome. This is actually a name given to three serious conditions:

• Unstable angina: chest pain that can often be relieved with oral medications, is unstable, and may progress to a heart attack. Usually more intense medical treatment or a procedure is required to treat this acute coronary syndrome.
• Non-ST segment elevation myocardial infarction (NSTEMI) or “non-Q-wave MI”: This heart attack, or MI, does not cause typical changes on an electrocardiogram (ECG). However, chemical markers in the blood indicate that damage has occurred to the heart muscle.
• ST segment elevation myocardial infarction (STEMI) or “Q-wave MI”: This heart attack, or MI, is caused by a prolonged period of blocked blood supply. It affects a large area of the heart muscle, and causes changes on the ECG as well as chemical markers in the blood.

Some people have symptoms that tell them that they may soon develop an acute coronary syndrome, others may have no symptoms until something happens, and still others have no symptoms of the acute coronary syndrome at all.

What Is Ischemia?
When plaque and fatty matter narrow the inside of an artery to a point where it cannot supply enough oxygen-rich blood to meet your organ’s needs, cramping of the muscle occurs. This is called ischemia.
Ischemia of the heart can be compared to a cramp in the leg. When someone exercises for a very long time, the muscles in the legs cramp up because they’re starved for oxygen and nutrients. Your heart, also a muscle, needs oxygen and nutrients to keep working. If its blood supply is inadequate to meet the heart muscle’s needs, ischemia occurs, and you may feel chest pain or other symptoms.
Ischemia is most likely to occur when the heart demands extra oxygen. This is most common during:

• Exertion (activity)
• Eating
• Excitement or stress
• Exposure to cold

Coronary artery disease can progress to a point where ischemia occurs even at rest.
When ischemia is relieved in a short period of time (less than 10 minutes) with rest or medications, you may be told you have “stable coronary artery disease” or “stable angina.”
What Are the Symptoms of Coronary Artery Disease?
The most common symptom is of coronary artery disease is angina, called or angina pectoris, or simply chest pain. Angina can be described as a discomfort, heaviness, pressure, aching, burning, numbness, fullness, squeezing or painful feeling. It can be mistaken for indigestion or heartburn. Angina is usually felt in the chest, but may also be felt in the left shoulder, arms, neck, back, or jaw.
Other symptoms that can occur with coronary artery disease include:

• Shortness of breath
• Palpitations (irregular heart beats, skipped beats, or a “flip-flop” feeling in your chest)
• A faster heartbeat
• Weakness or dizziness
• Nausea
• Sweating

Learn to recognize your heart disease symptoms and the situations that cause them. Call your doctor if you begin to have new symptoms or if they become more frequent or severe. If you or someone you are with experience chest discomfort, especially with one or more of the symptoms listed above, don’t wait longer than a few minutes (no more than 5) before calling 9-1-1 to get help.
If you have angina and have been prescribed nitroglycerin, call your doctor or have someone take you to the nearest emergency room if pain persists after taking two doses (taken at five-minute intervals) or after 15 minutes.
Emergency personnel may tell you to chew an aspirin to help break up a possible blood clot, if there is not a medical reason for you to avoid aspirin.
Ischemia, and even a heart attack, can occur without any warning symptoms. This is called silent ischemia. It can occur among all people with heart disease, though it is more common among people with diabetes.
How Is Coronary Artery Disease Diagnosed?
Your doctor can tell if you have coronary artery disease by:

• Talking to you about your symptoms, medical history, and risk factors.
• Performing a physical exam.
• Performing diagnostic tests, including an electrocardiogram (ECG or EKG), exercise stress tests, electron beam (ultrafast) CT scans, cardiac catheterization, and others. These tests help your doctor evaluate the extent of your coronary heart disease, its effect on the function of your heart and the best form of treatment for you.

How Is Coronary Artery Disease Treated?
Treatment for coronary artery disease involves reducing your risk factors, taking medications, possibly undergoing invasive and/or surgical procedures, and seeing your doctor for regular health care follow up visits.

• Reduce your risk factors. This involves making lifestyle changes. If you smoke, you should quit. Your diet will likely need modifying to reduce your cholesterol, keep your blood pressure in check, and keep blood sugar in control if you have diabetes. Low fat, low salt, and low cholesterol foods are recommended. You should also get more exercise to help maintain a healthy weight and . But, check with your doctor before starting an exercise program.
• Medications. If making lifestyle changes isn’t enough to control your heart disease, medications may be needed to help your heart work more efficiently and receive more oxygen-rich blood. The drugs you are on depend on you and your specific heart problem.
• Surgery and other procedures. Common procedures to treat coronary artery disease include balloon angioplasty (PTCA), stent placement, and coronary artery bypass surgery. All of these procedures increase blood supply to your heart, but they do not cure coronary heart disease. You will still need to decrease your risk factors to prevent future disease.

Doctors are also studying several innovative ways to treat heart disease. Here are a couple of the more promising ones:

• Angiogenesis. This involves giving substances through the vein or directly into the heart that trigger the heart to grow new blood vessels to bypass the clogged ones.
• EECP. There are an increasing number of patients who have persistent, frequent, and severe chest pain, who have exhausted the standard treatments without successful results. Enhanced External Counterpulsation (EECP) may stimulate the openings or formation of collaterals (small branches of blood vessels) to create a natural bypass around narrowed or blocked arteries. EECP is a non-invasive treatment for people who have chronic, stable angina; who are not receiving adequate relief from angina by taking nitrate medications; and who do not qualify for an invasive procedure such as bypass surgery, angioplasty, or stenting.

This article is for your information only.  Always consult your physician prior to making any changes in your diet, exercise or medical program.

Coronary artery disease

Coronary artery disease (CAD), also called heart disease, is a condition in which fatty plaque deposits build up in the hearts arteries. These plaque deposits cause arteries to become narrow and blocked, which restricts blood and oxygen flow to the heart muscle. CAD is the leading cause of death, for both men and women, in the United States.

Risk Factors 
Some of the main risk factors that increase the risk for CAD are:

• Smoking
• Unhealthy cholesterol and lipid levels
• High blood pressure
• Diabetes
• Lack of exercise
• Obesity

Symptoms 
Angina is the primary symptom of coronary artery disease. Angina feels like gripping pain or pressure in the chest area.

• Stable angina is predictable chest pain that lasts a few minutes or less and is usually relieved by rest or medication. It is oftentimes triggered by physical exertion or emotional stress.
• Unstable angina is unpredictable chest pain that occurs unexpectedly, even when at rest. It is a more serious condition than stable angina and can be a warning sign of a heart attack.

Some patients with CAD have few or no symptoms. Sometimes a heart attack may be the first sign that a person has CAD

Risk Factors
Heart disease is the leading cause of death in the United States. Over the past decades, heart disease rates declined in both men and women as they quit smoking and improved dietary habits. This rate, however, has stabilized in recent years, most likely because of the dramatic increase in obesity in the U.S. and other industrialized nations.

Age
The risks for coronary artery disease increase with age. About 85% of people who die from heart disease are over the age of 65.

Gender
Men have a greater risk for coronary artery disease and are more likely to have heart attacks earlier in life than women. Womens risk for heart disease increases after menopause, and they are more likely to have angina than men.

Genetic Factors and Family History
Certain genetic factors increase the likelihood of developing important risk factors, such as diabetes and high blood pressure. For example, one genetic variant called apolipoprotein E4 (ApoE4) affects cholesterol levels, particularly those associated with heart disease.
Heart disease tends to run in families. People whose parents or siblings developed heart disease at a younger age are more likely to develop it themselves.

Race and Ethnicity
African-Americans have the highest risk of heart disease, in part due to their high rates of severe high blood pressure, as well as diabetes and obesity.

Lifestyle Factors
Smoking. Smoking is the most important risk factor for heart disease. Smoking can cause elevated blood pressure, worsen lipids, and make platelets very sticky, raising the risk of clots. Cigarette smoking may be directly responsible for at least 20% of all deaths from heart disease. Although heavy cigarette smokers are at greatest risk, people who smoke as few as three cigarettes a day are at higher risk for blood vessel abnormalities that endanger the heart. Regular exposure to passive smoke also increases the risk of heart disease in nonsmokers. 

Alcohol. Moderate alcohol consumption (one or two drinks a day; 5 ounces wine, 12 ounces beer, or 1.5 ounces hard liquor is one drink) can help boost HDL good cholesterol levels. Alcohol may also prevent blood clots and inflammation. By contrast, heavy drinking harms the heart. In fact, heart disease is the leading cause of death in alcoholics.

Diet. Diet plays an important role in the health of the heart, especially in controlling dietary sources of cholesterol and restricting salt intake that contributes to high blood pressure. 

Physical Inactivity. Exercise has a number of effects that benefit the heart and circulation, including improving cholesterol and lipid levels and maintaining weight control. People who are sedentary are almost twice as likely to suffer heart attacks as are people who exercise regularly.

Medical Conditions
Obesity and Metabolic Syndrome. Excess body fat, especially around the waist, can increase the risk for heart disease. Obesity also increases the risk for other conditions (high blood pressure, diabetes) that are associated with heart disease. Obesity is particularly hazardous when it is part of the metabolic syndrome, a pre-diabetic condition that is significantly associated with heart disease. This syndrome is diagnosed when three of the following are present:

• Abdominal obesity (fat around the waist)
• Low HDL (“good”) cholesterol
• High triglyceride levels
• High blood pressure
• Insulin resistance

Unhealthy Cholesterol and Lipid Levels. Low-density lipoprotein (LDL) cholesterol is the “bad” cholesterol responsible for many heart problems. Triglycerides are another type of lipid (fat molecule) that can be bad for the heart. High-density lipoprotein (HDL) cholesterol is the “good” cholesterol that helps protect against heart disease. Doctors test for a “total cholesterol” profile that includes measurements for LDL, HDL, and triglycerides. The ratio of these lipids can affect heart disease risk. 

High Blood Pressure. High blood pressure, or hypertension, has long been a proven cause of coronary artery disease. A normal blood pressure reading is 120/80 mm Hg or lower. High blood pressure is generally considered to be a blood pressure reading greater than or equal to 140 mm Hg (systolic) or greater than or equal to 90 mm Hg (diastolic). Blood pressure readings in the prehypertension category (120 – 139 systolic or 80 – 89 diastolic) indicate an increased risk for developing hypertension. 

Diabetes. Diabetes, especially for people whose blood sugar levels are not well controlled, significantly increases the risk of developing heart disease. In fact, heart disease and stroke are the leading causes of death in people with diabetes. People with diabetes are also at risk for high blood pressure and unhealthy cholesterol levels, blood clotting problems, and impaired nerve function, all of which can damage the heart.

Peripheral Artery Disease. Peripheral artery disease (PAD) occurs when atherosclerosis affects the extremities, particularly the feet and legs. The major risk factors for heart disease and stroke are also the most important risk factors for PAD. (The combination of such conditions with PAD also produces more severe forms of heart or circulatory disease.) Even though signs of heart disease are often not evident in the majority of patients with PAD, most of these patients also have coronary artery disease present. 

Depression. Although people with heart disease may become depressed, this does not explain entirely the link between the two problems. Data suggest that depression itself may be a risk factor for heart disease as well as its increased severity. A number of studies indicate that depression has biologic effects on the heart, including blood clotting and heart rate

Risk Factors with Unclear Roles
Homocysteine and Vitamin B Deficiencies. Deficiencies in the B vitamins folate (known also as folic acid), B6, and B12 have been associated with a higher risk for heart disease in some studies. Such deficiencies produce higher blood levels of homocysteine, an amino acid that has been associated with a higher risk for heart disease, stroke, and heart failure.

However, while B vitamin supplements do help lower homocysteine levels, they appear to have no effect on heart disease outcomes, including preventing heart attack or stroke. Research indicates that homocysteine may be a marker for heart disease rather than a cause of it.
C-Reactive Protein. C-reactive protein (CRP) is a product of the inflammatory process. Evidence increasingly suggests that high levels may predict future heart disease. It is not known if the protein plays any causal role or whether it is simply a marker for other factors in the disease process.

C. pneumoniae and Other Infectious Organisms. Some microorganisms and viruses have been under suspicion for triggering the inflammation and damage in the arteries that contribute to heart disease. The strongest evidence to date supports a possible role from Chlamydia (C.) pneumoniae (a non-bacterial organism that causes mild pneumonia in young adults). C. pneumoniae has been detected in plaques in the arteries of patients with heart disease. However, treatment with appropriate antibiotics is not found to reduce the risk of future heart problems for patients infected with this organism.

Other studies also suggest that cytomegalovirus (CMV), a common virus, may have similar effects. Many people, however, have been infected with these organisms, and no clear association has been found with any of these infections.

Sleep Apnea. Obstructive sleep apnea is a condition in which tissues in the upper throat collapse at intervals during sleep, thereby blocking the passage of air. About a third of patients with coronary artery disease also have obstructive sleep apnea. Patients with severe, untreated apnea have been found to have an increased incidence of stroke and cardiac events (such as heart attack). However, there is no evidence to date that identifies obstructive sleep apnea as an independent cause of cardiac events or stroke.

Symptoms
Common symptoms of coronary artery disease (CAD) include angina, shortness of breath (particularly during physical exertion), and rapid heartbeat. Sometimes patients with CAD have few or no symptoms until they have heart attack or heart failure.

Angina
Angina is a symptom, not a disease. It is the primary symptom of coronary artery disease and, in severe cases, of a heart attack. It is typically felt as chest pain and occurs as a consequence of a condition called myocardial ischemia. Ischemia results when the heart muscle does not get as much blood (and, as a result, as much oxygen) as it needs for a given level of work. Angina is usually referred to as one of two states:

• Stable Angina (which is predictable)
• Unstable Angina (which is less predictable and a sign of a more serious situation)

Angina may be experienced in different ways and can be mild, moderate, or severe. The intensity of the pain does not always relate to the severity of the medical problem. Some people may feel a crushing pain from mild ischemia, while others might feel only mild discomfort from severe ischemia.

Stable Angina and Chest Pain
Stable Angina. Stable angina is predictable chest pain. Although less serious than unstable angina, it can be extremely painful or uncomfortable. It is usually relieved by rest and responds well to medical treatment (typically nitroglycerin). Any event that increases oxygen demand can cause an angina attack. Some typical triggers include:

• Exercise
• Cold weather
• Emotional tension
• Large meals

Angina attacks can happen at any time during the day, but most occur between 6 a.m. and noon.
Specific symptoms that are more likely to indicate angina include:

• Angina pain or discomfort is typically described by patients as fullness or tingling, squeezing, pressure, heavy, suffocating, or griplike. It is rarely described as stabbing or burning. Changing one’s position or breathing in and out does not affect the pain.
• A typical angina attack lasts minutes. If it is more fleeting or lasts for hours, it is probably not angina.
• Pain is usually in the chest under the breast bone. It often radiates to the neck, jaw, or left shoulder and arm. Less commonly, patients report symptoms that radiate to the right arm or back, or even to the upper abdomen.
• Stable angina is usually relieved by rest or by taking nitroglycerin under the tongue.

