• Coronary Artery Disease

    (CAD; Coronary Atherosclerosis; Silent MI; Coronary Heart Disease; Ischemic Heart Disease; Atherosclerosis of the Coronary Arteries)

    Definition

    Coronary arteries bring oxygen rich blood to the heart muscle. Coronary artery disease (CAD) is narrowing of these arteries. If the blockage is complete, areas of the heart muscle may be damaged. In a severe case, the heart muscle dies. This can lead to a heart attack, also known as a myocardial infarction (MI).
    Coronary Artery Disease
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    Causes

    Causes include:
    • Thickening of the walls of the arteries that feed the heart muscle
    • Build up of fatty plaques within the coronary arteries
    • Sudden spasm of a coronary artery
    • Narrowing of the coronary arteries
    • Inflammation within the coronary arteries
    • Development of a blood clot within the coronary arteries that blocks blood flow

    Risk Factors

    Men, especially those who are over 45 years of age, are at increased risk. Women who are over 55 years of age are also at increased risk.
    Factors that may increase your risk of CAD include:
    • Strong family history of heart disease
    • Obesity and being overweight
    • Smoking
    • High blood pressure
    • Inactive lifestyle
    • High cholesterol—specifically, high LDL cholesterol and triglycerides, and low HDL cholesterol
    • Diabetes
    • Metabolic syndrome—a combination of elevated blood pressure and cholesterol, abdominal obesity, and insulin resistance
    Other risk factors may include:
    • Chronic stress, fatigue, or disinterest can lead you to make poor decisions about your health
    • Excessive alcohol use
    • Psychological disorders, such as depression and anxiety.
    • A diet that is high in saturated fat, trans fat, cholesterol, and/or calories
    • Drinking sugary beverages on a regular basis

    Symptoms

    CAD may progress without any symptoms.
    Angina is chest pain that comes and goes. It often has a squeezing or pressure-like quality. It may radiate into the shoulder(s), arm(s), or jaw. Angina usually lasts for about 2-10 minutes. It is often relieved with rest. Angina can be triggered by:
    • Exercise or exertion
    • Emotional stress
    • Cold weather
    • A large meal
    Chest pain may indicate more serious unstable angina or a heart attack if it includes the following:
    • It is unrelieved by rest or nitroglycerin
    • Severe angina
    • Angina that begins at rest
    • Angina that lasts more than 15 minutes
    Accompanying symptoms may include:
    • Shortness of breath
    • Sweating
    • Nausea
    • Weakness
    Immediate medical attention is needed for unstable angina. CAD in women may not cause typical symptoms. It is likely to start with shortness of breath and fatigue.

    Diagnosis

    If you go to the emergency room with chest pain, some tests will be done right away. The tests will attempt to see if you are having angina or a heart attack. If you have a stable pattern of angina, other tests may be done to determine the severity of your disease.
    You will be asked about your symptoms and medical history. A physical exam will be done.
    You may need to have your bodily fluids tested. This can be done with blood tests.
    You may need to have pictures taken of your heart. This can be done with:
    You may need to have your heart function tested. This can be done with:

    Treatment

    Treatment may include:

    Nitroglycerin

    This medication is usually given during an attack of angina. It can be given as a tablet that dissolves under the tongue or as a spray. Longer-lasting types can be used to prevent angina before an activity known to cause it. These may be given as pills or applied as patches or ointments.

    Blood-Thinning Medications

    A small, daily dose of aspirin has been shown to decrease the risk of heart attack. Ask your doctor before taking aspirin daily.
    Other blood-thinning medications may be prescribed.

    Beta-Blockers, Calcium-Channel Blockers, and ACE-Inhibitors

    These may help prevent angina. In some cases, they may lower the risk of heart attack.

    Medications to Lower Cholesterol

    Medications, like statins, are often prescribed to people who have CAD. Statins lower cholesterol levels, which can help to prevent CAD events.

