Coronary Heart Disease

CORONARY HEART DISEASE

This condition is variously known as Coronary Artery Disease, Coronary Micro vascular Disease, and Obstructive Coronary Artery Disease etc.

Heart disease is a catch-all phrase for a variety of conditions that affect the heart's structure and function. Coronary heart disease is a type of heart disease that develops when the arteries of the heart cannot deliver enough of much needed oxygen-rich blood to the heart.

Coronary heart disease is often caused by the buildup of plaque, a waxy substance, inside the lining of the larger coronary arteries. This plaque buildup can partially or totally block blood flow in the large arteries of the heart. Some types of this condition may be caused by disease or injury affecting how the arteries work in the heart. Another type of coronary heart disease is coronary micro vascular disease. It occurs when the heart's tiny blood vessels do not work normally.

The symptoms of coronary heart disease may be different from person to person even if they have the same type of coronary heart disease. However, because many people have no symptoms, they do not know they have coronary heart disease until they have chest pain or a heart attack.

If a person has coronary heart disease, a doctor will recommend various heart-healthy lifestyle changes, medicines, surgery, or a combination of these approaches to treat the condition and prevent complications.

TYPES OF CORONARY ARTERY DISEASE

It is common to associate coronary artery disease with narrowed or blocked blood vessels, it remains the best-known form of the condition. However, other problems can develop in the coronary arteries and which may require additional, specialized expertise. The causes, symptoms, diagnostic tests, and appropriate treatments vary for each type of coronary artery disease:

• Spontaneous coronary artery dissection (SCAD), in which the layers of the artery suddenly split
• Obstructive coronary artery disease, with narrowed or blocked vessels
• Non-obstructive coronary artery disease, with arteries that inappropriately constrict or malfunction after branching into tiny vessels, or are squeezed by overlying heart muscle

CAUSES

Coronary artery disease is thought to begin with damage or injury to the inner layer of a coronary artery, sometimes as early as childhood. The damage may be caused by various factors, including:

• High cholesterol
• Not being active (sedentary lifestyle)
• Smoking
• Hypertension (High blood pressure)
• Diabetes or insulin resistance

There are three main types of coronary heart disease: obstructive coronary artery disease, non-obstructive coronary artery disease, and coronary micro vascular disease. Coronary artery disease affects the large arteries on the surface of the heart. Many people have both the obstructive and non-obstructive forms of this disease. Coronary micro vascular disease affects the tiny arteries in the heart muscle.

The cause will depend on the type of coronary heart disease. The condition may also have more than one cause, including plaque buildup or problems that affect how the heart's blood vessels work.

Plaque buildup

Plaque buildup in the arteries is known and called atherosclerosis. When this buildup happens in the heart's arteries, the arteries become narrower and harden over many years, this reduces oxygen-rich blood flow to the heart. The result is coronary artery disease.

Obstructive coronary artery disease means the heart's arteries are more than half blocked. The blood flow may eventually be completely blocked in one or more of the three large coronary arteries. In non-obstructive coronary artery disease, the large arteries may be narrowed by plaque, but not as much as they are in obstructive disease.

Small plaques can also develop in the small blood vessels in the heart, causing coronary micro vascular disease.

Problems affecting the blood vessels

Problems with how the heart's blood vessels work can cause coronary heart disease. For example, the blood vessels may not respond to signals that the heart needs more oxygen-rich blood. Normally, the blood vessels widen to allow more blood flow when a person is physically active or under stress, however, if one has coronary heart disease, the size of these blood vessels may not change, or the blood vessels may even narrow.

The cause of these problems is not fully clear. But it may involve:

Damage or injury to the walls of the arteries or tiny blood vessels from chronic inflammation, high blood pressure, or diabetes.

Molecular changes that are part of the normal aging process. Molecular changes affect the way genes and proteins are controlled inside cells.

In non-obstructive coronary artery disease, damage to the inner walls of the coronary arteries can cause them to suddenly tighten (spasm), this is referred to as vasospasm.