Other symptoms that may indicate angina or accompany the pain or pressure in the chest include:

• Shortness of breath
• Nausea, vomiting, and cold sweats
• A feeling of indigestion or heartburn
• Unexplained fatigue after activity (more common in women)
• Dizziness or lightheadedness
• Palpitations

Unstable Angina and Acute Coronary Syndrome
Unstable angina is a much more serious situation and is often an intermediate stage between stable angina and a heart attack, in which an artery leading to the heart (a coronary artery) becomes completely blocked. A patient is usually diagnosed with unstable angina under one or more of the following conditions:

• Pain awakens a patient or occurs during rest.
• A patient who has never experienced angina has severe or moderate pain during mild exertion (walking two level blocks or climbing one flight of stairs).
• Stable angina has progressed in severity and frequency within a 2-month period, and medications are less effective in relieving its pain.
• Fainting episode.

Unstable angina is usually discussed as part of a condition called acute coronary syndrome (ACS). ACS also includes people with a condition called NSTEMI (non ST-segment elevation myocardial infarction) — also referred to as non-Q wave heart attack. With NSTEMI, blood tests suggest a developing heart attack. These conditions are less severe than heart attacks but may develop into full-blown attacks without aggressive treatment. 

Other Types of Angina
Prinzmetal’s Angina. A third type of angina, called variant or Prinzmetal’s angina, is caused by a spasm of a coronary artery. It almost always occurs when the patient is at rest. Irregular heartbeats are common, but the pain is generally relieved immediately with standard treatment.
Silent Ischemia. Some people with severe coronary artery disease do not have angina pain. This condition is known as silent ischemia, which may occur when the brain abnormally processes heart pain. This is a dangerous condition because patients have no warning signs of heart disease. Some studies suggest that people with silent ischemia have higher complication and mortality rates than those with angina pain. (Angina pain may actually protect the heart by conditioning it before a heart attack.)

Other Causes of Chest Pain or Discomfort
Chest pain is a very common symptom in the emergency room, but heart problems account for only 10 – 33% of all episodes. There are many other causes of chest pain or discomfort including injured muscles, arthritis, heartburn, and asthma.

Diagnosis
Many tests can diagnose possible heart disease. The choice of which (and how many) tests to perform depends on the patient’s risk factors, history of heart problems, and current symptoms. Usually the tests begin with the simplest and may progress to more complicated ones.

Routine Tests to Determine Risk for Heart Disease
Doctors routinely check for high blood pressure and unhealthy cholesterol levels in all older adults. Specific tests are also important in people who may have risk factors or symptoms of diabetes.

Electrocardiograms (ECGs)
An electrocardiogram (ECG) measures and records the electrical activity of the heart. Between 25 – 50% of people who suffer from angina or silent ischemia, however, have normal ECG readings. The waves measured by the ECG correspond to the contraction and relaxation pattern of the different parts of the heart
The most important wave patterns in diagnosing and determining treatment for heart disease and heart attack are called ST elevations and Q waves.

• A depressed or horizontal ST wave suggests some blockage and the presence of a heart disease, even if there is no angina present. (This wave pattern, however, is not very accurate, particularly in women, and can occur without heart problems).
• ST elevations and Q waves are the most important wave patterns in diagnosing and determining treatment for a heart attack. They suggest that an artery to the heart is blocked, and that the full thickness of the heart muscle is damaged. ST segment elevations, however, do not always mean the patient has a heart attack. Other factors are important in making a diagnosis.

Exercise Stress Test
Exercise stress test for evaluation of coronary artery disease may be performed in the following situations:

• Patients with possible or probable angina to help determine the likelihood of coronary artery disease being present
• Patients who were previously stable who began having symptoms
• Follow-up of patients with known heart disease or after coronary bypass surgery or percutaneous procedure
• To determine a patient’s functional capacity (how well the heart can respond when extra demand is needed)
• Patients with certain types of heart rhythm disturbances
• After a heart attack, either before leaving the hospital or soon afterwards

Basic Procedure. A stress test (exercise tolerance test) monitors the patient’s heart rhythms, blood pressure, and clinical status. It can tell how well the heart handles work and if parts of the heart have decreased blood supply. A typical stress test involves:

• The patient walks on a treadmill or rides a stationary bicycle. Exercise continues until the heart is beating at least 85% of its maximum rate, until symptoms of heart trouble occur (changes in blood pressure, heart rhythm abnormalities, angina, fatigue), or the patient simply wants to stop.
• For patients who cannot exercise, the doctor may administer dobutamine or arbutamine, which are drugs that simulate the stress of exercise.

An ECG is used to monitor heart rhythms during a stress test. (An echocardiogram or more advanced imaging technique may also be used to visualize the actions of the heart and blood flow.)

Interpreting Results. To accurately assess heart problems, a variety of factors are measured or monitored using the ECG and other tools during exercise. They include:

• Exercise capacity. This is a measure of a person’s capacity to reach certain metabolic rates.
• ST waves on the ECG. Doctors specifically look for abnormalities in part of the wave tracing called an ST segment. A certain type of ST segment depression may suggest the presence of heart disease. However, gender, drugs, and other medical conditions can affect the ST segment.
• Heart rate. This is how fast the heart rate goes during exercise and how quickly it returns to normal recovery. Based on age and other factors, everyone’s heart rate should go up to a certain level during exercise. If it does not go up to the expected level, the patient is considered at risk for heart problems.
• Changes in systolic blood pressure. Generally, the blood pressure will go up during exercise.
• Oxygen levels may also be measured.

Using these and other measures, doctors can determine risk fairly accurately, particularly for men with chronic stable angina. The test has limitations, however, and some are significant. In patients with suspected unstable angina, normal or low risk results may not be as accurate in predicting future risk of cardiac events. In addition, for many reasons, the test is less accurate in women, and an echocardiogram may be a more accurate procedure for them. About 10% of patients, particularly younger people, will have false positive test results. In such cases, test results indicate abnormalities when there are no heart problems.

Echocardiograms
An echocardiogram is a noninvasive test that uses ultrasound images of the heart. This test is more expensive than an ECG, but it can be very valuable, particularly in identifying whether there is damage to the heart muscle and the extent of heart muscle damage.
A stress echocardiogram may be performed to further evaluate abnormal findings from an exercise treadmill test or a routine echocardiogram. Examples include identifying exactly which part of the heart may be involved and quantifying how much muscle has been infected. It may be the first test done when the exercise treadmill test cannot be performed due to certain abnormal rhythms.

Radionuclide Imaging
Radionuclide procedures use imaging techniques and computer analyses to plot and detect the passage of radioactive tracers through the region of the heart. Such tracing elements are typically given intravenously. Radionuclide imaging is useful for diagnosing and determining:

• Severity of unstable angina when less expensive diagnostic approaches are unavailable or unreliable
• Severity of chronic coronary artery disease
• Success of surgeries for coronary artery disease.
• Whether a heart attack has occurred

Myocardial Perfusion (Blood Flow) Imaging Test (also called the Thallium Stress Test). This radionuclide test is typically used with an exercise stress test to determine blood flow to the heart muscles. It is a reliable measure of severe heart events. It may be useful in determining the need for angiography if CT scans have detected calcification in the arteries. About a minute before the patient is ready to stop exercising, the doctor administers a radioactive tracer into the intravenous line. (Tracers include thallium, technetium, or sestamibi.) Immediately afterwards, the patient lies down for a heart scan. If the scan detects damage, more images are taken 3 or 4 hours later. Damage due to a prior heart attack will persist when the heart scan is repeated. Injury caused by angina, however, will have resolved by that time.

Radionuclide Angiography. This is a technique for visualizing the chambers and major blood vessels of the heart. It uses an injected radioactive tracer and can be performed during exercise, at rest, or with use of stress-inducing drugs. It can help determine the severity of coronary artery disease and is an alternative to echocardiograms in certain situations.

Angiography
Angiography is an invasive test. It is used for patients who show strong evidence for severe obstruction on stress and other tests, and for patients with acute coronary syndrome. It is required when there is a need to know the exact anatomy and disease present within the coronary arteries. A limitation of angiography is that it is not always the most occluded (blocked) blood vessel that causes the next heart attack

Computed Tomography
Computed tomography (CT) scans may be used to evaluate coronary artery disease.
Calcium Scoring CT Scans of the Heart. May be used to detect calcium deposits on the arterial walls. The presence of calcium correlates well with the presence of atherosclerosis of the heart. If the calcium score is very low, a patient is unlikely to have coronary artery disease. A higher calcium score may indicate an increased risk of current and future coronary artery disease. However, the presence of calcium does not necessarily signify narrowing of the arteries that would need further immediate evaluation or treatment.
CT Angiography. CT scans are also used to visualize the coronary arteries. When compared to invasive angiography, CT angiography is not as accurate in identifying who truly has coronary artery disease and who does not. Other types of newer CT techniques include electron beam computed tomography and multidetector computed tomography

Prevention
Heart disease prevention is considered important before and after someone is diagnosed with the condition:

• Primary prevention refers to measures that should be done to reduce the risk of heart disease in everyone.
• Secondary prevention refers to measures to reduce the risk of progression of heart disease in a patient who has already been diagnosed. Many of these measures are similar or the same as those recommended for primary prevention.

Key prevention measures include:

• All patients should stop smoking
• Maintain cholesterol levels at appropriate levels using a heart healthy diet, exercise, and medications
• Maintain an appropriate low blood pressure level
• Maintain an active lifestyle
• Use an antiplatelet drug, such as aspirin, if appropriate (see Medications section of this report)
• Manage diabetes and kidney disease when present

Smoking Cessation
Your doctor should ask about your smoking habits at every visit. Smoking is a chronic condition and often requires repeat therapy using more than one technique.

Cholesterol and Other Lipid Disorders
All patients should start following a heart-healthy diet and exercise regularly, after talking to their doctors. [For more information on diet, see In-Depth Report #43: Heart-healthy diet.]
Statin drugs are the primary medications used for lowering LDL (bad) cholesterol levels. For patients without heart disease, the doctor will start or consider medication, increase dosage of medication, or add new medication when:

• LDL cholesterol is 190 mg/dL or higher.
• LDL cholesterol is 160 mg/dL or higher AND patient has one risk factor for heart disease.
• LDL cholesterol is 130 mg/dL or higher AND patient has either diabetes or two other risk factors for heart disease.
• LDL cholesterol is 100 mg/dL or higher AND patient has diabetes. Even without heart disease, medication may be considered for an LDL cholesterol of 100 mg/dL.

For patients with heart disease, the doctor will start or consider medication, increase dosage of medication, or add new medication when:

• LDL cholesterol is 100 mg/dL or higher
• LDL cholesterol is greater than 70 mg/dL. According to national guidelines, treating a patient with LDL cholesterol levels between 70 – 100 mg/dL is not required but is considered reasonable. This would be true particularly for patients who have had a recent heart attack or have known heart disease along with diabetes, current cigarette smoking, poorly controlled high blood pressure, or metabolic syndrome (high triglycerides, low HDL, and obesity).

Manage High Blood Pressure
Keep Blood Pressure Low. People in normal health should have a blood pressure reading of 120/80 mm Hg or less. Blood pressure readings of 120/80 are considered normal, readings of 140/90 or higher indicate hypertension, and readings in between the two are called pre-hypertension. Patients with diabetes chronic kidney disease, or atherosclerosis should maintain blood pressure readings of 130/80 mm Hg or less, while others should be no higher than 140/90 mm Hg.

Depending on blood pressure levels and presence of either risk factors for heart disease or known coronary artery disease, patients may be recommended to try lifestyle changes first or to immediately begin medications. Several of the medications used to treat coronary artery disease also reduce blood pressure. 

Diabetes
All patients with diabetes should have their blood sugar (glucose) levels well managed. For most patients, a goal would be to bring HbA1c levels down to 7% or below. 

Heart-Healthy Diet
Current American Heart Association (AHA) guidelines recommend:

• Balance calorie intake and physical activity to achieve or maintain a healthy body weight.
• Consume a diet rich in a variety of vegetables and fruits.
• Choose whole-grain, high-fiber foods. These include fruits, vegetables, and legumes (beans). Good whole grain choices include whole wheat, oats/oatmeal, rye, barley, brown rice, buckwheat, bulgur, millet, and quinoa.
• Consume fish, especially oily fish, at least twice a week (about 8 ounces/week). Oily fish such as salmon, mackerel, and sardines are rich in the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Consumption of these fatty acids is linked to reduced risk of sudden death and death from coronary artery disease. People with existing heart disease should consider taking fish oil supplements of 850 – 1,000 mg eicosapentaenoic acid (EPA) and docosahexaenoic acid (DPA).
• Limit daily intake of saturated fat (found mostly in animal products) to less than 7% of total calories, trans fat (found in hydrogenated fats, commercially baked products, and many fast foods) to less than 1% of total calories, and cholesterol (found in eggs, dairy products, meat, poultry, fish, and shellfish) to fewer than 300 mg per day. Choose lean meats and vegetable alternatives (such as soy). Select fat-free and low-fat dairy products. Grill, bake, or broil fish, meat, and skinless poultry.
• Use little or no salt in your foods. Reducing salt can lower blood pressure and decrease the risk of heart disease and heart failure.
• Cut down on beverages and foods that contain added sugars (corn syrups, sucrose, glucose, fructose, maltrose, dextrose, concentrated fruit juice, and honey.)
• If you drink alcohol, do so in moderation. The AHA recommends limiting alcohol to no more than 2 drinks per day for men and 1 drink per day for women.

Weight Reduction
People should aim for a BMI index of 18.5 – 24.9. Weight reduction is recommended for obese patients who have high blood pressure, high cholesterol levels, metabolic syndrome, or diabetes.
Some obese patients with coronary artery disease may consider having bariatric surgery (stomach bypass) to lose excess weight. The weight lost after surgery can help improve blood pressure, cholesterol, blood sugar and other factors associated with CAD.

Exercise and Cardiac Rehabilitation
Everyone in normal health should do at least moderate physical activity for a minimum of 30 – 60 minutes on most, if not all, days of the week
Even low amounts of moderate or high intensity exercise (walking or jogging 12 miles a week) can help produce beneficial changes in cholesterol and lipid levels. However, more prolonged exercise is required to significantly change cholesterol levels, notably by increasing HDL (“good cholesterol”). Resistance (weight) training has also been associated with heart protection.

Sudden strenuous exercise (especially snow shoveling) puts many people at risk for angina and heart attack. Patients with angina should never exercise shortly after eating. People with risk factors for heart disease should seek medical clearance and a detailed exercise prescription. And all people, including healthy individuals, should listen carefully to their bodies for signs of distress as they exercise. 

Influenza Vaccination (Flu Shot)
Patients with CAD are considered at high risk for complications from influenza. People with CAD should get an annual flu shot.

