Coronary artery disease (CAD): causes, symptoms and treatment

Medically reviewed: 1, February 2024

What is coronary artery disease (heart disease)?

Coronary artery disease (CAD) remains the number one cause of death in the industrially developed countries. Nearly 600,000 individuals will succumb annually to CAD and nearly half will do so suddenly. For approximately one-quarter of the individuals who die suddenly, death is the first manifestation of underlying CAD.

The American Heart Association estimates that more than 25% of the adult population in the United States has some form of heart disease. This is a striking figure, given the fact that over the past 4 decades the mortality from coronary disease has declined by nearly 40%.

Much of the decrement in mortality began to emerge prior to the widespread use of interventional revascularization, such as percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG) surgery.

Risk Factors for Coronary artery disease

Risk factors for coronary disease can be classified as follows:

Major Modifiable Risk Factors

• Lipid abnormalities
• Hypertension
• Cigarette smoking
• Sedentary lifestyle.

Possible Major Modifiable Abnormalities

• Diabetes mellitus
• Obesity
• Alcohol consumption

Stress in the most general sense, as well as individual personality patterns:

• Hostility
• Anger
• Social isolation.

Non-modifiable Major Risk Factors

• Age
• Male gender
• Family history of heart disease before age 55.

Management of the patient with angina requires aggressive attention to risk factor modification. Physicians emphasize to cigarette smokers, for example, that discontinuation of cigarettes will reduce their risks for cardiac events to that of nonsmokers within 2 years following cessation. Incorporating a regular exercise program and maintaining ideal body weight also result in a significant reduction in risk for coronary disease, as does intermittent aspirin therapy.

Recently, studies have supported the use of vitamin E and perhaps other antioxidants in certain populations.

Lipid Abnormalities and Coronary artery disease

A full discussion of hyperlipidemia is beyond the intent of this section. However, recent studies have underscored the importance of lipid-lowering drugs in improved outcome for both primary and secondary prevention.

Assessing total cholesterol, including the high-density lipoproteins (HDLs) and low-density lipoproteins (LDLs), is now an official recommendation of the National Institutes of Health. Elevated HDL cholesterol exerts a cardioprotective effect, particularly among individuals with levels greater than 50 mg/dL. Levels of HDL cholesterol less than 35 mg/dL are an independent risk factor for coronary disease.

Similarly, elevations in LDL cholesterol have an independent relationship to development of coronary disease, and recommended “desirable” LDL cholesterol levels are less than 130 mg/dL. An additional advantage among patients who discontinue cigarette smoking is that HDL cholesterol will increase quite significantly in some individuals.

Significant decrease in intake of saturated fat is probably the most important element for control of lipids.

It is currently recommended that fat in the diet not exceed 30% of total calories, and some studies (particularly those by Ornish and co-workers) suggest that extremely low percentages of fat (10%) may, in fact, result in a regression or at least a significant plateauing of plaque deposition in the coronary vessels.

Hypertension with Coronary artery disease

Modification of the important risk factor hypertension not only reduces the level of active angina but also reduces the additive risk among individuals with hyperlipidemia and continued cigarette smoking.

Moreover, patients with significant hypertension and ventricular dysfunction are more likely to experience the anginal equivalent of breathlessness, particularly occurring at night and awakening them from sleep. With the availability of once-daily beta-blockers and calcium channel blockers, both angina and hypertension can be treated with the same agents simultaneously.

Cigarette Smoking

Approximately 20% of deaths in the United States from coronary disease may be directly attributable to cigarette smoking. Women under age 65 have even higher death rates, with smoking accounting for approximately 50% of all myocardial infarctions in women under age 55.

Women who smoke and use oral contraceptives may increase their risk for coronary disease 20- to 40-fold.

Cessation of cigarette smoking is mandatory for the proper management of patients with active angina. Physicians are loathe to aggressively pursue elective invasive interventions among cigarette smokers in view of the increased risk for graft occlusion in patients undergoing CABG surgery who continue to smoke, as well as higher percentages of patients returning with reocclusion of a previously PTCA-dilated vessel.

Sedentary Lifestyle

A consistent program of aerobic exercise has many advantages for the coronary patient including:

• Improvement in lipid profile
• Lowering of blood pressure
• Improved control of diabetes.

Regular exercise is associated with reduction in the frequency of anginal attacks (see Section #17, Exercise, for further discussion of objective and subjective benefits associated with aerobic exercise).