The spasm causes the arteries to narrow temporarily and blocks blood flow to the heart. These problems can also happen in the tiny blood vessels in the heart, causing coronary micro vascular disease. Coronary micro vascular disease can happen with or without obstructive or non- obstructive coronary artery disease

SIGNS AND SYMPTOMS

An acute coronary event, such as a heart attack, may cause the following symptoms:

Angina, which can feel like pressure, squeezing, burning, or tightness during physical activity. The pain or discomfort usually starts behind the breastbone, but it can also occur in the arms, shoulders, jaw, throat, or back. The pain may sometimes feel like indigestion.

• Neck pain
• Cold sweats
• Weakness
• Dizziness
• Light-headedness
• Nausea or a feeling of indigestion
• Shortness of breath, especially with activity
• Sleep disturbances

Women are somewhat less likely than men to experience chest pain. Instead, they are more likely to experience:

• Stomach pain
• Pressure or tightness in the chest
• Dizziness
• Fatigue
• Nausea

Women are also more likely than men to have no symptoms of coronary heart disease.

Chronic (long-term) coronary heart disease can cause symptoms such as the following:

• Angina
• Shortness of breath (especially during physical activity)
• Fatigue
• Neck pain

The symptoms may get worse as the buildup of plaque continues to narrow the coronary arteries. Chest pain or discomfort that does not go away or happens more often or while resting might be a sign of a heart attack.

RISK FACTORS

Risk factors for coronary artery disease include:

• Age. Getting older increases the risk of damaged and narrowed arteries.
• Sex. Generally, men are at greater risk of coronary artery disease. The risk for women however increases after menopause.
• Unhealthy diet. Eating too much food that has high amounts of saturated fat, trans fat, salt and sugar can increase the risk of coronary artery disease.
• Physical inactivity. Lack of exercise also is associated with coronary artery disease and some of its risk factors.
• Family history. A family history of heart disease is associated with a higher risk of coronary artery disease, especially if a close relative developed heart disease at an early age. A person's risk is highest if their father or a brother was diagnosed with heart disease before age 55 or if their mother or a sister developed it before age 65.
• Overweight or obesity. Excess weight typically worsens other risk factors.
• Smoking. People who smoke have a significantly increased risk of heart disease. Breathing in secondhand smoke also does increase a person's risk of coronary artery disease.
• High blood pressure. Uncontrolled high blood pressure can result in hardening and thickening of the arteries, narrowing the channel through which blood can flow.
• High blood cholesterol levels. High levels of cholesterol in a person's blood can increase the risk of formation of plaque and atherosclerosis. High cholesterol is caused by a high level of low-density lipoprotein (LDL) cholesterol, known as the 'bad' cholesterol or a low level of high-density lipoprotein (HDL) cholesterol, known as the good cholesterol.
• Diabetes. Diabetes is associated with an increased risk of coronary artery disease. Type 2 diabetes and coronary artery disease share obesity and high blood pressure as similar risk factors.
• High stress. Unrelieved stress in may damage the arteries as well as worsen other risk factors for coronary artery disease.

Risk factors often occur together and one may trigger another. Obesity can for instance, lead to type 2 diabetes and high blood pressure. When grouped together, certain risk factors will make one even more likely to develop coronary artery disease.

Sometimes coronary artery disease develops without any classic risk factors. some studies are researching into other possible risk factors, including:

• Homocysteine. An amino acid the body uses to make protein and to build and maintain tissue. But high levels of homocysteine may increase a person's risk of coronary artery disease.
• Sleep apnea. This disorder causes a person to repeatedly stop and start breathing while they are asleep. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system, which could possibly lead to coronary artery disease.
• Autoimmune diseases. People who have conditions such as rheumatoid arthritis and lupus have an increased risk of atherosclerosis.
• High-sensitivity C-reactive protein (hs-CRP). This protein appears in higher-than-normal amounts when there's inflammation somewhere in the body.

High hs-CRP levels may be a risk factor for heart disease.