Treatment
Lifestyle changes (such as dieting, exercising, and quitting smoking) are the first approach for all degrees of coronary artery disease. Depending on severity and individual conditions, patients may also need one or more medications, surgery, or both.
Medications. Many types of medications are used to treat angina and CAD. They include:

• Anti-platelet and anticoagulant drugs (used for preventing heart disease and preventing blood clots prior to surgery or after stent insertion)
• Beta blockers
• ACE inhibitors
• Nitrates
• Calcium channel blockers

Surgery. Surgery is usually recommended for people who have:

• Unstable angina that does not respond promptly to medical treatment
• Severe recurrent episodes of angina that last more than 20 minutes
• Acute coronary syndrome
• Severe coronary artery disease (severe angina, multi-artery involvement, evidence of ischemia, or significant narrowing of left main coronary artery), particularly if abnormalities are evident in the left ventricle of the heart, the main pumping chamber

The two main surgical procedures for patients with coronary artery disease are:

• Coronary artery bypass grafting (commonly called bypass or CABG), which is usually reserved for patients with severe coronary artery disease.
• Percutaneous coronary intervention (commonly called angioplasty or PCI), usually with coronary artery stent placement. PCI is less invasive than CABG, but blood vessels can close up again (restenosis) so that patients require additional procedures.

The decision to choose angioplasty or coronary artery bypass depends on a patients individual profile, including the number and types of coronary arteries involved, the health stability, previous procedures, patient choice, and more.
Patients considering surgery should discuss all options and risks with their doctors. No surgical procedure cures coronary artery disease, and patients must continue to rigorously maintain a healthy lifestyle and any necessary medications. For some patients, lifestyle changes and medications may be able to control the disease without surgery or angioplasty.

Medications
Anti-Platelet and Anticoagulant Drugs
Anti-clotting drugs that inhibit or break up blood clots are used at every stage of heart disease. They are generally classified as either anti-platelets oranticoagulants. All anti-clotting therapies carry the risk of bleeding, which can lead to dangerous situations, including stroke.

Aspirin. Aspirin is known as a nonsteroidal anti-inflammatory drug (NSAID). It stops blood platelets, which are major clotting factors, from sticking together to form a blood clot. Aspirin therapy is extremely beneficial for patients with coronary artery disease, peripheral artery disease, or history of stroke.

A daily low-dose aspirin (75 – 81 mg) is usually the first choice for preventing heart disease in high-risk individuals. Aspirin can reduce the risk of heart attack and ischemic stroke. However, prolonged use of aspirin can increase the risks for stomach bleeding. A doctor needs to consider a patients overall medical condition and risk factors for heart attack before recommending aspirin therapy.
In general, daily aspirin is recommended for prevention of heart disease for the following people who have never had a heart attack or stroke:

• Women age 55 to 79. (Women who are younger than age 55 should not take aspirin for primary prevention.)
• Men age 45 to 79 years should take aspirin if the chances for preventing stroke or heart attack outweigh the risks of gastrointestinal bleeding. Men younger than age 45 should not take aspirin for primary prevention.
• For women and men age 80 years or older, it is not clear if the benefits of aspirin for heart protection outweigh the risks for bleeding.

Clopidogrel. Clopidogrel (Plavix) is an anti-platelet drug known as a thienopyridine. For most patients, the addition of Clopidogrel to aspirin for the prevention of heart disease is not recommended, as it adds no significant benefit, adds significantly to the cost, and increases the risk of bleeding. It may be used in place of aspirin for patients who are aspirin allergic or who cannot tolerate aspirin.

When taken with aspirin, clopidogrel is recommended for patients with acute coronary syndrome (unstable angina or early signs of heart attack) or those who have had a drug-eluting stent inserted. According to the American Heart Association, patients who have a drug-eluting stent must take both aspirin and a thienopyridine for at least 1 year after the stent is inserted.

Clopidogrel is also recommended for patients who are undergoing angioplasty. Patients having coronary bypass surgery should not take clopidogrel forat least 5 – 7 days prior to surgery because of a significant bleeding risk. Researchers are investigating whether clopidogrel and aspirin together are better than aspirin alone in reducing the risks following coronary bypass surgery.

Warfarin and Anticoagulants. Anticoagulants are drugs that prevent or delay blood coagulation and the formation of blood clots. Warfarin (Coumadin) is an oral anticoagulant. It prevents clots by inhibiting vitamin K. Warfarin is used for patients with certain types of prosthetic heart valves and to prevent blood clots in patients with atrial fibrillation. Warfarin therapy poses a dangerous risk for bleeding, and blood coagulation must be monitored with frequent blood tests. A third of all people are genetically predisposed to a higher bleeding risk with warfarin. A genetic test can help doctors determine which patients may be especially sensitive to this drug.

Beta Blockers
Beta blockers are useful for preventing angina attacks and reducing high blood pressure. They reduce the heart’s oxygen demand by slowing the heart rate and lowering blood pressure. They can help reduce risk of death from heart disease and from heart surgeries, including angiography and coronary bypass.
Beta blockers are used or recommended in a number of situations:

• They are started in nearly all patients who have just had a heart attack or acute coronary syndrome.
• They are the drugs of choice for older patients with stable angina and may also be beneficial for people with silent ischemia. They are less useful for the treatment of Prinzmetals angina.
• They may be used alone or with other medications for management of rhythm disturbances or high blood pressure.

Beta blockers include propranolol (Inderal), carvedilol (Coreg), bisoprolol (Zebeta), acebutolol (Sectral), atenolol (Tenormin), labetalol (Normodyne, Trandate), metoprolol (Lopressor, Toprol-XL), and esmolol (Brevibloc). A nasal spray form of propranolol appears to be very helpful in reducing exercise-induced angina attacks.

Side Effects. Beta blocker side effects include fatigue, lethargy, vivid dreams and nightmares, depression, memory loss, and dizziness. They can lower HDL (good) cholesterol. Beta blockers are categorized as non-selective or selective. Non-selective beta blockers, such as carvedilol and propranolol, can narrow bronchial airways. These beta blockers should not be used by patients with asthma, emphysema, or chronic bronchitis.
PATIENTS SHOULD NEVER ABRUPTLY STOP TAKING THESE DRUGS. The sudden withdrawal of beta blockers can rapidly increase heart rate and blood pressure. The doctor may advise a patient to slowly decrease the dose before stopping completely.

Angiotensin Converting Enzyme (ACE) Inhibitors
Angiotensin converting enzyme (ACE) inhibitors are important heart-protective drugs, particularly for people with diabetes and high blood pressure. They reduce the production of angiotensin, a chemical that causes arteries to narrow, and so are commonly used to lower blood pressure. They may also reduce risk for heart attack, stroke, complications of diabetes, and death in patients at high risk for heart disease.
ACE inhibitors are indicated for most patients with coronary artery disease or any other vascular diseases, such as peripheral vascular disease. They are particularly helpful for patients with coronary artery disease who also have diabetes or who have left ventricular dysfunction (when the heart’s main chamber does not pump as well as it should).

ACE inhibitors include captopril (Capoten), ramipril (Altace), enalapril (Vasotec), quinapril (Accupril), benazepril (Lotensin), perindopril (Aceon), and lisinopril (Prinivil, Zestril).

Side Effects. Side effects of ACE inhibitors may include an irritating cough. More serious side effects are uncommon but may include excessive drops in blood pressure, allergic reactions, and high blood potassium levels.

Nitrates
Nitrates have been used in the treatment of angina for over 100 years. These drugs release nitric oxide, thereby relaxing the smooth muscles in blood vessels. Nitrates are used primarily for control of angina symptoms. Many nitrate preparations are available. The most commonly used are nitroglycerin, isosorbide dinitrate, and isosorbide mononitrate. Nitrates can be absorbed from the gastrointestinal tract (oral tablet), skin (ointment or patch), or from under the tongue (sublingual tablet or spray).

Rapid Acting Nitrates. Rapid-acting nitrates are used to treat acute attacks. Nitroglycerin is the most widely used drug for this purpose. It can be administered under the tongue (sublingually or as a spray) or pocketed between the upper lip and gum (buccally) and can relieve angina within minutes. The procedure for taking nitroglycerin during an attack is as follows:

• At the onset of an angina attack, the patient administers one sublingual or buccal tablet or one metered dose of the spray.
• If the pain is not relieved within 5 minutes the patient takes a second dose; a third can be taken after another 5 minutes if symptoms persist.
• If pain continues after a total of three doses in 15 minutes, the patient should go immediately to the nearest emergency room.

Nitroglycerin is very unstable so its potency can be easily lost. Patients should take the following precautions:

• Keep no more than 100 tablets on hand, stored in their original container.
• When first opened, the cotton filler should be discarded, and the cap screwed on tightly immediately after each use.
• A supply should always be kept close at hand in case of an attack, with the rest kept in a cool dry place.

Intermediate to Long-Term Nitrates. Sublingual tablets of isosorbide dinitrate have a slower onset of action than nitroglycerin and are useful for preventing exercise angina. Ointments, patches, and oral tablets are used for longer-term prevention of angina attacks:

• Transdermal patches are applied in the morning to any hair- or injury-free area on the chest, back, stomach, thigh, or upper arm. Hands should be washed after each patch or ointment application, and sites of application should be rotated to avoid skin irritation.
• Nitroglycerin ointment is applied by measuring out an even amount on an applicator paper and then placing, not rubbing or massaging, it on the chest, stomach, or thigh. Any ointment that remains from the previous application should be removed.

Long-acting forms may lose their effectiveness over time, so doctors generally schedule nitrate-free breaks to prevent tolerance.

Side Effects. Nitrates can have many side effects, some of which can be serious.
Common side effects of nitrates include headaches, dizziness, nausea and vomiting, blurred vision, fast heartbeat, sweating, and flushing on the face and neck. Low blood pressure and dizziness can be relieved by lying down with the legs elevated. These effects are significantly worsened by alcohol, beta blockers, calcium channel blockers, and certain antidepressants. Patients who take nitrates in any form cannot take medications for erectile dysfunction, such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). The doctor may prescribe medicines to lessen these side effects. Patients should contact their doctor if these side effects are persistent or severe.

Serious side effects requiring immediate medical help include fever, joint or chest pain, sore throat, skin rash (especially on the face), unusual bleeding or bruising, weight gain, and swelling of the ankles.

Withdrawal. Withdrawal from nitrates should be gradual. Abrupt termination may cause angina attacks.

Calcium Channel Blockers (CCBs)
Calcium channel blockers reduce heart rate and slightly dilate the blood vessels of the heart, thereby decreasing oxygen demand and increasing oxygen supply. They also reduce blood pressure. CCBs vary chemically, however, and although some are helpful, others may even be dangerous for certain patients with angina.

• Long-acting nifedipine (Adalat, Procardia) and nisoldipine (Sular) and newer CCBs, such as amlodipine (Norvasc) and nicardipine (Cardene), may be beneficial for some patients with angina. They can be considered alone for patients who cannot tolerate beta blockers, but may provide the best results when used in combination with a beta blocker. Studies suggest that they reduce the need for repeat angioplasties. Their effects on other outcomes, including mortality rates and heart attack, are less clear.
• Short-acting CCBs, including short-acting forms of verapamil, diltiazem, nifedipine, and nicardipine, are helpful for many patients with Prinzmetal’s angina. However, short-acting forms of certain CCBs, such as nifedipine and nisoldipine, have been associated with severe and even dangerous side effects, including an increase in heart attacks and sudden death in some patients with unstable angina. They also increase the risk for adverse effects in patients with stable angina. Short-acting CCBs are, therefore, not used for stable or unstable angina.

There is no strong evidence that any calcium channel blockers improve survival rates. Overdose can cause dangerously low blood pressure and slow heart beats. Patients with heart failure have a higher risk for death with these drugs and should not take them. No one taking any calcium channel blocker should withdraw abruptly because such action could dangerously increase the risk of high blood pressure. Note: Grapefruit and Seville oranges boost the effects of CCBs, sometimes to toxic levels. (Regular oranges do not appear to pose any hazard.)

Other Drugs
Ranolazine (Ranexa) is used to treat chronic angina in patients who have not responded to other angina drugs. Ranolazine is taken in combination with amlodipine, beta blockers, or nitrates.

Surgery
Angioplasty and Stents
Angioplasty, also called percutaneous coronary intervention (PCI), involves procedures such as percutaneous transluminal coronary angioplasty (PTCA) that help open the blocked artery.

Angioplasty can help reduce the frequency of angina attacks. It is commonly recommended for patients who have critically blocked arteries or have already had a recent, acute heart attack. Angioplasty can also help improve survival and prevent heart attacks in patients with acute coronary syndrome (ACS). However, doctors have been uncertain about angioplasty’s benefits for survival and heart attack prevention in lower-risk patients with stable coronary artery disease.
Angioplasty works no better than standard heart medication (drugs to control blood pressure, lower cholesterol, and prevent blood clots) in preventing heart attack, stroke, and hospitalization in patients with stable coronary artery disease. Doctors are now recommending angioplasty only for patients who have severe heart disease. For patients with stable heart disease, drug therapy may be sufficient enough treatment and allow them to safely defer having surgery.
Complications. Complications are generally rare but can include bleeding, infections, heart attack, and stroke. Finding a surgeon who performs at least 100 of the procedures a year helps reduce the risk for complications.

Blood clots may form in the new graft, closing it up or narrowing the treated vessel over time. Therapy with aspirin and other anti-clotting drugs help keep the graft open and working properly.

Recuperation and Rehabilitation. After leaving the hospital, patients have cardiac rehabilitation. Rehabilitation includes education about healthy diet and lifestyle choices, as well as exercise training to rebuild strength and stamina.

• This information is for you only.
• Always follow your healthcare provider’s instructions for taking medicines. Do not miss any doses, do not take less medicine, and do not stop taking medicine without talking to your provider first. It can be dangerous to suddenly stop taking blood pressure medicine. Also, do not increase your dosage of any medicine without first talking with your provider.
• Ask your healthcare provider or pharmacist for information about the drugs you are taking.
• Ask your provider about nonprescription medicines and supplements before you take them.

Becker RC, Meade TW, Berger PB, Ezekowitz M, O’Connor CM, Vorchheimer DA, et al. The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):776S-814S.

Coronary artery disease is the narrowing or blockage of the coronary arteries, usually caused by atherosclerosis. Atherosclerosis (sometimes called “hardening” or “clogging” of the arteries) is the buildup of cholesterol and fatty deposits (called plaques) on the inner walls of the arteries. These plaques can restrict blood flow to the heart muscle by physically clogging the artery or by causing abnormal artery tone and function.

Without an adequate blood supply, the heart becomes starved of oxygen and the vital nutrients it needs to work properly. This can cause chest pain called angina.
If blood supply to a portion of the heart muscle is cut off entirely, or if the energy demands of the heart become much greater than its blood supply, a heart attack (injury to the heart muscle) may occur.