Diabetes Mellitus and Coronary artery disease

The wide spectrum of disease in patients with Type I and Type II diabetes does not allow for simple conclusions other than its optimal management. Control of hyperglycemia will help to modify the vascular effects for the diabetic patient. Insulin-dependent diabetics:

• Are at particularly high risk for all vascular injury
• Are prone to silent ischemia
• Are more likely to experience associated carotid and peripheral vascular occlusive disease.

Obesity

Obesity is currently defined as an increase of at least 30% over desired body weight. Modification of diet with associated weight reduction is difficult without a life-long commitment. It is emphasized to patients that absolute portions of food, if reduced, will result in weight loss.

If there is a simultaneous elimination of dietary fat, lipid levels will drop significantly. Patients should:

• Spend at least 30 minutes eating lunch or dinner
• Eat slowly
• Not “fast” during the day only to engorge themselves at dinner.

Losing weight by reducing portions requires that sufficient time be taken during the meal to allow visual and physical cues to create a feeling of satiety. When eating in restaurants, patients should:

• Drink two or three glasses of water prior to dinner
• Eliminate bread
• Divide an entree with another individual or order two appetizers rather than the invariably larger entree.

Modification of the traditional risk factors (eg, cigarette smoking, hypertension, hyperlipidemia) needs to be part of a program to keep patients’ lives in balance. Patients are encouraged to develop levels of priorities so that there is adequate time for relaxation, family, and the development of hobbies.

Without attention to the “total picture,” neither pharmacotherapy nor invasive interventions will alter the course of this disease.

Stress/Personality Profile

Individuals who are angry and hostile, particularly if they are socially isolated and depressed, are at significantly higher risk for all cardiac events.

Many patients with coronary disease bring to the process a life filled with “joyless striving,” dealing with internal furies, job dissatisfaction, and significant amounts of anger.

Encouraging these patients to seek counsel support groups or organized rehabilitation programs, or to embark on a regular exercise program are elements in management of equal importance to any pharmacologic or invasive intervention.

Although physicians caring for patients with coronary disease and active angina may not be able to change their patients’ social environments, they can do much to alleviate patients’ anxieties and fears by demonstrating significant interest and lending a sympathetic ear.

Symptoms of Coronary Artery Disease (CAD)

As an assistant committed to enhancing public health literacy, deciphering concerning signs is pivotal in seeking appropriate medical evaluation and intervention. Today, let us illuminate the varied expressions of coronary artery disease (CAD), painting vivid pictures conducive to prompt recognition. Knowledge equips us to act decisively against CAD manifestations, safeguarding our collective cardiovascular fortitude.

Symptomatic Spectrum

1. Chest Discomfort: Often described as pressure, tightness, heaviness, squeezing, burning, or fullness, chest distress frequently radiates across expansive territories encompassing shoulders, arms, neck, jaw, or back. Epitomizing classic anginal presentations, these sensations predominantly surface during physical exertion, emotional turmoil, or cold weather exposure, subsiding shortly after resting or administering sublingual nitroglycerin. Be vigilant for nocturnal episodes instigated by dream-associated physical activity (“coital coronaries”).
2. Shortness of Breath: Progressive respiratory compromise heralds escalating heart muscle strain due to compromised coronary reserve. Struggling to complete sentences, climbing stairs, or performing daily activities signifies mounting pulmonary ventilation deficiencies synchronously unfolding alongside evolving myocardial infarctions. Paroxysmal nocturnal dyspnea ensues as recumbency gravitationally pools peripheral edema, engendering higher venous return and precipitating pulmonary congestion. Alleviated by upright posture alterations, termed orthopnea, prompt diagnosis elucidates potential causality.
3. Fatigue and Weakness: Diminished energy reserves underscore effete homeostasis mechanisms attempting to compensate for impaired oxygen delivery efficiency amid waning cardiac output. Ensuing lethargy intensifying throughout routine duties should raise suspicion. Accompanying lightheadedness, dizziness, or syncope implicates hemodynamic fluctuations contributing to cerebral hypoperfusion, demanding thorough investigation.
4. Arrhythmias: Irregular heartbeats arise when electrical conduction abnormalities disturb sinus rhythmicity, resulting in palpitations, fluttering, skipped beats, rapid poundings, or racing pulse perceptions. Atrial fibrillation, paroxysmal supraventricular tachycardia, atrioventricular blocks, or ventricular arrhythmias materialize along CAD trajectories, occasionally portending severe sequalae mandating emergent attention.
5. Silent Myocardial Infarction: Devoid of conventional prodromal warnings, silent myocardial infarctions transpire inconspicuously, only detected retrospectively via electrocardiogram (ECG) changes or elevated biomarkers revealing subtle yet consequential myocyte necrosis. Elderly population stratums, diabetic cohorts, females, and nocturnal incidents typify underreported stealth presentations necessitating heightened index vigilance amongst healthcare providers attending seemingly asymptomatic subjects.

