Coronary Artery Disease (CAD) (Coronary Heart Disease, Ischemic Heart Disease, Atherosclerosis of the Coronary Arteries)

Major risk factors include: Sex: male (men have a greater risk of heart attack than women)Age: 45 and older for men, 55 and older for womenHeredity: strong family history of heart diseaseObesity and being overweight SmokingHigh blood pressureSedentary lifestyleHigh blood cholesterol (specifically, high LDL cholesterol, and low HDL cholesterol) Diabetes Other risk factors include: StressExcessive alcohol useMetabolic syndrome combination of high blood pressure, abdominal obesity, and insulin resistance SymptomsCAD may progress without any noticeable symptoms. Symptoms include: Angina intermittent chest pain that often has a squeezing or pressure-like quality, that may radiate into the shoulder(s), arm(s), or jaw. Angina usually lasts for about 2-10 minutes and is often relieved with rest. Angina can be triggered by: Exercise or exertionEmotional stressCold weatherA large meal Angina unrelieved by rest or nitroglycerin, severe angina, angina that begins at rest (with no activity), or angina that lasts more than 15 minutes are warning signs of unstable angina or a heart attack. Accompanying symptoms may include:

Shortness of breathSweatingNauseaWeaknessImmediate medical attention is needed for unstable angina.CAD in women may cause less classic chest pain and be heralded by shortness of breath on exertion and fatigue. DiagnosisIf you go to the emergency room with chest pain, some tests will be done right away to see if you are having an episode of angina or a heart attack. If you have a stable pattern of angina, other tests may be done more electively to determine the severity and extent of your disease and to create a treatment plan.The doctor will ask about your symptoms and medical history, and perform a physical exam. Tests may include: Blood teststo look for certain substances in the blood called troponins which help the doctor determine if you are having an acute heart attackElectrocardiogram (ECG, EKG) records the heart's activity by measuring electrical currents through the heart muscle, and can reveal evidence of past heart attacks, acute heart attacks, and heart rhythm problems Echocardiogram uses high-frequency sound waves (ultrasound) to examine the size, shape, and motion of the heart, giving information about the structure and function of the heart Exercise stress test records the heart's electrical activity during increased physical activity Nuclear stress testradioactive material is injected into a vein during exercise or pharmacologic stress and observed as it is absorbed by the heart muscle. This can help tell your doctor whether there is impaired blood flow suggesting an obstructed coronary artery. Coronary calcium scoringa type of x-ray called a CAT scan that uses a computer to make pictures of the heart. The presence of calcium in the heart arteries suggests that atherosclerosis or hardening of the arteries is occurring Coronary angiography x-rays taken after a dye is injected into the arteries to allows the doctor to look for abnormalities in the arteries. This can be done through a puncture into the large artery in the groin or noninvasively with new CAT Scan technology. TreatmentTreatment may include:

Nitrate MedicationsNitroglycerin is usually given during an acute attack of angina. It can be given as a tablet that dissolves under the tongue or as a spray. There are also longer-lasting types that can be used to prevent angina before you participate in an activity known to cause it. These may be given as pills or applied as patches or ointments. Blood-Thinning MedicationsA small, daily dose of aspirin has been shown to decrease the risk of heart attack. Ask your doctor before taking aspirin daily. Warfarin (Coumadin), ticlopidine (Ticlid), and clopidogrel (Plavix) are also used for some patients. Beta-Blockers, Calcium-Channel Blockers, and ACE-InhibitorsThese may help prevent angina and, in some cases, lower the risk of heart attack. Medications to Lower CholesterolThese medication may prevent the progression of coronary artery disease and may even improve existing coronary artery disease.Evidence shows that lowering cholesterol has a positive effect on prevention of CAD events. Revascularization Patients with severe blockages in their coronary arteries may benefit from procedures to improve blood flow to the heart muscle: Percutaneous coronary interventions (PCI)catheter-based procedures done through a small puncture into the large artery in the groin. These include balloon angioplasty where a small balloon is inflated in a coronary artery to widen and compress plaque out of the way. In some cases, a wire mesh stent is placed to hold the artery open. Some newer stents are coated with a medication (drug eluting stents) to prevent recurrent narrowing due to clot formations. Coronary artery bypass grafting (CABG) done surgically through an incision in the chest. Segments of arteries taken from the chest wall and wrist or veins taken from the legs are sewn into the heart arteries to reroute blood flow around blockages. According to a review of 23 studies, patients who received CABG had more angina relief and less need for another, similar procedure than those who received PCI. * 2

Another study compared PCI plus optimal medical therapy (intensive medications and lifestyle changes) to optimal medical therapy alone in stable heart patients. Researchers found that adding PCI to treatment did not reduce the risk of death, myocardial infarction, or other heart-related events. * 1 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 like blood pressure cuffs are inflated around the legs in sequence with the patients heart beat. The patient receives 5 one-hour treatments per week for seven weeks. This has been shown to reduce angina frequency and may improve symptom-free exercise duration.Transmyocardial revascularization (TMR)surgical procedure done with laser to reduce chest painResearchers are also studying gene therapy as a possible treatment. Prevention To reduce your risk of getting coronary artery disease: Maintain a healthy weight.Begin a safe exercise program with the advice of your doctor.If you smoke, quit.Eat a healthful diet, low in saturated fat and rich in whole grains, fruits, and vegetables.Treat your high blood pressure and/or diabetes.Treat high cholesterol or triglycerides. RESOURCES:

American Heart Associationhttp://www.americanheart.org National Heart, Lung, and Blood Institutehttp://www.nhlbi.nih.gov CANADIAN RESOURCES: Heart and Stroke Foundation of Canadahttp://ww2.heartandstroke.ca/Page.asp?PageID=24 University of Ottawa Heart Institutehttp://www.ottawaheart.ca/UOHI/Welcome.do References: American Heart Association website. Available at: http://www.americanheart.org . Arora RR, Chou TM, et al. The multicenter study of enhanced external counterpulsation (MUST-EECP): effect of EECP on exercise-induced myocardial ischemia and anginal episodes. J Am Coll Cardiol . 1999;33:1833-1840. 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. Braunwalds Heart Disease . 7th ed. 2004. Griffith's 5-Minute Clinical Consult. Lippincott Williams & Wilkins; 2001. Hurst's The Heart . 11th ed. 2004. National Heart, Lung, and Blood Institute website. Available at: http://www.nhlbi.nih.gov . * 1 Updated Treatment section on 4/10/2007 according to the following study, as cited by DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : 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 Mar 26.

* 2 Updated Outcome section on 11/7/2007 according to the following study, as cited by DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : 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 Nov 20. Last reviewed February 2008 by Michael J. Fucci, DOPlease be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.