    Revascularization

    Patients with severe blockages in their coronary arteries may benefit from procedures to immediately improve blood flow to the heart muscle:
    • Percutaneous coronary interventions (PCI)—such as balloon angioplasty , in some cases, a wire mesh stent is placed to hold the artery open
    • Coronary artery bypass grafting (CABG)—segments of vessels are taken from other areas of the body and are sewn into the heart arteries to reroute blood flow around blockages

    Options for Refractory Angina

    For patients who are not candidates for revascularization procedures, but have continued angina despite medication, options include:
    • Enhanced external counterpulsation (EECP)—large air bags are inflated around the legs in tune with the heart beat. The patient receives 5 1-hour treatments per week for 7 weeks. This has been shown to reduce angina and may improve symptom-free exercise duration.
    • Transmyocardial revascularization (TMR)—surgical procedure done with laser to reduce chest pain

    Prevention

    To reduce your risk of CAD:
    • Maintain a healthy weight.
    • Eat a heart healthy diet that is low in saturated fat , red meat and processed meats, and rich in whole grains , fruits, vegetables, and nuts .
    • Begin a safe exercise program with the advice of your doctor.
    • If you smoke, talk to your doctor about ways to quit .
    • Treat your high blood pressure and/or diabetes.
    • Treat high cholesterol or triglycerides.
    • Ask your doctor about taking a low-dose aspirin every day.
    • Find ways to reduce stress.

    RESOURCES

    American Heart Association http://www.heart.org

    National Heart, Lung, and Blood Institute https://www.nhlbi.nih.gov

    CANADIAN RESOURCES

    Heart and Stroke Foundation of Canada http://www.heartandstroke.ca

    Public Health Agency of Canada https://www.canada.ca

    References

    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;356:1503-1516.

    Coronary artery disease–Coronary heart disease. American Heart Association website. Available at:http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Coronary-Artery-Disease---Coronary-Heart-Disease%5FUCM%5F436416%5FArticle.jsp#.WblGd7KGNQI. Updated April 26, 2017. Accessed September 13, 2017.

    Coronary artery disease (CAD). EBSCO DynaMed Plus website. Available at: http://www.dynamed.com/topics/dmp~AN~T116156/Coronary-artery-disease-CAD. Updated June 7, 2017. Accessed September 13, 2017.

    Explore coronary artery disease. National Heart, Lung, and Blood Institute website. Available at: https://www.nhlbi.nih.gov/health/health-topics/topics/cad. Updated June 22, 2016. Accessed September 13, 2017.

    Management of stable angina. DynaMed Plus website. Available at: http://www.dynamed.com/topics/dmp~AN~T114265/Management-of-stable-angina. Updated April 10, 2017. Accessed September 13, 2017.

    4/10/2007 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T114265/Management-of-stable-angina: 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;356(15):1503-1516.

    11/7/2007 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T901116/Revascularization-for-coronary-artery-disease-CAD: Bravata DM, Gienger AL, McDonald KM, et al. Systematic Review: The comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery. Ann Intern Med. 2007;147(10):703-716.

    1/6/2009 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113766/Coronary-artery-disease-possible-risk-factors: Surtees PG, Wainwright NW, Luben RN, Wareham NJ, Bingham SA, Khaw KT. Depression and ischemic heart disease mortality: evidence from the EPIC-Norfolk United Kingdom prospective cohort study. Am J Psychiatry. 2008;165(4):515-523.

    6/5/2009 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T116156/Coronary-artery-disease-CAD: Sinha R, Cross AJ, Graubard BI, Leitzmann MF, Schatzkin A. Meat intake and mortality: a prospective study of over half a million people. Arch Intern Med. 2009;169(6):562-571.

    7/6/2009 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113884/Physical-activity-for-cardiovascular-disease-prevention: Kodama S, Saito K, Tanaka S, et al. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA. 2009;301(19):2024-2035.

    7/6/2009 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113766/Coronary-artery-disease-possible-risk-factors: Fung TT, Malik V, Rexrode KM, Manson JE, Willett WC, Hu FB. Sweetened beverage consumption and risk of coronary heart disease in women. Am J Clin Nutr. 2009;89(4):1037-1042.

    11/26/2012 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113766/Coronary-artery-disease-possible-risk-factors: Kivimaki M, Nyberg S, Batty G, et al. Job strain as a risk factor for coronary heart disease: a collaborative meta-analysis of individual participant data. Lancet. 2012;380(9852):1491-1497.

    7/21/2014 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T115449/Dietary-considerations-for-cardiovascular-disease-prevention: Afshin A, Micha R, Khatibzadeh S, Mozaffarian D. Consumption of nuts and legumes and risk of incident ischemic heart disease, stroke, and diabetes: a systematic review and meta-analysis. Am J Clin Nutr. 2014;100(1):278-288.

    9/29/2016 DynaMed Plus Systematic Literature Surveillance http://www.dynamed.com/topics/dmp~AN~T113766/Coronary-artery-disease-possible-risk-factors: Batelaan NM, Seldenrijk A, Bot M, van Balkom AJ, Penninx BW. Anxiety and new onset of cardiovascular disease: critical review and meta-analysis. Br J Psychiatry. 2016;208(3):223-231.

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