Coronary Artery Disease (CAD)

Causes

• High Blood Pressure (Hypertension): Uncontrolled high blood pressure can harden and thicken your arteries, narrowing the channel through which blood can flow.
• High Cholesterol: High levels of low-density lipoprotein (LDL) cholesterol ("bad" cholesterol) contribute to plaque formation.
• Diabetes: High blood sugar levels from diabetes can damage blood vessels, including the coronary arteries.
• Smoking: Nicotine and other chemicals in tobacco smoke damage the artery walls, accelerate atherosclerosis, and increase blood clot formation.
• Obesity: Excess weight often contributes to other risk factors like high blood pressure, high cholesterol, and diabetes.
• Physical Inactivity: Lack of exercise is linked to higher blood pressure, cholesterol levels, and obesity.
• Unhealthy Diet: A diet high in saturated and trans fats, cholesterol, sodium, and sugar can contribute to atherosclerosis.
• Age: The risk of damaged and narrowed arteries increases with age.
• Sex: Men are generally at greater risk, but the risk for women increases after menopause.
• Family History: A strong family history of heart disease, especially at an early age, increases your risk.
• Stress: Chronic stress may contribute to CAD risk factors.

Symptoms

• Angina (Chest Pain): This is the most common symptom. It's often described as a pressure, tightness, heaviness, or squeezing in the chest. It may spread to the arms (especially the left), neck, jaw, back, or stomach. Angina is typically triggered by physical activity or emotional stress and relieved by rest or nitroglycerin.
• Shortness of Breath (Dyspnea): Feeling breathless, especially during exertion. This can occur if the heart isn't pumping enough blood to meet the body's needs or if fluid builds up in the lungs due to heart failure.
• Fatigue: Unusual tiredness, especially during activity.
• Nausea.
• Sweating.
• Dizziness or Lightheadedness.
• Pain in other parts of the body: Such as the arms, neck, jaw, or back.

Diagnosis

• Medical History and Physical Exam: The doctor will ask about your symptoms, risk factors, family history, and conduct a physical examination, including checking blood pressure and listening to your heart.
• Blood Tests:
  • Cholesterol levels: To check for high LDL cholesterol and triglycerides.
  • Blood sugar (glucose) and A1C: To check for diabetes or prediabetes.
  • High-sensitivity C-reactive protein (hs-CRP): A marker of inflammation that can indicate heart disease risk.
• Electrocardiogram (ECG/EKG): Records the electrical signals of your heart to detect heart attacks or signs of reduced blood flow.
• Stress Test: Involves exercising on a treadmill or stationary bike while your heart activity is monitored. If you can't exercise, medication may be used to simulate the effects of exercise on your heart. This helps evaluate blood flow to the heart during stress.
• Echocardiogram: An ultrasound of the heart that shows how well your heart chambers and valves are pumping blood.
• Coronary Angiography (Cardiac Catheterization): A thin, flexible tube (catheter) is inserted into an artery (usually in the groin or wrist) and guided to the heart. Dye is injected into the coronary arteries, and X-ray images are taken to show blockages or narrowing. This is considered the gold standard for diagnosing CAD.
• Cardiac CT Angiography (CCTA): A non-invasive CT scan that uses dye to visualize the coronary arteries and detect plaque buildup.

Treatment

• Lifestyle Changes (Cornerstone of Treatment):
  • Healthy Diet: Emphasize fruits, vegetables, whole grains, lean proteins, and healthy fats. Limit saturated and trans fats, cholesterol, sodium, and added sugars.
  • Regular Exercise: Aim for at least 150 minutes of moderate-intensity aerobic activity per week.
  • Quit Smoking: This is the most important step to prevent further damage.
  • Weight Management: Lose excess weight and maintain a healthy weight.
  • Stress Management: Practice relaxation techniques like meditation, yoga, or deep breathing.

• Medications:
  • Cholesterol-lowering medications (Statins): Reduce LDL cholesterol and stabilize plaque (e.g., atorvastatin, simvastatin).
  • Aspirin: Low-dose aspirin may be prescribed to reduce the risk of blood clots.
  • Beta-blockers: Slow the heart rate and lower blood pressure, reducing the heart's oxygen demand (e.g., metoprolol, carvedilol).
  • Nitroglycerin: Relieves angina by dilating blood vessels.
  • ACE inhibitors or ARBs: Lower blood pressure and can protect the heart (e.g., lisinopril, valsartan).
  • Calcium channel blockers: Relax blood vessels and can help with angina.

• Procedures:
  • Angioplasty and Stent Placement (Percutaneous Coronary Intervention - PCI): A catheter with a balloon is used to open narrowed arteries, and a stent (a small mesh tube) is often placed to keep the artery open.
  • Coronary Artery Bypass Grafting (CABG) Surgery: A healthy blood vessel from another part of the body is used to bypass (go around) a blocked or narrowed coronary artery, restoring blood flow to the heart.

Living With Coronary Artery Disease After the Diagnosis

A diagnosis of coronary artery disease, whether it arrives after a heart attack, a stent, or an abnormal stress test, marks the start of secondary prevention: a set of treatments with unusually strong evidence for keeping the next event from happening. The pieces that matter most are the ones that are easiest to let slide once you feel well.

Cardiac rehabilitation is the most underused treatment

A supervised program of exercise, education, and risk-factor coaching after a heart attack, stent, or bypass reduces rehospitalization and death, yet only a minority of eligible patients ever enroll. It is covered by Medicare and most insurers. If you were not referred, ask; if you were referred and did not go, it is not too late.

Statin intensity and LDL targets

Established coronary disease calls for a high-intensity statin, usually atorvastatin or rosuvastatin, with a goal of driving LDL cholesterol below 70 mg/dL and often lower after a recent event. When the statin alone does not get there, ezetimibe is added. Muscle aches are common and usually manageable by adjusting the dose or switching agents rather than abandoning treatment; our statin myths versus evidence article addresses the most frequent worries.

Antiplatelet therapy is not optional

Low-dose aspirin continues indefinitely unless there is a specific reason to stop. After a stent, a second antiplatelet drug such as clopidogrel is added for a defined period, and stopping it early, even for a dental procedure or a colonoscopy, carries a real risk of the stent clotting. Never pause either drug without speaking to the cardiologist who placed the stent.

Knowing when angina has changed

Stable angina follows a predictable pattern with exertion and eases with rest. Pain that arrives at rest, lasts longer, comes with less effort than before, or does not settle within five minutes of a nitroglycerin dose is a reason to call 911, not to wait and see. The early warning signs of a heart attack article describes the symptoms women and people with diabetes are more likely to have.

Blood pressure, blood sugar, and the heart muscle

High blood pressure and diabetes keep driving atherosclerosis after a stent is placed, so their control is part of heart treatment. Several newer diabetes medications reduce cardiovascular events in people with established heart disease and are chosen for that reason. Coronary disease that has weakened the heart muscle progresses to heart failure, which is why an echocardiogram is repeated when breathlessness or swelling appears. Our cardiovascular team coordinates this care with cardiology. The NHLBI and the American Heart Association publish detailed patient guidance.

If you have coronary artery disease and are unsure whether your cholesterol, blood pressure, or medications are where they should be, schedule a review.