Coronary Artery Disease

What is Coronary artery disease?

This means development of plaque in the blood vessels supplying the heart muscle. Plaque is complex to define but in simple terms means deposits of lipids, calcium, smooth muscles over a period of time in a part of the blood vessel. When this phenomena happens in the heart arteries we call this coronary atherosclerosis.. This leads to narrowing of the blood vessels ultimately leading to varying degrees of blockage as a result of which oxygen rich blood cannot reach the heart muscle. When the heart muscle does not get adequate oxygen it can lead to chest pain which is called Angina in medical terms. When this plaque ruptures it can lead to a myocardial infarction commonly known as heart attack.

Insert picture of plaque here with reference.

Why is it important to know about it?- Coronary artery disease remains one of the number causes of mortality/death in the United states and world wide. When we talk about heart disease being one of the top causes of mortality , a substantial number of times that may involve coronary artery disease in some capacity. It can present in a number of ways and we will talk about this subsequently. 

Who is at risk? What are the risk factors? A number of factors can put you at risk with the development of coronary artery disease. Some of them are modifiable( you can change) and some are not modifiable( not in your hands). Aging for example is a non modifiable risk factor. The modifiable risk factors include high blood pressure , hyperlipidemia( high cholesterol), obesity, sedentary( physically less active) lifestyle, high lipid diet, diabetes, smoking  to name some of the prominent ones. The good news is that we can take measures to modify these risk factors to prevent progression of coronary disease and we are going to talk about this subsequently. 

What are the signs and symptoms of coronary artery disease? This disease can present in a variety of ways throughout a spectrum. The most classical symptom is that of chest pain, feels like a squeezing sensation, brought on by exertion or stress and relieved by rest. It can also feel like a dull looming ache in the center of the chest and may move down to the left arm or to the jaw. This is the classical way of presenting however is not the only way and it can present in different forms especially in females and diabetic patients. It can also cause dizziness, nausea and upper stomach(epigastric)  pain sometimes . It can also present itself as shortness of breath / dyspnea on exertion along with fatigue. 

In its most concerning form it will present as an  ‘Heart attack’, typically very bad chest pressure (people may describe this as something sitting on the chest), not resolved with rest and can be associated with sudden shortness of breath, sweating, and passing out. This obviously is sudden and hard to know when it will come on. Thus a lot of times we try to catch the disease early before it presents with a heart attack.

Now remember not all chest pain means coronary artery disease as there are a number of things that can cause chest pain like lung disorders, acid reflux, musculoskeletal pain being some common reasons. Thus no form of chest pain should be ignored. The goal here is not to scare you but to educate you so you do not ignore these concerns and seek medical attention. 

What can be done to prevent progression?

Well remember the risk factors we talked about. Now is the time to act on them. 

There are 2 aspects to this. Lifestyle modifications and medications. For medications it is important to see a physician and discuss if you qualify for any medical therapy based on risk factors, disease burden and disease progression. 

However there are a number of things that you can do independently to prevent coronary disease and prevent progression.

Diet - You have probably heard this before but I will again harp on this as this is extremely important. Include more vegetables, fruits, legumes, whole grains, fish in your diet. 

Limiting cholesterol and sodium in your diet may be beneficial. Keeping salt intake it about 2 grams/day is a good starting goal. 

Minimize processed meats and sweetened beverages. Limit intake of ‘red meat’ which includes beef, pork, lamb.  A good diet plan to consider for example is the Mediterranean diet.

Consider replacing saturated fats with  monounsaturated and polyunsaturated fats. 

Exercise - Try and get at least 150 mins of moderate physical activity or 75 mins of vigorous exercise per week. Now this is a little different than ‘walking or standing at work’. Yes that is beneficial too but ideally you want dedicated exercise time. I frequently tell my patients the idea is to sweat a little or feel just a little out of breath during these sessions so you know you worked out. Just walking at work and counting those steps unfortunately does not work if you are trying to do this seriously. Weight loss in people who are obese/overweight has consistently shown to have a beneficial effect overall on health. 

Smoking is another major modifiable risk factor- Not surprisingly tobacco and in particular cigarette smoking carries one of the highest risk of cardiovascular events. Even though the incidence of smoking is decreasing it is still one of the major prevalent risk factors. Second hand smoking ( exposure to smoke on a consistent basis)  also increases your risk of cardiovascular events by about 25%. Remember you are never too old or it is never too late to quit smoking. 

It not only significantly decreases your risk of heart disease but also a number of other health disorders including lung cancer. Smokers in general die about 10 years earlier than non-smokers. 

Other modifiable risk factors like high blood pressure , diabetes , hyperlipidemia all need individualized treatment plans but remember all the factors I talked about above work for all these problems too.  

When should you see a doctor?

If you experience chest pain similar to the one described above then you should make an appointment to see a physician. If you have risk factors for coronary artery disease as detailed above and have been experiencing chest pain of any type, shortness of breath, dizziness, or have passed out then you should seek medical attention. It is also not unreasonable to make an appointment with your doctor to discuss heart disease prevention and risk stratification in detail if you do have any or all of the risk factors mentioned above. 

What can be done to treat coronary artery disease?

Lifestyle modification as detailed above is one of the most important components to prevent further progression. 

Medications - We have a number of medications we can use to treat coronary artery disease , mostly to prevent progression of atherosclerotic heart disease in conjunction with all the risk factor modifications. 

Procedures - These will include minimally invasive procedures( like angioplasty) and bypass surgery if needed. This is a complex decision and depends on multiple things including inability to control disease progression with conservative and medical management. 

Just to give you an idea,

Angioplasty/stent- We can go in and open up the blocked artery with a balloon which pushes the plaque against the blood vessel wall and then out a stent there. A stent is basically a small tube which keeps the blood vessel open. 

Bypass surgery - Involves taking blood vessels from other parts of the body and attaching them to the heart artery bypassing the area of the blockage to continue to provide blood flow to the heart muscle. 

However this decision should definitely be taken by your individual treating team and at this point you should be under the care of a cardiovascular specialist.