What causes the coronary arteries to narrow?
Your coronary arteries are shaped like hollow tubes through which blood can flow freely. The muscular walls of the coronary arteries are normally smooth and elastic and are lined with a layer of cells called the endothelium. The endothelium provides a physical barrier between the blood stream and the coronary artery walls, while regulating the function of the artery by releasing chemical signals in response to various stimuli.

Coronary artery disease starts when you are very young. Before your teen years, the blood vessel walls begin to show streaks of fat. As you get older, the fat builds up, causing slight injury to your blood vessel walls. Other substances traveling through your blood stream, such as inflammatory cells, cellular waste products, proteins and calcium begin to stick to the vessel walls. The fat and other substances combine to form a material called plaque.

Over time, the inside of the arteries develop plaques of different sizes. Many of the plaque deposits are soft on the inside with a hard fibrous “cap” covering the outside. If the hard surface cracks or tears, the soft, fatty inside is exposed. Platelets (disc-shaped particles in the blood that aid clotting) come to the area, and blood clots form around the plaque. The endothelium can also become irritated and fail to function properly, causing the muscular artery to squeeze at inappropriate times. This causes the artery to narrow even more.

Sometimes, the blood clot breaks apart, and blood supply is restored. In other cases, the blood clot (coronary thrombus) may suddenly block the blood supply to the heart muscle (coronary occlusion), causing one of three serious conditions, and called acute coronary syndromes 

What are acute coronary syndromes?
Unstable angina: This may be a new symptom or a change from stable angina. The angina may occur more frequently, occur more easily at rest, feel more severe, or last longer. Although this can often be relieved with oral medications, it is unstable and may progress to a heart attack. Usually more intense medical treatment or a procedure are required to treat unstable angina.

Non-ST segment elevation myocardial infarction (NSTEMI): This type of heart attack, or MI, does not cause major changes on an electrocardiogram (ECG). However, chemical markers in the blood indicate that damage has occurred to the heart muscle. In NSTEMI, the blockage may be partial or temporary, so the extent of the damage is relatively minimal.

ST segment elevation myocardial infarction (STEMI): This type of heart attack, or MI, is caused by a prolonged period of blocked blood supply. It affects a large area of the heart muscle, and causes changes on the ECG as well as in blood levels of key chemical markers.

Some people have symptoms that indicate they may soon develop an acute coronary syndrome; others may have no symptoms until something happens, and still others have no symptoms of the acute coronary syndrome at all.
All acute coronary syndromes require emergency evaluation and treatment.

Collateral Circulation?
As the size of the blockage in a coronary artery increases, the narrowed coronary artery my develop “collateral circulation.” Collateral circulation is the development of new blood vessels that reroute blood flow around the blockage. However, during times of increased exertion or stress, the new arteries may not be able to supply enough oxygen-rich blood to the heart muscle. 

What Is Ischemia? 
Ischemia is a condition described as “cramping of the heart muscle.” Ischemia occurs when the narrowed coronary artery reaches a point where it cannot supply enough oxygen-rich blood to meet the heart’s needs. The heart muscle becomes “starved” for oxygen.
Ischemia of the heart can be compared to a cramp in the leg. When someone exercises for a very long time, the muscles in the legs cramp up because they’re starved for oxygen and nutrients. Your heart, also a muscle, needs oxygen and nutrients to keep working. If the heart muscle’s blood supply is inadequate to meet its needs, ischemia occurs, and you may feel chest pain or other symptoms.
Ischemia is most likely to occur when the heart demands extra oxygen. This is most common during:

• Exertion (activity)
• Eating
• Excitement or stress
• Exposure to cold

When ischemia is relieved in less than 10 minutes with rest or medications, you may be told you have “stable coronary artery disease” or “stable angina.” Coronary artery disease can progress to a point where ischemia occurs even at rest. 
Ischemia, and even a heart attack, can occur without any warning signs and is called “silent” ischemia. Silent ischemia can occur among all people with heart disease, though it is more common among people with diabetes.

What are the symptoms of coronary artery disease? 
The most common symptom of coronary artery disease is angina (also called angina pectoris). Angina is often referred to as chest pain. It is also described as chest discomfort, heaviness, tightness, pressure, aching, burning, numbness, fullness, or squeezing. It can be mistaken for indigestion or heartburn. Angina is usually felt in the chest, but may also be felt in the left shoulder, arms, neck, back or jaw. 
Other symptoms that can occur with coronary artery disease include:

• Shortness of breath
• Palpitations (irregular heart beats, skipped beats or a “flip-flop” feeling in your chest)
• A faster heartbeat
• Dizziness
• Nausea
• Extreme weakness
• Sweating

If you experience any of these symptoms, it is important to call your doctor, especially if these are new symptoms or if they have become more frequent or severe. 

Symptoms in Women 
Women often have different symptoms of coronary artery disease than men. For example, symptoms of a heart attack in women include:

• Pain or discomfort in the chest, left arm or back
• Unusually rapid heartbeat
• Shortness of breath
• Nausea or fatigue

If any of these symptoms occur, it is important to get medical help right away – call 9-1-1 or have someone take you to the nearest emergency room. 
What you should do if you have symptoms:

• If you or someone you are with has chest, left arm or back pain that lasts more than 5 minutes, with one or more of the symptoms listed previously, call 9-1-1 to get emergency help. DO NOT DELAY. Quick treatment of a heart attack is very important to reduce the amount of damage to your heart. Emergency personnel may tell you to chew an aspirin to break up a possible blood clot, if there is no medical reason for you not to take aspirin.
• If your symptoms stop completely in 5 minutes, still call your doctor to report your symptoms.
  Call your doctor if this is the first time you have experienced these symptoms so you can be evaluated.
• Learn to recognize your symptoms and the situations that cause them.
• Call your doctor if you have new symptoms or if they become more frequent or severe.
• If you have been prescribed nitroglycerin and you experience angina, stop what you are doing and rest. Take one nitroglycerin tablet and let it dissolve under your tongue, or if using the spray form, spray it under your tongue. Wait 5 minutes. If you still have angina after 5 minutes, call 9-1-1 to get emergency help.

DO NOT DELAY. Emergency personnel may tell you to chew an aspirin to break up a possible blood clot, if there is not a medical reason for you not to take aspirin.

SPECIAL NOTE: Some people worry that they shouldn’t call 9-1-1 because they think their symptoms will subside or they are embarrassed. However, it’s better to have your symptoms evaluated as soon as possible so you can receive quick treatment in the event of a heart attack.

How is coronary artery disease diagnosed?
Your doctor diagnoses coronary artery disease by talking to you about your symptoms, reviewing your medical history and risk factors, and performing a physical exam.

Diagnostic tests, including blood tests, an electrocardiogram (ECG or EKG), exercise stress tests, cardiac catheterization and others may be required to appropriately diagnose and treat coronary artery disease. These tests help your doctor evaluate the extent of your coronary heart disease, its effect on the function of your heart, and the best form of treatment for you.

Research into new testing procedures, such as coronary computed tomography angiogram (CTA), may change the way coronary artery disease is diagnosed in the future. 
What are the risk factors for coronary artery disease?
Non-modifiable risk factors (those that cannot be changed) include:

• Male gender. The risk of heart attack is greater in men than in women, and men have heart attacks earlier in life than women. However, at age 70 and beyond, men and women are equally at risk.
• Advanced age. Coronary artery disease is more likely to occur as you get older, especially after age 65.
• Family history of heart disease. If your parents have heart disease (especially if they were diagnosed with heart disease before age 50), you have an increased risk of developing it.

Ask your doctor when it’s appropriate for you to start screenings for heart disease so it can be detected and treated early.

• Race. African Americans have more severe high blood pressure than Caucasians and therefore have a higher risk of heart disease. Heart disease risk is also higher among Mexican Americans, American Indians, native Hawaiians and some Asian Americans. This is partly due to higher rates of obesity and diabetes in these populations.

Modifiable risk factors (those you can treat or control) include:

• Cigarette smoking and exposure to tobacco smoke
• High blood cholesterol and high triglycerides — especially high LDL or “bad” cholesterol over 100 mg/dL and low HDL or “good” cholesterol under 40 mg/dL. Some patients who have existing heart or blood vessel disease and other patients who have a very high risk should aim for a LDL level less than 70 mg/dL. Your doctor can provide specific guidelines.
• High blood pressure (140/90 mm/Hg or higher)
• Uncontrolled diabetes
• Physical inactivity
• Being overweight (body mass index or BMI from 25-29 kg/m2) or being obese (BMI higher than 30 kg/m2)

NOTE: How your weight is distributed is important. Your waist measurement is one way to determine fat distribution. Your waist circumference is the measurement of your waist, just above your navel. The risk of cardiovascular disease increases with a waist measurement of over 35 inches in women and over 40 inches in men.

• Uncontrolled stress or anger
• Diet high in saturated fat and cholesterol
• Drinking too much alcohol

The more risk factors you have, the greater your risk of developing coronary artery disease.

How is coronary artery disease treated?
Treatment for coronary artery disease involves reducing your risk factors, taking medications, possibly undergoing invasive and/or surgical procedures and seeing your doctor for regular visits.  Treating coronary artery disease is important to reduce your risk of heart attack or stroke.

Reduce your risk factors 
Reducing your risk factors involves making lifestyle changes. Your doctor will work with you to help you make these changes.

• If you smoke, you should quit.
• Make changes in your diet to reduce your cholesterol, control your blood pressure, and manage blood sugar if you have diabetes. Low fat, low sodium, low cholesterol foods are recommended. Limiting alcohol to no more than one drink a day is also important. A registered dietitian can help you make the right dietary changes. Cleveland Clinic offers nutrition programs and classes to help you reach your goals.
• Increase your exercise/activity level to help achieve and maintain a healthy weight and reduce stress. But, check with your doctor before starting an exercise program. Ask your doctor about participating in a cardiac rehabilitation program.

Test your 10 year risk for heart attack. 

Take Medications As Prescribed 
If lifestyle changes aren’t enough to control your heart disease, medications may be prescribed to treat certain risk factors, such as high cholesterol or high blood pressure. The medications prescribed will depend on your personal needs, presence of other health conditions and your specific heart condition. 
Have Procedures to Treat Coronary Artery Disease, as Recommended

Interventional procedures
Common interventional procedures to treat coronary artery disease include balloon angioplasty (PTCA) and stent or drug eluting stent placement. These procedures are considered non-surgical because they are done by a cardiologist through a tube or catheter inserted into a blood vessel, rather than by a surgeon through an incision. Several types of balloons and/or catheters are available to treat the plaque within the vessel wall. The physician chooses the type of procedure based on individual patient needs. 

Coronary artery bypass graft (CABG) surgery
One or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. These grafts usually come from the patient’s own arteries and veins located in the chest, leg, or arm. The graft goes around the clogged artery (or arteries) to create new pathways for oxygen-rich blood to flow to the heart. 
When these traditional treatments are not an option, doctors may suggest other less traditional therapies, such as TMR or EEC.

Transmyocardial laser revascularization (TMR) 
TMR is a treatment aimed at improving blood flow to areas of the heart that were not treated by angioplasty or surgery. A special carbon dioxide (CO2) laser is used to create small channels in the heart muscle, improving blood flow in the heart. Frequently, it is performed with coronary artery bypass, occasionally alone. 

EECP 
For patients who have persistent angina symptoms and have exhausted the standard treatments without successful results, Enhanced External Counterpulsation (EECP) may stimulate the openings or formation of collaterals (small branches of blood vessels) to create a natural bypass around narrowed or blocked arteries. EECP is a non-invasive treatment for people who have chronic, stable angina; who are not receiving adequate relief from angina by taking nitrate medications; and who do not qualify for an invasive procedure such as bypass surgery, angioplasty or stenting. ] 

Important Note: These procedures increase blood supply to your heart, but they do not cure coronary heart disease. You will still need to decrease your risk factors by making lifestyle changes, taking medications as prescribed and following your doctor’s recommendations to prevent future disease.
The Miller Family Heart & Vascular Institute cardiologists and surgeons specialize in the treatment of coronary artery disease. The team approach at the Miller Family Heart & Vascular Institute at Cleveland Clinic insures that patients receive the best care before, during and after their procedure. 

Follow-Up Care 
Your cardiologist (heart doctor) will want to see you on a regular basis for a physical exam and possibly to perform diagnostic tests. Your doctor will use the information gained from these visits to monitor the progress of your treatment.

This article is for your information only.  Dr Ben-Zur recommends consulting your physician prior to making any changes in your diet, exercise or medical program.

© Copyright 2000-2009 Cleveland Clinic. All rights reserved. 8/09

Coronary artery disease is a condition in which the blood supply to the heart muscle is partially or completely blocked.

The heart muscle needs a constant supply of oxygen-rich blood. The coronary arteries, which branch off the aorta just after it leaves the heart, deliver this blood. Coronary artery disease can block blood flow, causing chest pain (angina) or a heart attack (also called myocardial infarction, or MI).

Coronary artery disease was once widely thought to be a man’s disease. On average, men develop it about 10 years earlier than women because, until menopause, women are protected by high levels of estrogen. However, after menopause, coronary artery disease becomes more common among women. Among people aged 75 and older, a higher proportion of women have the disease, because women live longer.

In developed countries, coronary artery disease is the leading cause of death in both men and women. Coronary artery disease, specifically coronary atherosclerosis (literally “hardening of the arteries,” which involves fatty deposits in the artery walls and may progress to narrowing and even blockage of blood flow in the artery), occurs in about 5 to 9% (depending on sex and race) of people aged 20 and older. The death rate increases with age and overall is higher for men than for women, particularly between the ages of 35 and 55. After age 55, the death rate for men declines, and the rate for women continues to climb. After age 70 to 75, the death rate for women exceeds that for men who are the same age.

Coronary artery disease affects people of all races, but the incidence is extremely high among blacks and Southeast Asians. The death rate is higher for black men than for white men until age 60 and is higher for black women than for white women until age 75.

Causes
Coronary artery disease is almost always due to the gradual buildup of cholesterol and other fatty materials (called atheromas or atherosclerotic plaques) in the wall of a coronary artery. This process is called atherosclerosis and can affect many arteries, not just those of the heart.

Occasionally, however, coronary artery disease is caused by spasm of a coronary artery, which can occur spontaneously, or from use of certain drugs such as cocaine and nicotine. Rarely, the cause is a birth defect, a viral infection (such as Kawasaki disease), systemic lupus erythematosus (lupus), inflammation of the arteries (arteritis), a blood clot that traveled from a heart chamber into one of the coronary arteries, or physical damage (from an injury or radiation therapy).

As an atheroma grows, it may bulge into the artery, narrowing the interior (lumen) of the artery and partially blocking blood flow. With time, calcium accumulates in the atheroma. As an atheroma blocks more and more of a coronary artery, the supply of oxygen-rich blood to the heart muscle (myocardium) can become inadequate. The blood supply is more likely to be inadequate during exertion, when the heart muscle requires more blood. An inadequate blood supply to the heart muscle (from any cause) is called myocardial ischemia. If the heart does not receive enough blood, it can no longer contract and pump blood normally.