• High triglycerides. This is a type of fat (lipid) found in the blood. High levels of which may raise the risk of coronary artery disease, especially for women.
• Preeclampsia. This condition that can develop in women during pregnancy causes high blood pressure and a higher amount of protein in urine. It can lead to a higher risk of heart disease later in life.
• Alcohol use. Heavy alcohol use can lead to heart muscle damage. It can also worsen other risk factors of coronary artery disease.

COMPLICATIONS

Coronary artery disease can lead to:

Chest pain (angina). When the coronary arteries narrow, the heart may not receive enough blood when demand is greatest particularly during physical activity. This can cause chest pain (angina) or shortness of breath.

Heart attack. If a cholesterol plaque ruptures and a blood clot forms, complete blockage of the heart artery may trigger a heart attack. The lack of blood flow to the heart may damage the heart muscle. The amount of damage depends in part on how quickly the patient receives treatment.

Heart failure. If some areas of a person's heart are chronically deprived of oxygen and nutrients because of reduced blood flow, or if the heart has been damaged by a heart attack, the heart may become too weak to pump enough blood to meet the body's needs. This condition is known as heart failure.

Abnormal heart rhythm (arrhythmia). Inadequate blood supply to the heart or damage to heart tissue can interfere with the heart's electrical impulses, causing abnormal heart rhythms.

WHEN TO SEE A DOCTOR

Immediately call local emergency number for help if one thinks they are having a heart attack. If anyone doesn't have access to emergency medical services, they should have someone drive them to the nearest hospital.

People who have the risk factors for coronary artery disease (i.e. high blood pressure, high cholesterol, tobacco use, diabetes, obesity a strong family history of heart disease) should talk to their doctor. The doctor may want to test for coronary artery disease, especially if they have the signs or symptoms of narrowed arteries.

DIAGNOSIS

A doctor can perform a physical examination, take a thorough medical history, and order a number of tests to diagnose CHD.

For example:

CT scans: These help the doctor visualize the arteries, detect calcium within fatty deposits, and characterize any heart anomalies.

Echocardiogram: An ultrasound scan that monitors the pumping heart. It uses sound waves to provide a video image

Stress test: This may involve the use of a treadmill or medication that stresses the heart in order to test how it functions when a person is active.

Electrocardiogram: This records the electrical activity and rhythm of the heart.

Blood tests: Doctors can run these to measure blood cholesterol levels, especially in people at risk of high blood cholesterol levels.

Nuclear ventriculography: This uses tracers, or radioactive materials, to create an image of the heart chambers. A doctor will inject the tracers into the vein. The tracers then attach to red blood cells and pass through the heart. Special cameras or scanners would then trace the movement of the tracers.

Coronary catheterization: A specialist will inject dye through a catheter they would have threaded through an artery, often in the leg or arm. The dye will help to show narrow spots or blockages on an X-ray.

Holter monitor: This is a portable device that a person wears under their clothes for 2 days or more. It records all the electrical activity of the heart, including the heartbeat.

TREATMENT

Lifestyle changes

Treatment may involve lifestyle changes. People must;

• Change to a diet low in trans fats, salt, and sugar
• Quit smoking if they do
• Eat less processed food
• Keep blood sugar in control if they have diabetes.
• Exercise regularly (but must talk to their doctor before beginning an exercise program)

Medications

If lifestyle changes aren't enough, medication will be needed. The drugs to be prescribed will depend on the situation.

One that has been diagnosed with coronary artery disease, could take:

• Evolocumab (which lowers the risk of heart attack and stroke in people with cardiovascular disease)
• Medications to help reduce cholesterol (statins, bile acid sequestrants etc.)
• Aspirin
• Beta blockers
• Calcium channel blockers
• Nitroglycerin
• ACE inhibitors
• Angiotensin II receptor blockers (ARBs)

Surgery and other procedures. Common ones to treat coronary artery disease include:

• Balloon angioplasty
• Coronary artery bypass surgery
• Stent placement

Whereas all of these treatments will boost blood supply to the heart, they can't cure coronary artery disease.

Doctors are studying new ways to treat heart disease, including:

Angiogenesis. For this treatment, stem cells and other genetic material is introduced through the vein or directly into the damaged heart tissue. It helps new blood vessels grow and go around the clogged ones.

