Coronary Artery Disease 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.

Atherosclerosis is a disease of the arteries in which fatty material is deposited in the vessel wall, resulting in narrowing and eventual impairment of blood flow. Severely restricted blood flow in the arteries to the heart muscle leads to symptoms such as chest pain. Atherosclerosis shows no symptoms until a complication occurs.

What Are the Symptoms of Coronary Artery Disease? The most common symptom of coronary artery disease is angina, or chest pain. Angina can be described as a 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

Etiology
Coronary heart disease (CHD) is the leading cause of death in the United States for men and women. Coronary heart disease is caused by the buildup of plaque in the arteries to your heart. This may also be called hardening of the arteries.

Fatty material and other substances form a plaque build-up on the walls of your coronary arteries. The coronary arteries bring blood and oxygen to your heart. This buildup causes the arteries to get narrow. As a result, blood flow to the heart can slow down or stop.

A risk factor for heart disease is something that increases your chance of getting it. You cannot change some risk factors for heart disease, but others you can change.

Pathophysiology
Limitation of blood flow to the heart causes ischemia (cell starvation secondary to a lack of oxygen) of the myocardial cells. Myocardial cells may die from lack of oxygen and this is called a myocardial infarction (commonly called a heart attack). It leads to heart muscle damage, heart muscle death and later myocardial scarring without heart muscle regrowth. Chronic high-grade stenosis of the coronary arteries can induce transient ischemia which leads to the induction of a ventricular arrhythmia, which may terminate into ventricular fibrillation leading to death.
DIAGNOSIS Specialists Involved

If you have coronary artery disease, your healthcare provider may

recommend other healthcare specialists. These may include: A cardiologist. This is a doctor who specializes in diagnosing and treating heart diseases and conditions. You may see a cardiologist if you have coronary heart disease (CHD). A vascular specialist. This is a doctor who specializes in diagnosing and treating blood vessel problems. You may see a vascular specialist if you have peripheral arterial disease (P.A.D.). A neurologist. This is a doctor who specializes in diagnosing and treating nervous system disorders. You may see a neurologist if you've had a stroke due to carotid artery disease.

Methods of Diagnosis

Physical Exam: During a physical exam, your health professional may use a stethoscope to check your arteries for an abnormal whooshing sound called a bruit, which may indicate poor blood flow due to plaque buildup. He or she also may check to see whether any of your pulses (for example, in the leg or foot) are weak or absent, which can be a sign of a blocked artery. Diagnostic Tests: Your healthcare provider may recommend one or more tests to diagnose atherosclerosis. These tests can help define the extent of your disease and the best treatment plan. Blood Tests check the levels of certain fats, cholesterol, sugar, and proteins in your blood. Abnormal levels may put you at risk for atherosclerosis. Ankle/Brachial Index compares the blood pressure in your ankle with the blood pressure in your arm to see how well your blood is flowing. Used to help diagnose P.A.D. EKG (Electrocardiogram) detects and records the heart's electrical activity. It shows how fast the heart is beating and its rhythm (steady or irregular). Echocardiography uses sound waves to create a moving picture of your heart. The test provides information about the size and shape of your heart, how well your heart chambers and valves are working, and areas of poor blood flow. Computed Tomography Scan creates computer-generated pictures and can show hardening and narrowing of large arteries. Stress Testing You exercise (or are given medicine if you are unable to exercise) to make your heart work hard and beat fast while heart tests are done. A stress test can show possible signs of CAD. Angiography: Angiography uses dye and special X-rays to reveal the insides of your arteries. It can show whether plaque is blocking your arteries and how severe the blockage is.

TREATMENT Treatment for coronary artery disease involves making lifestyle changes, taking medications, possibly undergoing invasive and/or surgical procedures, and seeing your cardiologist for regular checkups.

Reduce your risk factors. If you smoke, quit. Avoid highcholesterol foods and adopt a low-fat, low-salt diet. Keep your blood sugar in control if you have diabetes. Exercise more to maintain a healthy weight (but talk to your doctor before you 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, such as stem cells and other genetic material, through the vein or directly into damaged heart tissue to trigger the growth of new blood vessels to bypass the clogged ones. EECP (Enhanced External Counterpulsation). Patients who have chronic angina but are not helped by nitrate medications or who do not qualify for various surgeries and procedures may find relief with EECP. The outpatient procedure involves using treatment cuffs

placed on the legs that inflate and deflate, increasing the blood supply that feeds coronary arteries. MANAGEMENT
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.