An atheroma, even one that is not blocking very much blood flow, may rupture suddenly. The rupture of an atheroma often triggers the formation of a blood clot (thrombus). The clot further narrows or completely blocks the artery, causing acute myocardial ischemia. The consequences of this acute ischemia are referred to as acute coronary syndromes. These syndromes include unstable angina and several types of heart attack, depending on the location and degree of the blockage. In a heart attack, the area of the heart muscle supplied by the blocked artery dies.

Sometimes an acute coronary syndrome is caused by coronary artery spasm or another type of coronary artery disease.
Risk Factors

Some factors that affect whether a person develops coronary artery disease cannot be modified. They include

• Advancing age
• Male sex
• Family history of early coronary artery disease (that is, having a close relative who developed the disease before age 50 to 55)

Other risk factors for coronary artery disease can be modified or treated. These factors include

• High blood levels of low-density lipoprotein (LDL) cholesterol
• High blood levels of lipoprotein a
• Low blood levels of high-density lipoprotein (HDL) cholesterol
• Diabetes mellitus
• Smoking
• High blood pressure
• Obesity
• Physical inactivity
• Dietary factors

Smoking more than doubles the risk of developing coronary artery disease and having a heart attack. Secondhand smoke appears also to increase risk.
Dietary risk factors include a diet that is low in fiber, vitamins C and E, and phytochemicals (which are present in fruits and vegetables and are thought to promote health). For some people, a diet low in fish oils (omega-3 polyunsaturated fatty acids) increases risk.

Having one or two drinks of alcohol a day appears to slightly reduce the risk of coronary artery disease (while slightly increasing that of stroke). However, having more than two drinks a day increases the risk, and the larger the amount, the greater the risk.

Certain metabolic disorders, such as hypothyroidism, hyperhomocysteinemia, and a high level of apoprotein B (apo B), also are risk factors.
Whether infection with certain organisms contributes to the development of coronary artery disease is uncertain. The organisms suspected include Chlamydia pneumoniae (which can cause pneumonia), Helicobacter pylori (which can contribute to stomach ulcers), and a virus (as yet unidentified). One example of the relationship between infection and premature coronary artery disease is the finding that people who have poor dental health, particularly periodontal disease (infection of the gums), appear somewhat more likely to have a heart attack. Nonetheless, inflammation, whether caused by infection or not, appears to contribute to the development of acute coronary syndromes. If an atheroma becomes inflamed, it softens and is more likely to rupture, and blood clots are more likely to form.

Prevention
Modifying risk factors can help prevent coronary artery disease. Some of these factors are interrelated, so that modifying one also modifies another.

Smoking: Quitting smoking is most important. People who quit smoking decrease their risk of developing coronary artery disease by half compared with those who continue to smoke. How long people smoked before quitting does not matter. Quitting also decreases the risk of death after coronary artery bypass surgery or after a heart attack. Avoiding secondhand smoke is also important.

Diet: Limiting the amount of fat to no more than 25 to 35% of daily calories is recommended to promote good health. However, some experts believe that fat must be limited to 10% of daily calories to reduce the risk of coronary artery disease. A low-fat diet also helps lower high total and LDL (the bad) cholesterol levels, another risk factor for coronary artery disease. The type of fat consumed is as important as the amount of fat. Thus, eating oily fish, such as salmon, which are high in omega-3 fats (good fats), regularly and strictly avoiding the more harmful trans fats are recommended. Trans fats are being removed from ingredients in many fast food sites and restaurants.

Eating at least five servings of fruits and vegetables daily can decrease the risk of coronary artery disease. Such foods contain many phytochemicals. Whether the phytochemicals are responsible for the risk reduction is unclear because people who consume such diets also tend to eat less fat, more fiber, and more foods containing vitamins C and E. One group of phytochemicals called flavonoids (found in red and purple grapes, red wine, and black teas) appears to be particularly protective.

A high-fiber diet is also recommended. There are two kinds of fiber. Soluble fiber (which dissolves in liquid) is found in oat bran, oatmeal, beans, peas, rice bran, barley, citrus fruits, strawberries, and apple pulp. It helps lower high cholesterol levels. It may decrease or stabilize high blood sugar (glucose) levels and increase low insulin levels. Thus, soluble fiber may help people with diabetes reduce their risk of coronary artery disease. Insoluble fiber (which does not dissolve in liquid) is found in most grains and grain products and in fruits and vegetables such as apple skin, cabbage, beets, carrots, brussels sprouts, turnips, and cauliflower. It helps with digestive function. However, eating too much fiber can interfere with the absorption of certain vitamins and minerals.

The diet should contain the recommended daily requirements of vitamins and minerals. Vitamin supplements are not considered an acceptable substitute for a healthy diet. The role of supplements in reducing the risk of coronary artery disease is somewhat controversial. Taking supplements of vitamin E or vitamin C does not seem to prevent coronary artery disease. Taking folate or vitamins B6 and B12 may lower homocysteine levels, but studies have not shown that taking these supplements decreases the risk of coronary artery disease.

Limiting the amount of simple sugar carbohydrates (such as refined white flour, white rice, processed foods) and increasing the amount of whole grains may help reduce the risk of coronary artery disease because it reduces the risk of obesity and possibly of diabetes, which are also risk factors for coronary artery disease.

Overall, people should maintain a healthy weight and eat a variety of foods. The Mediterranean diet, which consists of large portions of fruits, vegetables, nuts, and olive oil, appears to reduce the risk of coronary artery disease.

Physical Inactivity: People who are physically active are less likely to develop coronary artery disease and high blood pressure. Exercise that promotes endurance (aerobic exercise such as brisk walking, bicycling, and jogging) or muscle strength (resistance training with free weights or weight machines) helps prevent coronary artery disease. Walking just 30 minutes each day can be beneficial. People who are out of shape or who have not exercised in a long time should consult their doctor before they start an exercise program.

Obesity: Modifying the diet and engaging in physical activity can help control obesity. Decreasing alcohol consumption can also help because alcohol is high in calories. A loss of even 10 to 20 pounds (4½ to 9 kilograms) can reduce the risk of coronary artery disease.

High Cholesterol Levels: High total and LDL (the bad) cholesterol levels can be lowered by exercising and by quitting smoking as well as by reducing the amount of fat in the diet. Drugs that lower levels of total and LDL cholesterol in the blood (lipid-lowering drugs) may be used. The benefits of lowering cholesterol levels are greatest in people with other risk factors, such as smoking, high blood pressure, obesity, and physical inactivity.

Increasing the level of HDL (the good) cholesterol also helps reduce the risk of coronary artery disease. The same lifestyle changes that lower total and LDL cholesterol levels can help increase HDL cholesterol levels, as can certain drugs. For people who are overweight, losing weight can also help.

High Blood Pressure: Lowering high blood pressure reduces the risk of coronary artery disease. Treatment of high blood pressure begins with lifestyle changes: eating a healthy diet that is low in salt and, if needed, losing weight and increasing physical activity. Drug therapy may also be necessary.

Diabetes Mellitus: Good control of diabetes reduces the risk of some complications of diabetes, but the effects of such control on the development of coronary artery disease are less clear. Good control of diabetes may also reduce the risk of complications of coronary artery disease.

Treatment
Doctors try to do three things for people with coronary artery disease. They try to reduce the heart’s workload, improve coronary artery blood flow, and slow down or reverse the buildup of atherosclerosis. The heart’s workload can be reduced by controlling the person’s blood pressure and using certain drugs such as beta-blockers or calcium channel blockers that keep the heart from pumping as hard. Coronary blood flow can be improved by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). A coronary artery blood clot may sometimes be dissolved by drugs. Modifying the diet, exercising, and taking certain drugs can help reverse atherosclerosis.

Percutaneous Coronary Intervention
In PCI (also called percutaneous transluminal coronary angioplasty—PTCA), doctors insert a large needle into the main artery of the thigh (femoral artery). Then a long guide wire is threaded through the needle, into the artery, and up through the aorta into the narrowed coronary artery. A catheter with a balloon attached to the tip is threaded over the guide wire and into the narrowed coronary artery. The catheter is positioned so that the balloon is at the level of the narrowing. The balloon is then inflated for several seconds. The inflated balloon compresses the atheroma that is narrowing the artery and widens the artery. Inflation and deflation may be repeated several times. In 80 to 90% of people, the narrowed arteries that are reached are opened.

To help keep the coronary artery open, doctors usually insert a tube made of wire mesh (a stent) into the artery. About ¾ of the time, doctors use stents that are coated with a drug. The drug is released slowly to help prevent the coronary artery from becoming blocked again, a common problem with bare-metal stents. However, although these drug-releasing stents are very helpful in keeping the artery open, people who have a drug-releasing stent have a slightly higher risk of developing a blood clot in the stent than do people who have a bare metal stent. To decrease the risk of such clots, people who have a drug-releasing stent are given an antiplatelet drug for at least a year after the stent is inserted. If the artery becomes blocked again, whether from a clot or other causes, doctors may do a second PCI.

Generally, PCI is preferred to bypass grafting because it is a less invasive procedure. However, the affected area of the coronary artery may not be suited to PCI because of its location, its length, the amount of calcium that accumulates, or other conditions. Thus, doctors carefully determine whether a person is a good candidate for the procedure.

Other Techniques: Doctors have tried other techniques to remove atheromas. These include the use of tiny blades, burrs, or lasers to remove thick, fibrous, and calcified atheromas by cutting, shaving, crushing, or dissolving them. Some of these techniques are still being evaluated, but so far, the results, especially over the long term, have been disappointing.

Coronary Artery Bypass Grafting
Coronary artery bypass grafting (CABG) is also called bypass surgery or coronary artery bypass surgery. In the procedure, doctors take an artery or vein from another part of the body to connect the aorta (the major artery that takes blood from the heart to the rest of the body) to a coronary artery past the point of its blockage. Blood flow is thus rerouted, skipping over (bypassing) the narrowed or blocked area. Veins are usually taken from the leg. Arteries are usually taken from beneath the breastbone (sternum) or from the forearm. Artery grafts rarely develop coronary artery disease, and more than 90% of them still work properly 10 years after the bypass surgery. However, vein grafts may gradually become narrowed by atheromas, and after 5 years, one third or more may be completely blocked.

The operation takes 2 to 4 hours, depending on the number of blood vessels to be grafted. A numeric modifier (for example, triple or quadruple) before bypass refers to the number of arteries (for example, 3 or 4) that are bypassed. The person is given a general anesthetic. Then, an incision is made down the center of the chest from the neck to the top of the stomach, and the breastbone is parted. This type of surgery is called open-heart surgery. Usually, the heart is stopped so that it is not moving and thus easier to operate on. A heart-lung machine is then used to put oxygen into the blood and pump the blood through the bloodstream. When only one or two blood vessels require grafting, the heart may be left pumping. The hospital stay is typically 5 to 7 days, usually less if a heart-lung machine was not used during surgery.

The risks from surgery include stroke and heart attack. For people who have a normal-sized and normally functioning heart, have never had a heart attack, and have no additional risk factors, risk is less than 5% for a heart attack during surgery, 2 to 3% for stroke, and less than 1% for death. Risk is somewhat higher for people with reduced pumping ability of the heart (poor left ventricular function), damaged heart muscle from a previous heart attack, or other cardiovascular problems. However, if these people survive the surgery, their prospects for long-term survival are improved.

Other Techniques: With new techniques, chest incisions can be much smaller, resulting in minimally invasive bypass surgery. One technique involves robotics. While sitting at a computer console, a surgeon uses pencil-sized robotic arms to do the operation. The arms hold specially designed surgical instruments that can do intricate movements, mimicking those of the surgeon’s hands. Through a viewing scope, the surgeon watches a magnified three-dimensional image of the operation. The operation requires three 1-inch (about 2 ½-centimeter) incisions—one for each of the two robotic arms and one for a camera, which is connected to the scope. Thus, the surgeon does not need to split open the person’s breastbone. The operating time and hospital stay are usually shorter with the newer procedures than with open-heart surgery.

This information is only for you. Always follow your healthcare provider’s instructions for taking medicines. Do not miss any doses, do not take less medicine, and do not stop taking medicine without talking to your provider first. It can be dangerous to suddenly stop taking blood pressure medicine. Also, do not increase your dosage of any medicine without first talking with your provider.

• Ask your healthcare provider or pharmacist for information about the drugs you are taking.
• Ask your provider about nonprescription medicines and supplements before you take them. 
  

Coronary Artery Disease
Coronary artery disease (CAD), also called heart disease, is a condition in which fatty plaque deposits build up in the hearts arteries. These plaque deposits cause arteries to become narrow and blocked, which restricts blood and oxygen flow to the heart muscle. CAD is the leading cause of death, for both men and women, in the United States.

Risk Factors 
Some of the main risk factors that increase the risk for CAD are:

• Smoking
• Unhealthy cholesterol and lipid levels
• High blood pressure
• Diabetes
• Lack of exercise
• Obesity

Symptoms 
Angina is the primary symptom of coronary artery disease. Angina feels like gripping pain or pressure in the chest area.

• Stable angina is predictable chest pain that lasts a few minutes or less and is usually relieved by rest or medication. It is oftentimes triggered by physical exertion or emotional stress.
• Unstable angina is unpredictable chest pain that occurs unexpectedly, even when at rest. It is a more serious condition than stable angina and can be a warning sign of a heart attack.

Some patients with CAD have few or no symptoms. Sometimes a heart attack may be the first sign that a person has CAD.
Treatment

• Lifestyle changes (such as a healthy diet and regular physical activity) are essential for preventing and treating CAD.
• Medications for preventing and treating CAD include aspirin, cholesterol-lowering drugs (statins), and high blood pressure medications. Some patients take nitroglycerin or other nitrate drugs to treat angina.
• Surgery may be needed to open blocked or narrowed coronary artery and improve blood flow to the heart. Percutaneous coronary intervention (PCI), also called angioplasty, uses a small balloon to open the blood vessel. Coronary artery bypass graft (CABG) is a more invasive procedure that is generally for patients with severe heart disease. It uses grafts from arteries or veins to reroute blood flow.

Introduction
Coronary artery disease (CAD), also called heart disease or ischemic heart disease, results from a complex process known as atherosclerosis (commonly called “hardening of the arteries”). In atherosclerosis, fatty deposits (plaques) of cholesterol and other cellular waste products build up in the inner linings of the hearts arteries. This causes blockage of arteries (ischemia) and prevents oxygen-rich blood from reaching the heart. There are many steps in the process leading to atherosclerosis, some not fully understood.

Cholesterol and Lipoproteins. The atherosclerosis process begins with cholesterol and sphere-shaped bodies called lipoproteins that transport cholesterol.

• Cholesterol is a substance found in all animal cells and animal-based foods. It is critical for many functions, but under certain conditions cholesterol can be harmful.
• The lipoproteins that transport cholesterol are referred to by their size. The most commonly known are low-density lipoproteins (LDL) and high density lipoproteins (HDL). LDL is often referred to as “bad” cholesterol; HDL is often called “good” cholesterol.