Enhanced external counter pulsation (EECP). People who have long-term angina but haven't gotten any help from nitrate medications or don't qualify for some procedures may find relief with this. It's an outpatient procedure that uses cuffs on the legs that inflate and deflate to boost blood supply to the coronary arteries.

LIVING WITH CORONARY HEART DISEASE

Receive follow-up care

It is important to get routine medical care and to take all medicines as the doctor prescribes. Do not change the amount of a prescription medicine or skip a dose unless the doctor advises.

Between visits, endeavor to call the doctor if one should experience any new symptoms, if symptoms worsen, or if one has problems with blood pressure or blood sugar.

Cardiac rehabilitation

The patient may be referred for exercise-based cardiac rehabilitation, also called cardiac rehab, to manage symptoms and reduce the chances of future problems such as heart attack. A lot of studies have shown that cardiac rehabilitation lowers the risk of hospitalization and death. It can also improve quality of life.

Prevent complications over lifetime

The doctor will work with patient to manage medical conditions that can raise the risk of heart problems and complications, such as heart-healthy lifestyle changes, being physically active, and quitting smoking.

The patient may be referred to other professionals, such as a registered dietitian or exercise physiologist for specialized professional care.

The benefits of quitting smoking no matter how long or how much one has been smoking is huge because coronary heart disease risk associated with smoking begins to decrease soon after quitting, and it continues to decrease over time.

In addition:

The patient will most likely be given a statin to lower LDL cholesterol, especially after a heart attack.

Aspirin may be recommended to prevent a heart attack or stroke. Low-dose aspirin is good at helping to prevent blood clots and lower the risk for heart attacks and other complications of coronary heart disease for some people, particularly those with micro vascular disease or who have diabetes. Aspirin unfortunately raises the risk of serious bleeding therefore people should talk to their doctors before taking it.

If one has diabetes, they will need to check their blood sugar regularly and keep taking any prescribed medicines.

If the coronary heart disease becomes unstable or has led to a heart attack or sudden cardiac arrest, the doctor may recommend a pacemaker or defibrillator to detect and treat certain types of serious arrhythmias.

Take care of mental health

Living with a heart disease may cause fear, anxiety, depression, and stress. One may worry about having heart problems or making lifestyle changes that are necessary for good health.

The doctor may talk about:

Talking to a professional counselor. If the patient has depression or anxiety, the doctor may also recommend medicines or other treatments that can improve quality of life.

Joining a patient support group. This may help the patient to adjust to living with heart disease. One may want to find out how other people manage similar symptoms. The doctor may be able to recommend local support groups, otherwise the patient can check with an area medical center.

Seeking support from family and friends. The patient will need to let loved ones know how they feel and what they can do to help relieve their stress and anxiety.

Patients will have to learn the warning signs of serious complications and have a plan of action in emergencies.

Coronary heart disease can lead to heart attack or stroke. Call a doctor if one or someone else is having the following symptoms.

The signs and symptoms of a heart attack include:

• Pain or discomfort in the chest that often lasts more than a few minutes or goes away and comes back.
• Prolonged or severe chest pain or discomfort that is not relieved by rest or nitroglycerin.
• Pain in the chest that involves uncomfortable pressure, squeezing, fullness, or pain in the center or left side of the chest that can be mild or strong.
• Upper body discomfort. This can be felt in one or both arms, the back, neck, jaw, or upper part of the stomach.
• Nausea, vomiting, light-headedness or fainting, or breaking out in a cold sweat. This particular symptoms of a heart attack are more common in women.
• Shortness of breath. This may accompany chest discomfort or happen before it

WOMEN AND CORONARY HEART DISEASE

Why coronary heart disease affects women differently

Coronary heart disease is different for women because of hormonal and anatomical differences.

Hormonal changes affect a woman's risk for coronary heart disease. Before menopause, estrogen a hormone provides women with some protection against coronary artery disease. Estrogen raises levels of good cholesterol (HDL) and helps keep the arteries flexible so they can widen to deliver more oxygen to the tissues of the heart in response to chemical and electrical signals. After menopause, estrogen levels drop, and that increases a woman's risk for coronary heart disease.