Coronary Artery Disease (CAD): An In-depth Look at Diagnostic Methods

Coronary artery disease (CAD) refers to the accumulation of plaque within the coronary arteries, causing them to narrow or harden over time. This restricts blood flow to the heart muscle, potentially leading to angina (chest pain), shortness of breath, or even life-threatening events like heart attacks. Detecting CAD early on can significantly improve treatment outcomes and overall prognosis, making accurate diagnostics vital. Let us explore some commonly employed methods for diagnosing coronary artery disease.

Electrocardiogram (ECG)

An ECG measures electrical activity generated by the heart, providing valuable insights into potential abnormalities. During rest or exercise stress tests, doctors assess changes in the heart’s rhythm, helping detect signs of impaired blood supply indicative of CAD. Regular ECGs may only capture transient symptoms; thus, additional techniques might be required for definitive diagnosis.

Stress Testing

Stress test echocardiogram can be taken as exercise or pharmacological interventions, which triggers physical responses mimicking those under exertion. By monitoring heart rate, blood pressure, and ECG patterns throughout, physicians identify areas where reduced blood flow might lead to insufficient oxygen delivery to the heart.

For patients unable to perform physical activities due to certain limitations, medications simulate similar conditions eliciting comparable diagnostic results.

Echocardiography

Heart ultrasound imaging technology captures moving images of heart structures and their functions, determining regional wall motion abnormalities caused by diminished blood flow. Assessments during rest and peak exercise reveal contractility differences between affected and healthy regions, allowing identification of specific vessels responsible for obstructed blood flow.

Nuclear Stress Testing

Radioactive tracers injected into the patient’s system visualize cardiac perfusion – distribution of blood flow within the heart tissue. Comparisons drawn between resting and stressed states establish discrepancies pointing towards compromised vascular systems suggestive of CAD.

Single-photon emission computed tomography (SPECT) or positron emission tomography (PET) scans enable high-resolution visualization of cardiovascular functioning, offering added precision in pinpointing culprit lesions.

Computed Tomography Angiography (CTA)

Non-invasive CT scanning generates cross-sectional views revealing calcium deposits along arterial walls – an indicator of atherosclerotic progression typical in CAD development. Combined with intravenous iodinated contrast agents highlighting vessel lumens, radiologists construct three-dimensional representations illustrating any stenoses or blockages contributing to restricted blood flow. Although less invasive than catheter-based alternatives, radiation exposure remains a notable drawback.

Coronary Angiography & Fractional Flow Reserve (FFR)

Invasive procedures entail threading thin tubes called catheters through peripheral blood vessels ascending into targeted coronaries for direct examination. Contrast injection outlines inner vessel linings, delineating sites requiring intervention based on detected obstructions.

Moreover, fractional flow reserve measurements evaluate pressure gradients across stenosed segments gauging severity, guiding decision-making regarding optimal therapeutic approaches. While carrying inherent risks compared to non-interventional counterparts, angiographic methods yield unparalleled accuracy and intervention possibilities simultaneously.

Coronary Artery Disease (CAD): Treatment Options Tailored for You

Coronary artery disease (CAD) has emerged as a significant global health concern due to our modern lifestyle, dietary habits, and increasing stress levels. This condition, often characterized by plaque accumulation within the coronary arteries, restricts blood flow to heart muscle cells leading to angina (chest pain), shortness of breath, or potentially life-threatening cardiac events like heart attacks.

However, advances in medical science have equipped healthcare providers with numerous evidence-based treatment strategies tailored to individual patient needs. Let us explore some common CAD treatment options aimed at improving patients’ prognoses and overall quality of life.