Blockage in the Arteries. Eventually these calcified (hardened) arteries become narrower (a condition known as stenosis).

• As this narrowing and hardening process continues, blood flow slows, preventing sufficient oxygen-rich blood from reaching the heart muscles.
• Such oxygen deprivation in vital cells is called ischemia. When it affects the coronary arteries, it causes injury to the tissues of the heart.
• These narrow and inelastic arteries not only slow down blood flow but also become vulnerable to injury and tears.

The End Result: Heart Attack. A heart attack can occur as a result of one or two effects of atherosclerosis:

• The artery becomes completely blocked and ischemia becomes so extensive that oxygen-bearing tissues around the heart die.
• The plaque itself develops fissures or tears. Blood platelets stick to the site to seal off the plaque, and a blood clot (thrombus) forms. A heart attack can then occur if the blood clot completely blocks the passage of oxygen-rich blood to the heart.

Risk Factors
Heart disease is the leading cause of death in the United States. Over the past decades, heart disease rates declined in both men and women as they quit smoking and improved dietary habits. This rate, however, has stabilized in recent years, most likely because of the dramatic increase in obesity in the U.S. and other industrialized nations.

Age
The risks for coronary artery disease increase with age. About 85% of people who die from heart disease are over the age of 65.

Gender
Men have a greater risk for coronary artery disease and are more likely to have heart attacks earlier in life than women. Women’s risk for heart disease increases after menopause, and they are more likely to have angina than men.

Genetic Factors and Family History
Certain genetic factors increase the likelihood of developing important risk factors, such as diabetes and high blood pressure. For example, one genetic variant called apolipoprotein E4 (ApoE4) affects cholesterol levels, particularly those associated with heart disease.
Heart disease tends to run in families. People whose parents or siblings developed heart disease at a younger age are more likely to develop it themselves.

Race and Ethnicity
African-Americans have the highest risk of heart disease, in part due to their high rates of severe high blood pressure, as well as diabetes and obesity.

Lifestyle Factors
Smoking. Smoking is the most important risk factor for heart disease. Smoking can cause elevated blood pressure, worsen lipids, and make platelets very sticky, raising the risk of clots. Cigarette smoking may be directly responsible for at least 20% of all deaths from heart disease. Although heavy cigarette smokers are at greatest risk, people who smoke as few as three cigarettes a day are at higher risk for blood vessel abnormalities that endanger the heart. Regular exposure to passive smoke also increases the risk of heart disease in nonsmokers. 

Alcohol. Moderate alcohol consumption (one or two drinks a day; 5 ounces wine, 12 ounces beer, or 1.5 ounces hard liquor is one drink) can help boost HDL good cholesterol levels. Alcohol may also prevent blood clots and inflammation. By contrast, heavy drinking harms the heart. In fact, heart disease is the leading cause of death in alcoholics.

Diet. Diet plays an important role in the health of the heart, especially in controlling dietary sources of cholesterol and restricting salt intake that contributes to high blood pressure

Physical Inactivity. Exercise has a number of effects that benefit the heart and circulation, including improving cholesterol and lipid levels and maintaining weight control. People who are sedentary are almost twice as likely to suffer heart attacks as are people who exercise regularly.

Medical Conditions
Obesity and Metabolic Syndrome. Excess body fat, especially around the waist, can increase the risk for heart disease. Obesity also increases the risk for other conditions (high blood pressure, diabetes) that are associated with heart disease. Obesity is particularly hazardous when it is part of the metabolic syndrome, a pre-diabetic condition that is significantly associated with heart disease. This syndrome is diagnosed when three of the following are present:

• Abdominal obesity (fat around the waist)
• Low HDL (“good”) cholesterol
• High triglyceride levels
• High blood pressure
• Insulin resistance

Unhealthy Cholesterol and Lipid Levels. Low-density lipoprotein (LDL) cholesterol is the “bad” cholesterol responsible for many heart problems. Triglycerides are another type of lipid (fat molecule) that can be bad for the heart. High-density lipoprotein (HDL) cholesterol is the “good” cholesterol that helps protect against heart disease. Doctors test for a “total cholesterol” profile that includes measurements for LDL, HDL, and triglycerides. The ratio of these lipids can affect heart disease risk

High Blood Pressure. High blood pressure, or hypertension, has long been a proven cause of coronary artery disease. A normal blood pressure reading is 120/80 mm Hg or lower. High blood pressure is generally considered to be a blood pressure reading greater than or equal to 140 mm Hg (systolic) or greater than or equal to 90 mm Hg (diastolic). Blood pressure readings in the prehypertension category (120 – 139 systolic or 80 – 89 diastolic) indicate an increased risk for developing hypertension

Diabetes. Diabetes, especially for people whose blood sugar levels are not well controlled, significantly increases the risk of developing heart disease. In fact, heart disease and stroke are the leading causes of death in people with diabetes. People with diabetes are also at risk for high blood pressure and unhealthy cholesterol levels, blood clotting problems, and impaired nerve function, all of which can damage the heart

Peripheral Artery Disease. Peripheral artery disease (PAD) occurs when atherosclerosis affects the extremities, particularly the feet and legs. The major risk factors for heart disease and stroke are also the most important risk factors for PAD. (The combination of such conditions with PAD also produces more severe forms of heart or circulatory disease.) Even though signs of heart disease are often not evident in the majority of patients with PAD, most of these patients also have coronary artery disease present

Depression. Although people with heart disease may become depressed, this does not explain entirely the link between the two problems. Data suggest that depression itself may be a risk factor for heart disease as well as its increased severity. A number of studies indicate that depression has biologic effects on the heart, including blood clotting and heart rate.

Risk Factors with Unclear Roles
Homocysteine and Vitamin B Deficiencies. Deficiencies in the B vitamins folate (known also as folic acid), B6, and B12 have been associated with a higher risk for heart disease in some studies. Such deficiencies produce higher blood levels of homocysteine, an amino acid that has been associated with a higher risk for heart disease, stroke, and heart failure.
However, while B vitamin supplements do help lower homocysteine levels, they appear to have no effect on heart disease outcomes, including preventing heart attack or stroke. Research indicates that homocysteine may be a marker for heart disease rather than a cause of it.

C-Reactive Protein. C-reactive protein (CRP) is a product of the inflammatory process. Evidence increasingly suggests that high levels may predict future heart disease. It is not known if the protein plays any causal role or whether it is simply a marker for other factors in the disease process.

C. pneumoniae and Other Infectious Organisms. Some microorganisms and viruses have been under suspicion for triggering the inflammation and damage in the arteries that contribute to heart disease. The strongest evidence to date supports a possible role from Chlamydia (C.) pneumoniae (a non-bacterial organism that causes mild pneumonia in young adults). C. pneumoniae has been detected in plaques in the arteries of patients with heart disease. However, treatment with appropriate antibiotics is not found to reduce the risk of future heart problems for patients infected with this organism.

Other studies also suggest that cytomegalovirus (CMV), a common virus, may have similar effects. Many people, however, have been infected with these organisms, and no clear association has been found with any of these infections.

Sleep Apnea. Obstructive sleep apnea is a condition in which tissues in the upper throat collapse at intervals during sleep, thereby blocking the passage of air. About a third of patients with coronary artery disease also have obstructive sleep apnea. Patients with severe, untreated apnea have been found to have an increased incidence of stroke and cardiac events (such as heart attack). However, there is no evidence to date that identifies obstructive sleep apnea as an independent cause of cardiac events or stroke.

Symptoms
Common symptoms of coronary artery disease (CAD) include angina, shortness of breath (particularly during physical exertion), and rapid heartbeat. Sometimes patients with CAD have few or no symptoms until they have heart attack or heart failure.

Angina
Angina is a symptom, not a disease. It is the primary symptom of coronary artery disease and, in severe cases, of a heart attack. It is typically felt as chest pain and occurs as a consequence of a condition called myocardial ischemia. Ischemia results when the heart muscle does not get as much blood (and, as a result, as much oxygen) as it needs for a given level of work. Angina is usually referred to as one of two states:

• Stable Angina (which is predictable)
• Unstable Angina (which is less predictable and a sign of a more serious situation)

Angina may be experienced in different ways and can be mild, moderate, or severe. The intensity of the pain does not always relate to the severity of the medical problem. Some people may feel a crushing pain from mild ischemia, while others might feel only mild discomfort from severe ischemia.

Other Types of Angina
Prinzmetal’s Angina. A third type of angina, called variant or Prinzmetal’s angina, is caused by a spasm of a coronary artery. It almost always occurs when the patient is at rest. Irregular heartbeats are common, but the pain is generally relieved immediately with standard treatment.

Silent Ischemia. Some people with severe coronary artery disease do not have angina pain. This condition is known as silent ischemia, which may occur when the brain abnormally processes heart pain. This is a dangerous condition because patients have no warning signs of heart disease. Some studies suggest that people with silent ischemia have higher complication and mortality rates than those with angina pain. (Angina pain may actually protect the heart by conditioning it before a heart attack.)

Other Causes of Chest Pain or Discomfort
Chest pain is a very common symptom in the emergency room, but heart problems account for only 10 – 33% of all episodes. There are many other causes of chest pain or discomfort including injured muscles, arthritis, heartburn, and asthma.

Diagnosis
Many tests can diagnose possible heart disease. The choice of which (and how many) tests to perform depends on the patient’s risk factors, history of heart problems, and current symptoms. Usually the tests begin with the simplest and may progress to more complicated ones.

Routine Tests to Determine Risk for Heart Disease
Doctors routinely check for high blood pressure and unhealthy cholesterol levels in all older adults. Specific tests are also important in people who may have risk factors or symptoms of diabetes.

Electrocardiograms (ECGs)
An electrocardiogram (ECG) measures and records the electrical activity of the heart. Between 25 – 50% of people who suffer from angina or silent ischemia, however, have normal ECG readings

The most important wave patterns in diagnosing and determining treatment for heart disease and heart attack are called ST elevations and Q waves.

• A depressed or horizontal ST wave suggests some blockage and the presence of a heart disease, even if there is no angina present. (This wave pattern, however, is not very accurate, particularly in women, and can occur without heart problems).
• ST elevations and Q waves are the most important wave patterns in diagnosing and determining treatment for a heart attack. They suggest that an artery to the heart is blocked, and that the full thickness of the heart muscle is damaged. ST segment elevations, however, do not always mean the patient has a heart attack. Other factors are important in making a diagnosis.

Exercise Stress Test
Exercise stress test for evaluation of coronary artery disease may be performed in the following situations:

• Patients with possible or probable angina to help determine the likelihood of coronary artery disease being present
• Patients who were previously stable who began having symptoms
• Follow-up of patients with known heart disease or after coronary bypass surgery or percutaneous procedure
• To determine a patient’s functional capacity (how well the heart can respond when extra demand is needed)
• Patients with certain types of heart rhythm disturbances
• After a heart attack, either before leaving the hospital or soon afterwards

Basic Procedure. A stress test (exercise tolerance test) monitors the patient’s heart rhythms, blood pressure, and clinical status. It can tell how well the heart handles work and if parts of the heart have decreased blood supply. A typical stress test involves:

• The patient walks on a treadmill or rides a stationary bicycle. Exercise continues until the heart is beating at least 85% of its maximum rate, until symptoms of heart trouble occur (changes in blood pressure, heart rhythm abnormalities, angina, fatigue), or the patient simply wants to stop.
• For patients who cannot exercise, the doctor may administer dobutamine or arbutamine, which are drugs that simulate the stress of exercise.

An ECG is used to monitor heart rhythms during a stress test. (An echocardiogram or more advanced imaging technique may also be used to visualize the actions of the heart and blood flow.)

Interpreting Results. To accurately assess heart problems, a variety of factors are measured or monitored using the ECG and other tools during exercise. They include:

• Exercise capacity. This is a measure of a person’s capacity to reach certain metabolic rates.
• ST waves on the ECG. Doctors specifically look for abnormalities in part of the wave tracing called an ST segment. A certain type of ST segment depression may suggest the presence of heart disease. However, gender, drugs, and other medical conditions can affect the ST segment.
• Heart rate. This is how fast the heart rate goes during exercise and how quickly it returns to normal recovery. Based on age and other factors, everyone’s heart rate should go up to a certain level during exercise. If it does not go up to the expected level, the patient is considered at risk for heart problems.
• Changes in systolic blood pressure. Generally, the blood pressure will go up during exercise.
• Oxygen levels may also be measured.

Using these and other measures, doctors can determine risk fairly accurately, particularly for men with chronic stable angina. The test has limitations, however, and some are significant. In patients with suspected unstable angina, normal or low risk results may not be as accurate in predicting future risk of cardiac events. In addition, for many reasons, the test is less accurate in women, and an echocardiogram may be a more accurate procedure for them. About 10% of patients, particularly younger people, will have false positive test results. In such cases, test results indicate abnormalities when there are no heart problems.

Echocardiograms
An echocardiogram is a noninvasive test that uses ultrasound images of the heart. This test is more expensive than an ECG, but it can be very valuable, particularly in identifying whether there is damage to the heart muscle and the extent of heart muscle damage.

A stress echocardiogram may be performed to further evaluate abnormal findings from an exercise treadmill test or a routine echocardiogram. Examples include identifying exactly which part of the heart may be involved and quantifying how much muscle has been infected. It may be the first test done when the exercise treadmill test cannot be performed due to certain abnormal rhythms.

Radionuclide Imaging
Radionuclide procedures use imaging techniques and computer analyses to plot and detect the passage of radioactive tracers through the region of the heart. Such tracing elements are typically given intravenously. Radionuclide imaging is useful for diagnosing and determining:

• Severity of unstable angina when less expensive diagnostic approaches are unavailable or unreliable
• Severity of chronic coronary artery disease
• Success of surgeries for coronary artery disease.
• Whether a heart attack has occurred

Myocardial Perfusion (Blood Flow) Imaging Test (also called the Thallium Stress Test). This radionuclide test is typically used with an exercise stress test to determine blood flow to the heart muscles. It is a reliable measure of severe heart events. It may be useful in determining the need for angiography if CT scans have detected calcification in the arteries. About a minute before the patient is ready to stop exercising, the doctor administers a radioactive tracer into the intravenous line. (Tracers include thallium, technetium, or sestamibi.) Immediately afterwards, the patient lies down for a heart scan. If the scan detects damage, more images are taken 3 or 4 hours later. Damage due to a prior heart attack will persist when the heart scan is repeated. Injury caused by angina, however, will have resolved by that time.

Radionuclide Angiography. This is a technique for visualizing the chambers and major blood vessels of the heart. It uses an injected radioactive tracer and can be performed during exercise, at rest, or with use of stress-inducing drugs. It can help determine the severity of coronary artery disease and is an alternative to echocardiograms in certain situations.