The size and structure of the heart is different for women and men. A woman's heart and blood vessels are comparatively smaller, and the muscular walls of women's hearts are thinner.

Women are more likely to have non-obstructive coronary heart disease or coronary micro vascular disease. These types are harder to diagnose than obstructive coronary artery disease. This can cause delays in getting diagnosed and treated.

Factors that affect risk for women

Women are more likely than men to have medical conditions or life issues that raise their risk for coronary heart disease.

• Lack of physical activity
• Anemia (during pregnancy)
• Overweight and obesity
• Early menopause (before 40yrs)
• Hormonal birth control
• Inflammatory and autoimmune diseases
• Endometriosis
• High blood pressure (after 65yrs)
• History of problems during pregnancy (e.g. gestational diabetes, pre-eclampsia external link, eclampsia external link etc.).
• Mental health issues (e.g. stress, anxiety, depression, or low social support)
• Metabolic syndrome (a collection of risk factors that raises the risk of heart disease and other health problems)

The following factors raise women's risk for coronary heart disease more than they do in men.

• Diabetes
• Low levels of HDL cholesterol
• Mild to moderate high blood pressure
• Smoking

Symptoms differ for women

Women often experience no symptoms of coronary heart disease or have different symptoms than men do.

Activity that brings on chest pain. In men, angina actually worsens with physical activity and instead, goes away with rest. Conversely, women are more likely than men to have angina while they are resting. In women who have coronary micro vascular disease, angina often happens during routine daily activities, such as shopping or cooking, rather than during exercise. Micro vascular angina events may last longer in women and be more painful than other types of angina.

Location and type of pain. Pain symptoms are different for each person. Women having angina or a heart attack often describe their chest pain as crushing, or they say it feels like pressure, squeezing, or tightness.

Mental stress. Mental stress is more likely to trigger angina pain in women than in men.

Other symptoms. Common signs and symptoms of coronary heart disease for women include nausea, vomiting, shortness of breath, abdominal pain, sleep problems, fatigue, and lack of energy.

Diagnosis and treatment for women

Tests and procedures for diagnosing coronary heart disease are very similar for women and men, but;

• Women may experience some delays in diagnosis or treatment.
• Doctors are less likely to refer women for diagnostic tests for coronary heart disease.
• Women are more likely than men to experience delays receiving an initial EKG,
• Women are less likely to receive care from a heart specialist during hospitalization
• Women are less likely to receive certain types of therapy and medicines.
• Younger women are more likely than men to be misdiagnosed and sent home from the emergency department after cardiac events that occur from undiagnosed and untreated vascular heart disease.
• Women may be less likely than men to receive aspirin, statins, and beta blockers for treating their heart disease.
• Although women may be as likely as men to benefit from a pacemaker or a defibrillator, women are less likely to receive these treatments for complications of coronary heart disease.
• Women are often less likely to receive percutaneous coronary intervention or coronary artery bypass grafting than men are, even though research shows that both men and women can benefit from these procedures.

Know and share the risk factors. Doctors may not recognize women's risk for coronary heart disease. Commonly used risk-scoring systems may not accurately predict risk in women.

Learn the symptoms and seek medical care right away. Being familiar with the symptoms of coronary heart disease and how they may differ in women may help recognize when to talk to a doctor or when to seek medical care. Immediate care may help prevent complications such as heart attack or sudden cardiac arrest.

PREVENTION

The same lifestyle habits used to help treat coronary artery disease can also help prevent it.

A healthy lifestyle can help keep the arteries strong and clear of plaque. To improve heart health, follow these general tips:

• Quit smoking.
• Conditions such as high blood pressure, high cholesterol and diabetes must be controlled effectively.
• Stay physically active.
• Eat a low-fat, low-salt diet that's rich in fruits, vegetables and whole grains.
• Maintain a healthy weight.
• Reduce and manage stress.