What Is Coronary Artery Disease? Heart disease is a result of plaque buildup in your coronary arteries -- a condition called atherosclerosis -- that leads to blockages. The arteries, which start out smooth and elastic, become narrow and rigid, restricting blood flow to the heart. The heart becomes starved of oxygen and the vital nutrients it needs to pump properly.

CAUSES: How Does Coronary Artery Disease Develop? From a young age, cholesterol-laden plaque can start to deposit in the blood vessel walls. As you get older, the plaque burden builds up, inflaming the blood vessel walls and raising the risk of blood clots and heart attack. The plaques 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, lipoproteins, and calcium that travel in your bloodstream start sticking to the inside of the vessel walls. 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 some cases, a blood clot may totally block the blood supply to the heart muscle, causing heart attack. If a blood vessel to the brain is blocked, usually from a blood clot, an ischemic stroke can result. If a blood vessel within the brain bursts, most likely as a result of uncontrolled hypertension (high blood pressure), a hemorrhagic stroke can result.

What Is Ischemia? Cardiac ischemia occurs when plaque and fatty matter narrow the inside of an artery to a point where it cannot supply enough oxygenrich blood to meet your heart's needs. Heart attack can occur - with or without chest pain and other symptoms. Ischemia is most commonly experienced during:

Exercise or exertion Eating Excitement or stress Exposure to cold

Coronary artery disease can progress to a point where ischemia occurs even at rest. And ichemia can occur without any warning signs in anyone with heart disease, although it is more common in 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),exercisestress 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? What to Do If You Have a Coronary Emergency 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 experiences chest discomfort, especially if there is shortness of breath, heart palpitations, dizziness, a fast heart beat, nausea or sweating, don't wait longer than a few minutes to call 911 for 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.

Coronary Artery Disease (CAD)

Background

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 animalbased 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.

an image of cholesterol inside an artery - Cholesterol may build-up at the site of a tear in the lining of an internal carotid artery.

Oxidation

The damaging process called oxidation is an important trigger in the atherosclerosis story.

Oxidation is a chemical process in the body caused by the release of unstable particles known as oxygen-free radicals. It is one of the normal processes in the body, but under certain conditions (such as exposure to cigarette smoke or other environment stresses) these free radicals are overproduced. In excess amounts, they can be very dangerous, causing damaging inflammation and even affecting genetic material in cells. In heart disease, free radicals are released in artery linings and oxidize low-density lipoproteins (LDL). The oxidized LDL is the basis for cholesterol build-up on the artery walls and damage leading to heart disease.
Inflammatory Response

For the arteries to harden there must be a persistent reaction in the body that causes ongoing harm. Researchers now believe that this reaction is an immune process known as the inflammatory response.

an image of atherosclerosis - Atherosclerosis is a disease of the arteries in which fatty material and plaque are deposited in the wall of an artery, resulting in narrowing of the arterial lumen and eventual impairment of blood flow.

There is growing evidence that the inflammatory response may be present not only in local plaques in single arteries but also throughout the arteries leading to the heart.
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.

an image of coronary artery blockage

- Atherosclerosis is a common disorder of the arteries. Fat, cholesterol, and other substances collect in the walls of arteries. Larger accumulations are called atheromas or plaque and can damage artery walls and block blood flow. Severely restricted blood flow in the heart muscle leads to symptoms such as chest pain.

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.

an image of the developmental process of atherosclerosis

- The development of arterial atherosclerosis may occur when deposits of cholesterol and plaque accumulate at a tear in the inner lining of an artery. As the deposits harden and occlude the arterial lumen, blood flow to distant tissues decreases and a clot may become lodged, completely blocking the artery.

The external structures of the heart include the ventricles, atria, arteries, and veins. Arteries carry blood away from the heart while veins carry blood into the heart. The vessels colored blue indicate the transport of blood with relatively low content of oxygen and high content of carbon dioxide. The vessels colored red indicate the transport of blood with relatively high content of oxygen and low content of carbon dioxide.

an image of the anterior heart arteries

- The

coronary arteries supply blood to the heart muscle. The right

coronary artery supplies both the left and the right heart; the left coronary artery supplies the left heart.