Angiography
Angiography is an invasive test. It is used for patients who show strong evidence for severe obstruction on stress and other tests, and for patients with acute coronary syndrome. It is required when there is a need to know the exact anatomy and disease present within the coronary arteries. A limitation of angiography is that it is not always the most occluded (blocked) blood vessel that causes the next heart attack. In an angiography procedure:

• A narrow tube is inserted into an artery, usually in the leg or arm, and then threaded up through the body to the coronary arteries.
• A dye is injected into the tube, and an x-ray records the flow of dye through the arteries.
• This process provides a map of the coronary circulation, revealing any blocked areas.

Computed Tomography
Computed tomography (CT) scans may be used to evaluate coronary artery disease.
Calcium Scoring CT Scans of the Heart. May be used to detect calcium deposits on the arterial walls. The presence of calcium correlates well with the presence of atherosclerosis of the heart. If the calcium score is very low, a patient is unlikely to have coronary artery disease. A higher calcium score may indicate an increased risk of current and future coronary artery disease. However, the presence of calcium does not necessarily signify narrowing of the arteries that would need further immediate evaluation or treatment.

CT Angiography. CT scans are also used to visualize the coronary arteries. When compared to invasive angiography, CT angiography is not as accurate in identifying who truly has coronary artery disease and who does not. Other types of newer CT techniques include electron beam computed tomography and multidetector computed tomography.

Prevention
Heart disease prevention is considered important before and after someone is diagnosed with the condition:

• Primary prevention refers to measures that should be done to reduce the risk of heart disease in everyone.
• Secondary prevention refers to measures to reduce the risk of progression of heart disease in a patient who has already been diagnosed. Many of these measures are similar or the same as those recommended for primary prevention.

Key prevention measures include:

• All patients should stop smoking
• Maintain cholesterol levels at appropriate levels using a heart healthy diet, exercise, and medications
• Maintain an appropriate low blood pressure level
• Maintain an active lifestyle
• Use an antiplatelet drug, such as aspirin, if appropriate (see Medications section of this report)
• Manage diabetes and kidney disease when present

Smoking Cessation
Your doctor should ask about your smoking habits at every visit. Smoking is a chronic condition and often requires repeat therapy using more than one technique.

Cholesterol and Other Lipid Disorders
All patients should start following a heart-healthy diet and exercise regularly, after talking to their doctors.
Statin drugs are the primary medications used for lowering LDL (bad) cholesterol levels. For patients without heart disease, the doctor will start or consider medication, increase dosage of medication, or add new medication when:

• LDL cholesterol is 190 mg/dL or higher.
• LDL cholesterol is 160 mg/dL or higher AND patient has one risk factor for heart disease.
• LDL cholesterol is 130 mg/dL or higher AND patient has either diabetes or two other risk factors for heart disease.
• LDL cholesterol is 100 mg/dL or higher AND patient has diabetes. Even without heart disease, medication may be considered for an LDL cholesterol of 100 mg/dL.

For patients with heart disease, the doctor will start or consider medication, increase dosage of medication, or add new medication when:

• LDL cholesterol is 100 mg/dL or higher
• LDL cholesterol is greater than 70 mg/dL. According to national guidelines, treating a patient with LDL cholesterol levels between 70 – 100 mg/dL is not required but is considered reasonable. This would be true particularly for patients who have had a recent heart attack or have known heart disease along with diabetes, current cigarette smoking, poorly controlled high blood pressure, or metabolic syndrome (high triglycerides, low HDL, and obesity).

Manage High Blood Pressure
Keep Blood Pressure Low. People in normal health should have a blood pressure reading of 120/80 mm Hg or less. Blood pressure readings of 120/80 are considered normal, readings of 140/90 or higher indicate hypertension, and readings in between the two are called pre-hypertension. Patients with diabetes chronic kidney disease, or atherosclerosis should maintain blood pressure readings of 130/80 mm Hg or less, while others should be no higher than 140/90 mm Hg.

Depending on blood pressure levels and presence of either risk factors for heart disease or known coronary artery disease, patients may be recommended to try lifestyle changes first or to immediately begin medications. Several of the medications used to treat coronary artery disease also reduce blood pressure. 

Diabetes
All patients with diabetes should have their blood sugar (glucose) levels well managed. For most patients, a goal would be to bring HbA1c levels down to 7% or below. 

Heart-Healthy Diet
Current American Heart Association (AHA) guidelines recommend:

• Balance calorie intake and physical activity to achieve or maintain a healthy body weight.
• Consume a diet rich in a variety of vegetables and fruits.
• Choose whole-grain, high-fiber foods. These include fruits, vegetables, and legumes (beans). Good whole grain choices include whole wheat, oats/oatmeal, rye, barley, brown rice, buckwheat, bulgur, millet, and quinoa.
• Consume fish, especially oily fish, at least twice a week (about 8 ounces/week). Oily fish such as salmon, mackerel, and sardines are rich in the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Consumption of these fatty acids is linked to reduced risk of sudden death and death from coronary artery disease. People with existing heart disease should consider taking fish oil supplements of 850 – 1,000 mg eicosapentaenoic acid (EPA) and docosahexaenoic acid (DPA).
• Limit daily intake of saturated fat (found mostly in animal products) to less than 7% of total calories, trans fat (found in hydrogenated fats, commercially baked products, and many fast foods) to less than 1% of total calories, and cholesterol (found in eggs, dairy products, meat, poultry, fish, and shellfish) to fewer than 300 mg per day. Choose lean meats and vegetable alternatives (such as soy). Select fat-free and low-fat dairy products. Grill, bake, or broil fish, meat, and skinless poultry.
• Use little or no salt in your foods. Reducing salt can lower blood pressure and decrease the risk of heart disease and heart failure.
• Cut down on beverages and foods that contain added sugars (corn syrups, sucrose, glucose, fructose, maltrose, dextrose, concentrated fruit juice, and honey.)
• If you drink alcohol, do so in moderation. The AHA recommends limiting alcohol to no more than 2 drinks per day for men and 1 drink per day for women.

Weight Reduction
People should aim for a BMI index of 18.5 – 24.9. Weight reduction is recommended for obese patients who have high blood pressure, high cholesterol levels, metabolic syndrome, or diabetes.

Some obese patients with coronary artery disease may consider having bariatric surgery (stomach bypass) to lose excess weight. The weight lost after surgery can help improve blood pressure, cholesterol, blood sugar and other factors associated with CAD.

Exercise and Cardiac Rehabilitation
Everyone in normal health should do at least moderate physical activity for a minimum of 30 – 60 minutes on most, if not all, days of the week
Even low amounts of moderate or high intensity exercise (walking or jogging 12 miles a week) can help produce beneficial changes in cholesterol and lipid levels. However, more prolonged exercise is required to significantly change cholesterol levels, notably by increasing HDL (“good cholesterol”). Resistance (weight) training has also been associated with heart protection.

Sudden strenuous exercise (especially snow shoveling) puts many people at risk for angina and heart attack. Patients with angina should never exercise shortly after eating. People with risk factors for heart disease should seek medical clearance and a detailed exercise prescription. And all people, including healthy individuals, should listen carefully to their bodies for signs of distress as they exercise. 

Influenza Vaccination (Flu Shot)
Patients with CAD are considered at high risk for complications from influenza. People with CAD should get an annual flu shot.

Treatment
Lifestyle changes (such as dieting, exercising, and quitting smoking) are the first approach for all degrees of coronary artery disease. Depending on severity and individual conditions, patients may also need one or more medications, surgery, or both.
Medications. Many types of medications are used to treat angina and CAD. They include:

• Anti-platelet and anticoagulant drugs (used for preventing heart disease and preventing blood clots prior to surgery or after stent insertion)
• Beta blockers
• ACE inhibitors
• Nitrates
• Calcium channel blockers

Surgery. Surgery is usually recommended for people who have:

• Unstable angina that does not respond promptly to medical treatment
• Severe recurrent episodes of angina that last more than 20 minutes
• Acute coronary syndrome
• Severe coronary artery disease (severe angina, multi-artery involvement, evidence of ischemia, or significant narrowing of left main coronary artery), particularly if abnormalities are evident in the left ventricle of the heart, the main pumping chamber

The two main surgical procedures for patients with coronary artery disease are:

• Coronary artery bypass grafting (commonly called bypass or CABG), which is usually reserved for patients with severe coronary artery disease.
• Percutaneous coronary intervention (commonly called angioplasty or PCI), usually with coronary artery stent placement. PCI is less invasive than CABG, but blood vessels can close up again (restenosis) so that patients require additional procedures.

The decision to choose angioplasty or coronary artery bypass depends on a patients individual profile, including the number and types of coronary arteries involved, the health stability, previous procedures, patient choice, and more.

Patients considering surgery should discuss all options and risks with their doctors. No surgical procedure cures coronary artery disease, and patients must continue to rigorously maintain a healthy lifestyle and any necessary medications. For some patients, lifestyle changes and medications may be able to control the disease without surgery or angioplasty.

Medications
Anti-Platelet and Anticoagulant Drugs
Anti-clotting drugs that inhibit or break up blood clots are used at every stage of heart disease. They are generally classified as either anti-platelets oranticoagulants. All anti-clotting therapies carry the risk of bleeding, which can lead to dangerous situations, including stroke.

Aspirin. Aspirin is known as a nonsteroidal anti-inflammatory drug (NSAID). It stops blood platelets, which are major clotting factors, from sticking together to form a blood clot. Aspirin therapy is extremely beneficial for patients with coronary artery disease, peripheral artery disease, or history of stroke.

A daily low-dose aspirin (75 – 81 mg) is usually the first choice for preventing heart disease in high-risk individuals. Aspirin can reduce the risk of heart attack and ischemic stroke. However, prolonged use of aspirin can increase the risks for stomach bleeding. A doctor needs to consider a patients overall medical condition and risk factors for heart attack before recommending aspirin therapy.

In general, daily aspirin is recommended for prevention of heart disease for the following people who have never had a heart attack or stroke:

• Women age 55 to 79. (Women who are younger than age 55 should not take aspirin for primary prevention.)
• Men age 45 to 79 years should take aspirin if the chances for preventing stroke or heart attack outweigh the risks of gastrointestinal bleeding. Men younger than age 45 should not take aspirin for primary prevention.
• For women and men age 80 years or older, it is not clear if the benefits of aspirin for heart protection outweigh the risks for bleeding.

Clopidogrel. Clopidogrel (Plavix) is an anti-platelet drug known as a thienopyridine. For most patients, the addition of Clopidogrel to aspirin for the prevention of heart disease is not recommended, as it adds no significant benefit, adds significantly to the cost, and increases the risk of bleeding. It may be used in place of aspirin for patients who are aspirin allergic or who cannot tolerate aspirin.

When taken with aspirin, clopidogrel is recommended for patients with acute coronary syndrome (unstable angina or early signs of heart attack) or those who have had a drug-eluting stent inserted. According to the American Heart Association, patients who have a drug-eluting stent must take both aspirin and a thienopyridine for at least 1 year after the stent is inserted.

Clopidogrel is also recommended for patients who are undergoing angioplasty. Patients having coronary bypass surgery should not take clopidogrel forat least 5 – 7 days prior to surgery because of a significant bleeding risk. Researchers are investigating whether clopidogrel and aspirin together are better than aspirin alone in reducing the risks following coronary bypass surgery.

Warfarin and Anticoagulants. Anticoagulants are drugs that prevent or delay blood coagulation and the formation of blood clots. Warfarin (Coumadin) is an oral anticoagulant. It prevents clots by inhibiting vitamin K. Warfarin is used for patients with certain types of prosthetic heart valves and to prevent blood clots in patients with atrial fibrillation. Warfarin therapy poses a dangerous risk for bleeding, and blood coagulation must be monitored with frequent blood tests. A third of all people are genetically predisposed to a higher bleeding risk with warfarin. A genetic test can help doctors determine which patients may be especially sensitive to this drug.

Beta Blockers
Beta blockers are useful for preventing angina attacks and reducing high blood pressure. They reduce the heart’s oxygen demand by slowing the heart rate and lowering blood pressure. They can help reduce risk of death from heart disease and from heart surgeries, including angiography and coronary bypass.
Beta blockers are used or recommended in a number of situations:

• They are started in nearly all patients who have just had a heart attack or acute coronary syndrome.
• They are the drugs of choice for older patients with stable angina and may also be beneficial for people with silent ischemia. They are less useful for the treatment of Prinzmetals angina.
• They may be used alone or with other medications for management of rhythm disturbances or high blood pressure.

Beta blockers include propranolol (Inderal), carvedilol (Coreg), bisoprolol (Zebeta), acebutolol (Sectral), atenolol (Tenormin), labetalol (Normodyne, Trandate), metoprolol (Lopressor, Toprol-XL), and esmolol (Brevibloc). A nasal spray form of propranolol appears to be very helpful in reducing exercise-induced angina attacks.

Side Effects. Beta blocker side effects include fatigue, lethargy, vivid dreams and nightmares, depression, memory loss, and dizziness. They can lower HDL (good) cholesterol. Beta blockers are categorized as non-selective or selective. Non-selective beta blockers, such as carvedilol and propranolol, can narrow bronchial airways. These beta blockers should not be used by patients with asthma, emphysema, or chronic bronchitis.
PATIENTS SHOULD NEVER ABRUPTLY STOP TAKING THESE DRUGS. The sudden withdrawal of beta blockers can rapidly increase heart rate and blood pressure. The doctor may advise a patient to slowly decrease the dose before stopping completely.

Angiotensin Converting Enzyme (ACE) Inhibitors
Angiotensin converting enzyme (ACE) inhibitors are important heart-protective drugs, particularly for people with diabetes and high blood pressure. They reduce the production of angiotensin, a chemical that causes arteries to narrow, and so are commonly used to lower blood pressure. They may also reduce risk for heart attack, stroke, complications of diabetes, and death in patients at high risk for heart disease.
ACE inhibitors are indicated for most patients with coronary artery disease or any other vascular diseases, such as peripheral vascular disease. They are particularly helpful for patients with coronary artery disease who also have diabetes or who have left ventricular dysfunction (when the heart’s main chamber does not pump as well as it should).

ACE inhibitors include captopril (Capoten), ramipril (Altace), enalapril (Vasotec), quinapril (Accupril), benazepril (Lotensin), perindopril (Aceon), and lisinopril (Prinivil, Zestril).

Side Effects. Side effects of ACE inhibitors may include an irritating cough. More serious side effects are uncommon but may include excessive drops in blood pressure, allergic reactions, and high blood potassium levels. [For more information, 

Nitrates
Nitrates have been used in the treatment of angina for over 100 years. These drugs release nitric oxide, thereby relaxing the smooth muscles in blood vessels. Nitrates are used primarily for control of angina symptoms. Many nitrate preparations are available. The most commonly used are nitroglycerin, isosorbide dinitrate, and isosorbide mononitrate. Nitrates can be absorbed from the gastrointestinal tract (oral tablet), skin (ointment or patch), or from under the tongue (sublingual tablet or spray).

