Coronary Artery Disease

The leading cause of heart attacks

Coronary artery disease (CAD) is a blockage of the arteries leading to the heart. While symptoms can take different forms, they all have the same cause: the heart muscle isn't getting enough blood and oxygen.

To work normally, the heart muscle (myocardium) needs a continuous supply of oxygen-rich blood. But as the coronary arteries get narrower, ischemia (inadequate blood supply) can develop. The most common cause of myocardial ischemia is coronary artery disease. Coronary artery disease causes heart attacks.

But the best approach to CAD is prevention, and many of the risk factors can be avoided or minimized with relatively simple lifestyle modifications.

Synonyms

  • Arteriosclerotic heart disease
  • Coronary heart disease
  • Coronary arteriosclerosis
  • Ischemic heart disease
  • Coronary artery insufficiency

Detailed Description

Coronary artery disease can cause angina pectoris (chest pain), congestive heart failure, and sudden death. All of these effects of CAD have one thing in common: not enough oxygen is reaching the heart.

The risk of CAD increases with elevated levels of total cholesterol and low-density lipoprotein cholesterol (LDL, or "bad cholesterol") in the blood, but decreases when your levels of high-density lipoprotein (HDL, or "good cholesterol") increase. In other words, the higher your total and bad cholesterol levels are, the more likely you are to develop CAD.

Symptoms often don't appear until coronary artery disease reaches an advanced stage, but the numerous effective treatments for CAD range from lifestyle modifications to drugs to surgery.

How Common Is CAD?

In the United States, CAD is the leading cause of death in both genders, accounting for about one-third of deaths each year. The American Heart Association estimates that more than 12 million people have some form of CAD.


Established Causes

Over time, fatty deposits (called atheromas or plaques) gradually build up in the large branches of the two main coronary arteries that supply the heart with blood. This gradual process is known as atherosclerosis. Plaque deposits bulge into the arteries and narrow them. As the deposits get bigger, pieces may rupture and enter the bloodstream, or small blood clots may form on their surfaces.

As the arteries narrow, blood flow to the heart decreases. Less blood equals less oxygen and decreased heart function.

Risk Factors

The many risk factors for CAD include the following:

  • Obesity
  • High blood pressure
  • Elevated LDL (low-density lipoprotein)
  • Decreased HDL (high-density lipoprotein)
  • Cigarette smoking
  • Diabetes mellitus (uncontrolled)
  • Sustained psychological stress
  • Sedentary lifestyle
  • Increasing age
  • Male gender
  • Postmenopause
  • Family history of CAD and/or cholesterol disorder
  • Elevated levels of fats (triglycerides)

Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.

Symptoms

Some people with CAD have no tell-tale symptoms, but most people experience one or more of the following:

Conditions That May Be Mistaken for Coronary Artery Disease

Several other conditions may simulate CAD since they also cause chest pain and shortness of breath:

  • Gastrointestinal disorders such as peptic ulcer, indigestion, hiatal hernia, gallbladder disease, and spasms or inflammation of the esophagus
  • Chronic shortness of breath (dyspnea)
  • Blood clot in the lung, pneumonia, or pleurisy
  • Inflammation of the membrane around the heart (pericarditis)
  • Inflammation of or damage to the ribs
  • Disease of the spinal nerve roots (radiculopathy)
  • Inflammation of the gallbladder (cholecystitis)
  • Psychological disorders due to panic or anxiety
  • Cervical or thoracic spine disease
  • Aortic aneurysm: injury of the tissue in the wall of aorta (the major artery carrying blood out of the heart)

How Is Coronary Artery Disease Diagnosed?

Checking your blood-cholesterol level should be part of your routine physical if you are over age 30. Men over 45 and women over 55 should have a cholesterol test annually. If your physician suspects that you have coronary artery disease, further testing is required to confirm the diagnosis:

  • Your medical history and physical exam, including blood pressure
  • Blood tests
  • Electrocardiogram (EKG or ECG)
  • Exercise testing
  • Various methods of imaging

Laboratory Work

Laboratory blood tests for diabetes and for detecting levels of triglycerides, total cholesterol, LDL, and HDL are usually helpful to the diagnosis.

Specific Tests

Special tests are performed to confirm coronary artery disease by evaluating the cardiovascular system.

  • An electrocardiogram (EKG) measures electrical activity of the heart, which may be abnormal if there is diminished blood flow to the heart.
  • Exercise stress tests measure blood pressure, heartbeat, and breathing rate as well as an EKG, during exercise. This test can show if not enough blood (or oxygen) is reaching the heart during exercise.

Imaging

Imaging allows your physician to locate the narrowed artery, which is helpful in determining which therapy is best for your condition.

  • Coronary arteriography: A doctor guides a thin plastic tube through an artery in your arm or leg and into the coronary arteries, and then injects a liquid dye visible in x-rays through the catheter. High-speed X-ray movies show the liquid as it flows through the arteries. Doctors can identify blockages in the arteries by tracing the liquid's flow.
  • Radionuclide scintigraphy: An imaging technique that involves the use of radioactive elements to demonstrate blood flow in the heart.
  • Stress echocardiography: A diagnostic procedure that studies the structure and motion of the heart.
  • Stress thalium: Imaging test to measure cardiac function and blood flow.