Conservative Approach: Lifestyle Modifications & Medications

The initial stage of managing CAD usually focuses on controlling symptoms, reducing risk factors, and slowing down disease progression without invasive interventions. Healthcare professionals may recommend the following conservative approaches based on each patient’s presentation and comorbidities:

• Adopting Heart-Healthy Diet Habits: Nutrition plays a crucial role in maintaining vascular health. Consuming diets rich in whole grains, fruits, vegetables, lean proteins, legumes, and nuts can improve lipid profiles, decrease inflammation, and ultimately lessen the burden on the circulatory system.
• Incorporating Regular Physical Activity: Engaging in moderate exercise programs like brisk walking, cycling, swimming, or yoga can significantly improve endothelial function, promote weight loss, enhance mental wellbeing, and aid in secondary prevention efforts.
• Smoking Cessation Counseling: Nicotine intake causes vasoconstriction, increases oxidative stress, and promotes platelet aggregation predisposing smokers to premature atherosclerosis development. Thus, smoking cessation counseling serves as an integral part of any CAD management plan.
• Pharmacotherapy: Antiplatelet agents, antihyperlipidemic drugs, beta blockers, calcium channel blockers, ACE inhibitors, and ARBs might be prescribed depending on individuals’ clinical presentations to alleviate symptoms, stabilize plaques, manage hypertension, target hyperglycemia, and minimize thrombus formation risks associated with CAD complications.

Interventional Procedures: Restoring Optimal Blood Flow

When medications fail to sufficiently relieve symptoms, revascularization procedures emerge as viable alternatives to salvage jeopardized myocardium and augment functional capacity. Two primary modalities used today include Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Grafting (CABG).

Percutaneous Coronary Intervention (PCI)

Also known as coronary angioplasty, PCI involves threading a catheter typically through radial or femoral arteries reaching stenotic lesions where balloons dilate obstructed segments followed by deploying drug-eluting stents to maintain luminal patency preventing restenosis occurrence.

Coronary Artery Bypass Grafting (CABG)

Commonly termed open-heart surgery, CABG entails creating grafts sourced from internal mammary arteries or saphenous veins harvested from legs, subsequently connecting them above and below the occluded vessels allowing restoration of adequate perfusion to affected regions beyond the blockages.

Coronary Artery Disease (CAD): Conclusion and Key Takeaways

Coronary artery disease (CAD) poses substantial threats to human health worldwide, primarily driven by modifiable lifestyle factors. Seeking knowledge about coronary artery disease enables you to make informed decisions regarding prevention and treatment.

After delving into several facets of CAD over our series of articles, let us revisit the fundamental concepts, underlying mechanisms, diagnostic methods, and available treatments. By understanding these elements, we hope you feel inspired to actively engage in combatting coronary artery disease and promoting better cardiovascular health.

Key Points:

• Coronary Artery Anatomy & Function:

Our coronary circulation originates from two major branches: the left main coronary artery and the right coronary artery. These vessels branch out extensively, providing oxygenated blood to pumping chambers and surrounding tissues. Efficient functioning depends on unobstructed vessel walls devoid of plaque depositions, ensuring healthy myocardial contractility.

• Major Risks & Prevalence:

Despite advancements in diagnostic tools and therapeutics, CAD remains widespread, disproportionately affecting certain demographic groups. Primary contributors include aging, male sex, family history, tobacco abuse, dyslipidemia, diabetes, hypertension, sedentary behavior, poor nutrition, psychological stressors, and social determinants of health disparities. Addressing these issues requires concerted action across populations, industries, and policymakers.

Pathophysiological Processes:

Overarching themes driving CAD pathogenesis involve chronic low-grade inflammation, altered lipid metabolism, vascular smooth muscle cell migration, and extracellular matrix remodeling. Comprehending how molecular mediators participate in plaque genesis empowers researchers to develop innovative intervention targets disrupting atheroma growth.

• Diagnostic Testing:

Various imaging modalities facilitate non-invasive identification and quantification of coronary artery disease severity. Electrocardiography, echocardiography, radionuclide studies, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) provide valuable insights, albeit differing costs, accessibilities, radiation exposures, and indications necessitate careful clinician consideration prior to test ordering.

• Therapeutic Measures

No universal blueprint exists for managing coronary artery disease given heterogeneous patient phenotypes, coexisting conditions, and shared decision-making priorities. Nevertheless, core tenets revolve around aggressive risk reduction incorporating lifestyle modifications, medication initiation or adjustment, device implantation, surgical referral, and structured follow-up regimens for ongoing monitoring.

References:

Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-e528.

Smith SC Jr, Blankenship JC, Ruzyllo W, Jacobs AK, Roger VL, Nishimura RA. 2018 ACC expert consensus decision pathway on novel therapies for established coronary artery disease: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. Journal of the American College of Cardiology. 2018;72(16):1859-1873.

Pursnani ASK, Kamat SD. Management Strategies For Patients With Acute Coronary Syndromes Amid COVID-19 Pandemic. Circulation. 2020;142(2):115-118.

Ferencik M, Dilsizian V. Imaging Techniques Providing Physiologic Insight Into Ischemia. Methodist DeBakey Cardiovasc J. 2017;13(1):13-18.