Rapid Acting Nitrates. Rapid-acting nitrates are used to treat acute attacks. Nitroglycerin is the most widely used drug for this purpose. It can be administered under the tongue (sublingually or as a spray) or pocketed between the upper lip and gum (buccally) and can relieve angina within minutes. The procedure for taking nitroglycerin during an attack is as follows:

• At the onset of an angina attack, the patient administers one sublingual or buccal tablet or one metered dose of the spray.
• If the pain is not relieved within 5 minutes the patient takes a second dose; a third can be taken after another 5 minutes if symptoms persist.
• If pain continues after a total of three doses in 15 minutes, the patient should go immediately to the nearest emergency room.

Nitroglycerin is very unstable so its potency can be easily lost. Patients should take the following precautions:

• Keep no more than 100 tablets on hand, stored in their original container.
• When first opened, the cotton filler should be discarded, and the cap screwed on tightly immediately after each use.
• A supply should always be kept close at hand in case of an attack, with the rest kept in a cool dry place.

Intermediate to Long-Term Nitrates. Sublingual tablets of isosorbide dinitrate have a slower onset of action than nitroglycerin and are useful for preventing exercise angina. Ointments, patches, and oral tablets are used for longer-term prevention of angina attacks:

• Transdermal patches are applied in the morning to any hair- or injury-free area on the chest, back, stomach, thigh, or upper arm. Hands should be washed after each patch or ointment application, and sites of application should be rotated to avoid skin irritation.
• Nitroglycerin ointment is applied by measuring out an even amount on an applicator paper and then placing, not rubbing or massaging, it on the chest, stomach, or thigh. Any ointment that remains from the previous application should be removed.

Long-acting forms may lose their effectiveness over time, so doctors generally schedule nitrate-free breaks to prevent tolerance.
Side Effects. Nitrates can have many side effects, some of which can be serious.

Common side effects of nitrates include headaches, dizziness, nausea and vomiting, blurred vision, fast heartbeat, sweating, and flushing on the face and neck. Low blood pressure and dizziness can be relieved by lying down with the legs elevated. These effects are significantly worsened by alcohol, beta blockers, calcium channel blockers, and certain antidepressants. Patients who take nitrates in any form cannot take medications for erectile dysfunction, such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). The doctor may prescribe medicines to lessen these side effects. Patients should contact their doctor if these side effects are persistent or severe.

Serious side effects requiring immediate medical help include fever, joint or chest pain, sore throat, skin rash (especially on the face), unusual bleeding or bruising, weight gain, and swelling of the ankles.

Withdrawal. Withdrawal from nitrates should be gradual. Abrupt termination may cause angina attacks.

Calcium Channel Blockers (CCBs)
Calcium channel blockers reduce heart rate and slightly dilate the blood vessels of the heart, thereby decreasing oxygen demand and increasing oxygen supply. They also reduce blood pressure. CCBs vary chemically, however, and although some are helpful, others may even be dangerous for certain patients with angina.

• Long-acting nifedipine (Adalat, Procardia) and nisoldipine (Sular) and newer CCBs, such as amlodipine (Norvasc) and nicardipine (Cardene), may be beneficial for some patients with angina. They can be considered alone for patients who cannot tolerate beta blockers, but may provide the best results when used in combination with a beta blocker. Studies suggest that they reduce the need for repeat angioplasties. Their effects on other outcomes, including mortality rates and heart attack, are less clear.
• Short-acting CCBs, including short-acting forms of verapamil, diltiazem, nifedipine, and nicardipine, are helpful for many patients with Prinzmetal’s angina. However, short-acting forms of certain CCBs, such as nifedipine and nisoldipine, have been associated with severe and even dangerous side effects, including an increase in heart attacks and sudden death in some patients with unstable angina. They also increase the risk for adverse effects in patients with stable angina. Short-acting CCBs are, therefore, not used for stable or unstable angina.

There is no strong evidence that any calcium channel blockers improve survival rates. Overdose can cause dangerously low blood pressure and slow heart beats. Patients with heart failure have a higher risk for death with these drugs and should not take them. No one taking any calcium channel blocker should withdraw abruptly because such action could dangerously increase the risk of high blood pressure. Note: Grapefruit and Seville oranges boost the effects of CCBs, sometimes to toxic levels. (Regular oranges do not appear to pose any hazard.)

Other Drugs
Ranolazine (Ranexa) is used to treat chronic angina in patients who have not responded to other angina drugs. Ranolazine is taken in combination with amlodipine, beta blockers, or nitrates.

Surgery
Angioplasty and Stents
Angioplasty, also called percutaneous coronary intervention (PCI), involves procedures such as percutaneous transluminal coronary angioplasty (PTCA) that help open the blocked artery.

Angioplasty can help reduce the frequency of angina attacks. It is commonly recommended for patients who have critically blocked arteries or have already had a recent, acute heart attack. Angioplasty can also help improve survival and prevent heart attacks in patients with acute coronary syndrome (ACS). However, doctors have been uncertain about angioplasty’s benefits for survival and heart attack prevention in lower-risk patients with stable coronary artery disease.

Angioplasty works no better than standard heart medication (drugs to control blood pressure, lower cholesterol, and prevent blood clots) in preventing heart attack, stroke, and hospitalization in patients with stable coronary artery disease. Doctors are now recommending angioplasty only for patients who have severe heart disease. For patients with stable heart disease, drug therapy may be sufficient enough treatment and allow them to safely defer having surgery.

• Long-acting nifedipine (Adalat, Procardia) and nisoldipine (Sular) and newer CCBs, such as amlodipine (Norvasc) and nicardipine (Cardene), may be beneficial for some patients with angina. They can be considered alone for patients who cannot tolerate beta blockers, but may provide the best results when used in combination with a beta blocker. Studies suggest that they reduce the need for repeat angioplasties. Their effects on other outcomes, including mortality rates and heart attack, are less clear.
• Short-acting CCBs, including short-acting forms of verapamil, diltiazem, nifedipine, and nicardipine, are helpful for many patients with Prinzmetal’s angina. However, short-acting forms of certain CCBs, such as nifedipine and nisoldipine, have been associated with severe and even dangerous side effects, including an increase in heart attacks and sudden death in some patients with unstable angina. They also increase the risk for adverse effects in patients with stable angina. Short-acting CCBs are, therefore, not used for stable or unstable angina.

There is no strong evidence that any calcium channel blockers improve survival rates. Overdose can cause dangerously low blood pressure and slow heart beats. Patients with heart failure have a higher risk for death with these drugs and should not take them. No one taking any calcium channel blocker should withdraw abruptly because such action could dangerously increase the risk of high blood pressure. Note: Grapefruit and Seville oranges boost the effects of CCBs, sometimes to toxic levels. (Regular oranges do not appear to pose any hazard.)

Other Drugs
Ranolazine (Ranexa) is used to treat chronic angina in patients who have not responded to other angina drugs. Ranolazine is taken in combination with amlodipine, beta blockers, or nitrates.

Surgery
Angioplasty and Stents
Angioplasty, also called percutaneous coronary intervention (PCI), involves procedures such as percutaneous transluminal coronary angioplasty (PTCA) that help open the blocked artery.

Angioplasty can help reduce the frequency of angina attacks. It is commonly recommended for patients who have critically blocked arteries or have already had a recent, acute heart attack. Angioplasty can also help improve survival and prevent heart attacks in patients with acute coronary syndrome (ACS). However, doctors have been uncertain about angioplasty’s benefits for survival and heart attack prevention in lower-risk patients with stable coronary artery disease.

Angioplasty works no better than standard heart medication (drugs to control blood pressure, lower cholesterol, and prevent blood clots) in preventing heart attack, stroke, and hospitalization in patients with stable coronary artery disease. Doctors are now recommending angioplasty only for patients who have severe heart disease. For patients with stable heart disease, drug therapy may be sufficient enough treatment and allow them to safely defer having surgery.

Complications. Complications are generally rare but can include bleeding, infections, heart attack, and stroke. Finding a surgeon who performs at least 100 of the procedures a year helps reduce the risk for complications.

Blood clots may form in the new graft, closing it up or narrowing the treated vessel over time. Therapy with aspirin and other anti-clotting drugs help keep the graft open and working properly.

Recuperation and Rehabilitation. After leaving the hospital, patients have cardiac rehabilitation. Rehabilitation includes education about healthy diet and lifestyle choices, as well as exercise training to rebuild strength and stamina.

# Remember this article is for your information only. Dr. Ben-Zur recommends consulting your physician prior to making any changes in your diet, exercise or medical program.

Ref//. 
Becker RC, Meade TW, Berger PB, Ezekowitz M, O’Connor CM, Vorchheimer DA, et al. The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):776S-814S.

Coronary artery disease

What is coronary artery disease? 
Coronary artery disease occurs when fatty deposits called plaque (say “plak”) build up inside the coronary arteries. The coronary arteries wrap around the heart and supply it with blood and oxygen. When plaque builds up, it narrows the arteries and reduces the amount of blood that gets to your heart. This can lead to serious problems, including heart attack.

Coronary artery disease (also called CAD) is the most common type of heart disease. It is also the number one killer of both men and women in the United States. 

It can be a shock to find out that you have coronary artery disease. Many people only find out when they have a heart attack. Whether or not you have had a heart attack, there are many things you can do to slow coronary artery disease and reduce your risk of future problems.

What causes coronary artery disease? 
Coronary artery disease is caused by hardening of the arteries, or atherosclerosis. Atherosclerosis occurs when plaque builds up inside the arteries. (Arteries are the blood vessels that carry oxygen-rich blood throughout your body.) Atherosclerosis can affect any arteries in the body. When it occurs in the arteries that supply blood to the heart, it is called coronary artery disease. 
Plaque is a fatty material made up of cholesterol, calcium, and other substances in the blood. To understand why plaque is a problem, compare a healthy artery with an artery with atherosclerosis:

• A healthy artery is like a rubber tube. It is smooth and flexible, and blood flows through it freely. If your heart has to work harder, such as when you exercise, a healthy artery can stretch to let more blood flow to your body’s tissues.
• An artery with atherosclerosis is more like a clogged pipe. Plaque narrows the artery and makes it stiff. This limits the flow of blood to the tissues. When the heart has to work harder, the stiff arteries can’t flex to let more blood through, and the tissues don’t get enough blood and oxygen.

When plaque builds up in the coronary arteries, the heart doesn’t get the blood it needs to work well. Over time, this can weaken or damage the heart. If a plaque tears, the body tries to fix the tear by forming a blood clot around it. The clot can block blood flow to the heart and cause a heart attack. 

What are the symptoms? 
Usually people with coronary artery disease don’t have symptoms until after age 50. Then they may start to have symptoms at times when the heart is working harder and needs more oxygen, such as during exercise. Typical first symptoms include:

• Chest pain, called angina (say “ANN-juh-nuh” or “ann-JY-nuh”).
• Shortness of breath.
• Heart attack. Too often, a heart attack is the first symptom of coronary artery disease.

Less common symptoms include a fast heartbeat, feeling sick to your stomach, and increased sweating. Some people don’t have any symptoms. In rare cases, a person can have a “silent” heart attack, without symptoms.

How is coronary artery disease diagnosed? 
To diagnose coronary artery disease, doctors start by doing a physical exam and asking questions about your past health and your risk factors. Risk factors are things that increase the chance that you will have coronary artery disease. 
Some common risk factors are being older than 65; smoking; having high cholesterol, high blood pressure, or diabetes; and having heart disease in your family. The more risk factors you have, the more likely it is that you have coronary artery disease.
If your doctor thinks that you have coronary artery disease, you may have tests, such as:

• Electrocardiogram (EKG or ECG), which checks for problems with the electrical activity of your heart. An EKG can also show signs of an old or new heart attack.
• Chest X-ray.
• Blood tests.
• Exercise electrocardiogram, commonly called a “stress test.” This test checks for changes in your heart while you exercise.

Your doctor may order other tests to look at blood flow to your heart. You may have a coronary angiogram if your doctor is considering a procedure to remove blockages, such as angioplasty or bypass surgery.

How is it treated? 
Treatment focuses on taking steps to manage your symptoms and reduce your risk for heart attack and stroke. Some risk factors you can’t control, such as your age and family history. Other risk factors you can control, such as high blood pressure, high cholesterol, and smoking. Lifestyle changes can help lower your risks. You may also need to take medicines or have a procedure to open your arteries. 

Lifestyle changes are the first step for anyone with coronary artery disease. These changes may stop or even reverse coronary artery disease. To improve your heart health:

• Don’t smoke. This may be the most important thing you can do. Quitting smoking can quickly reduce the risk of heart attack or death.
• Eat a heart-healthy diet that includes plenty of fish, fruits, vegetables, beans, high-fiber grains and breads, and olive oil. See a dietitian if you need help making better food choices.
• Get regular exercise on most, if not all, days of the week. Your doctor can suggest a safe level of exercise for you. Walking is great exercise that most people can do. A good goal is 30 minutes or more a day.
• Lower your stress level. Stress can hurt your heart.

Changing old habits may not be easy, but it is very important to help you live a healthier and longer life. Having a plan can help. Start with small steps. For example, commit to eating five servings of fruits and vegetables a day. Instead of having dessert, take a short walk. When you feel stressed, stop and take some deep breaths. 

Medicines may be needed in addition to lifestyle changes. Medicines that are often prescribed for people with coronary artery disease include:

• Statins to help lower cholesterol.
• Beta-blockers or ACE inhibitors to lower blood pressure.
• Aspirin or other medicines to reduce the risk of blood clots.
• Nitrates to relieve chest pain.

Procedures may be done to improve blood flow to the heart.

• Angioplasty is used to open blocked arteries. It isn’t major surgery. During angioplasty, the doctor guides a thin tube (called a catheter) into the narrowed artery and inflates a small balloon. This widens the artery to help restore blood flow. Often a small wire-mesh tube called a stent is placed to keep the artery open. See a picture of angioplasty with stent placement. The doctor may use a stent that is coated with medicine, called a drug-eluting stent. When the stent is in place, it slowly releases a medicine that prevents the growth of new tissue. This helps keep the artery open.
• Bypass surgery, which is major surgery, may be used if more than one coronary artery is blocked. It uses healthy blood vessels to create detours around narrowed or blocked arteries.

What else can you do?
To stay as healthy as possible, it is important to:

• See your doctor for regular follow-up appointments. This lets your doctor keep track of your risk factors and adjust your treatment as needed.
• Take your medicines exactly as prescribed. Do not stop or change medicines without talking to your doctor.
• Keep nitroglycerin with you at all times, if your doctor prescribed it for chest pain.
• Tell your doctor about any chest pain you have had, even if it went away.
• Get the support you need to succeed in making lifestyle changes. Ask family or friends to share a healthy meal or join a stop-smoking program with you. Or ask your doctor about a cardiac rehab program. In cardiac rehab, a team of health professionals provides education and support to help you make new, healthy habits.

**Remember this article is for your information only.  Always consult your physician prior to making any changes in your diet, exercise or medical program.