Supplements

  • Vitamin E: Two landmark Harvard studies -- one involving men, the other, women -- showed that vitamin E (100 IU/day) substantially reduces the risk of heart disease. Compared with those who did not take the vitamin, the people who did suffered significantly percent fewer heart attacks -- 37% in men, 41% in women. [1, 2] Vitamin E is a powerful antioxidant that also helps treat heart disease.
  • Vitamin C: A major antioxidant, vitamin C also helps prevent and treat heart disease.
  • B vitamins: The B vitamins help reduce blood levels of homocysteine, a recently identified risk factor for heart disease. Researchers in Northern Ireland gave supplemental B vitamins to 101 men with high homocysteine levels. Eight weeks later, their homocysteine levels had dropped 28%, significantly reducing their risk of heart attack. [3] Nutrition experts suggest 3 mg of vitamin B-6 and 400 mcg of folic acid.
  • Fish oil: You can get the omega-3 fatty acids found in cold-water fish without eating them if you take fish-oil supplements. In addition to preventing heart disease, fish oil also increases the effectiveness of angioplasty and coronary artery bypass surgery. [4, 5]

Relaxation

  • Meditation is a key element of the Ornish program, and other studies also show its value. At the State University of New York, at Buffalo, researchers tested the exercise ability of 21 people with heart disease, and then taught them Transcendental Meditation (TM). Eight months later, they could exercise 15% more strenuously before experiencing chest pain, indicating a decreased risk of heart disease. [6]

    A great deal of research shows that the broad range of relaxation therapies helps prevent and treat heart disease. Practice whatever appeals to you: meditation, deep breathing, massage, hot baths, imagery/visualizations, progressive muscle relaxation, or self-hypnosis.
  • Cherish your friends and family. The Ornish program includes a support group, since many studies show that social support helps prevent and treat heart disease. New York researchers followed more than 1,000 heart-attack survivors for four years. Among those who lived alone, 16 had a recurrence. But among those who lived with a spouse, the figure was only about half that. [7]

Herbs

  • Garlic: Powerful medicine against heart disease. Some experts believe it reduces cholesterol and blood pressure, and makes blood less likely to form the clots that can cause heart attacks. Commission E, the German panel of doctors, pharmacists, and herbalists that judges the safety and effectiveness of herbal medicines for the German government, recommends one to four garlic cloves a day.
  • Willow bark: Doctors recommend low-dose aspirin to prevent the blood clots that trigger heart attacks. You can gain the same benefit from a cup of willow-bark tea. Willow bark contains salicin, aspirin's herbal precursor. A half-teaspoon of willow bark contains about 100 mg of salicin, enough to provide aspirin's benefits. [8]

For related news, products, and links to community, visit the Cardiovascular Health eCenter.

Last updated October 1999.

Sources

1 Rimm, E.B., et al. "Vitamin E Consumption and Risk of Coronary Heart Disease in Men," New England Journal of Medicine 328:1450, 1993.

2 Stampfer, M.J., et al. "Vitamin E Consumption and Risk of Coronary Disease in Women," New England Journal of Medicine 328:1444, 1993.

3 Woodside, J., et al. "Effect of Vitamin Supplementation on Cardiovascular Risk," Journal of Inheritable and Metabolic Diseases 19(Suppl 1):26, 1996.

4 Gapinski, J.P., et al. "Preventing Restenosis with Fish Oils Following Coronary Angioplasty: A Meta-Analysis," Archives of Internal Medicine 153;1595, 1993.

5 Eritsland, J., et al. "Effect of Dietary Supplementation with N-3 Fatty Acids on Coronary Artery Bypass Graft Patency," American Journal of Cardiology 77:31, 1996.

6 Zamarra J.W., et al. "Usefulness of TM in the Treatment of Patients with CAD," American Journal of Cardiology 77:867, 1996.

7 Case, R.B., et al. "Living Alone after MI: Impact on Prognosis," Journal of the American Medical Association 267:515, 1992.

8 Duke, J. The Green Pharmacy, Emmaus, PA: Rodale Press, 1997.

Preventing Coronary Artery Disease

Preventive measures can substantially lower your risk for heart disease. The following lifestyle choices are particularly helpful in preventing the underlying coronary artery disease that can cause a heart attack:

  • Stop smoking
  • Lose weight
  • Exercise regularly
  • Reduce stress
  • Eat a healthy, low-fat diet high in fiber and complex carbohydrates

Self-Care Measures

Once signs of coronary artery disease appear, most of the same preventive measures are still recommended for slowing its progress. The following recommendations are specifically aimed at keeping CAD under control:

  • If you smoke, quit. Smoking is a major risk factor for CAD, and quitting quickly reduces your risk.
  • An ultra low-fat, low-cholesterol, and high-fiber diet is a key element of the only program ever shown to reverse coronary artery disease. Pioneered by Dean Ornish, M.D., of the Preventive Medicine Research Institute in Sausalito, Calif., the program has five components:
    • Vegetarian diet containing just 10% fat (compared to the average American's 35%)
    • Daily exercise, like walking
    • Meditation
    • Yoga
    • Weekly support-group meetings
    In a series of three landmark studies, Ornish showed that people who embrace his program enjoy progressively increasing blood flow through their coronary arteries, a feat that drugs and surgery cannot match.
  • Eat more plant foods. Even if you don't adopt the entire Ornish program, it's a good idea to limit meats and eat more plant foods, which include fruits, vegetables, beans, and whole grains. In one study, Harvard researchers followed 44,000 middle-aged men for six years. As the men's plant-food consumption increased, their risk of heart disease decreased. Compared with those who ate the fewest plant foods, those who ate the most enjoyed substantial protection from heart attacks. Plant foods are high in antioxidant nutrients, which prevent the cell damage at the root of heart disease.

    Plant foods are central to the "Mediterranean diet" of people in Spain, Italy, and Greece. People there consume a good deal more fat than the Ornish-program limit, but it's mostly monounsaturated olive oil, the heart-healthiest fat, as opposed to the saturated fat found in meat, the kind that leads to heart disease. Several studies show that the Mediterranean diet helps prevent heart disease. And if you've survived a heart attack, this diet can prevent a recurrence. In one study, French researchers told 605 heart-attack survivors to eat either a diet heavier in saturated fat or a Mediterranean-style diet. During five years of follow-up, the Mediterranean group had 72% fewer second heart attacks.
  • Try drinking tea. Several recent studies have shown that, like plant foods, tea, especially green tea, is high in the antioxidants that prevent heart disease.
  • Eating cold-water fish, notably salmon, may also help prevent and treat heart disease. Cold-water fish are high in omega-3 fatty acids, which help prevent the arterial damage that leads to heart disease.
  • Drink a little red wine. Many studies show that modest alcohol consumption (about one drink a day) raises HDL (or "good") cholesterol, the kind that reduces risk of heart attack. In addition, red wine contains extra antioxidants that further reduce risk. Some people shouldn't drink at all, including current or former alcoholics, those with a family history of alcoholism, pregnant women, and people with liver disease. But if you can drink, a little alcohol, especially red wine, can help prevent heart disease.

The Ornish program encourages walking and yoga, but any regular, moderate exercise helps. Exercise is also a standard part of post-heart-attack rehabilitation.

Websites & Organizations

American College of Cardiology
911 Old Georgetown Road
Bethesda, MD 20814
Phone: 301-897-5400

American Heart Association
7320 Greenville Ave.
Dallas, TX 75231
Phone: 214-750-5300

The Coronary Club, Inc.
9500 Euclid Avenue, E-37
Cleveland, OH 44195
Phone: 216-444-3690

Doctor's Guide

Heart Failure Online

Heart Information Network

Heartmates, Inc.


P.O. Box 16202
Minneapolis, MN 55416
Phone: 800-9HM-3331 (800-946-3331)
Email: heartmates@outtech.com

The Mended Hearts
7272 Greenville Avenue
Dallas, TX 75231
Phone: 214-706-1442

National Heart, Lung, and Blood Institute
Information Office
P.O. Box 30105
Bethesda, MD 20892-0105
Phone: 301-251-1222

Sources for This Article

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Tierney, LM, McPhee, SJ, and Papadakis, MA. Current Medical Diagnosis and Treatment eds. Stamford, CT: Appleton & Lange, 1998.


Articles

Bates, MS. "A Critical Perspective on Coronary Artery Disease and Coronary Bypass Surgery." Soc Sci Med. 30(2):249-60. 1990.

Berlin, JA and GA Colditz. "Meta-Analysis of Physical Activity in the Prevention of CHD," Am. J. Epiedmiol, 132:612, 1990.

Case, RB et al. "Living Alone after MI: Impact on Prognosis," JAMA, 267:515, 1992.

Chang, JA, Froelicher, VF. "Clinical and Exercise Test Markers of Prognosis in Patients with Stable Coronary Artery Disease." Curr Probl Cardiol. 19(9):533-87. Sep 1994.

Duke, J. The Green Pharmacy, Rodale Press, Emmaus, PA, 1997.

Eritsland, J. et al. "Effect of Dietary Supplementation with N-3 Fatty Acids on Coronary Artery Bypass Graft Patency," Am. J. Cardiology, 77:31, 1996.

Frankel, EN. et al. "Inhibition of Oxidation of Human LDL by Phenolic Substances in Red Wine," Lancet, 341:454, 1993.
Gapinski, JP et al. "Preventing Restenosis with Fish Oils Following Coronary Angioplasty: A Meta-Analysis," Archives of Int. Med., 153;1595, 1993.

Gensini, GF, Comeglio, M, Colella, A. "Classical Risk Ractors and Emerging Elements in the Risk Profile for Coronary Artery Disease." Eur Heart J. 9 (suppl A): 53-61. 1998.

Gillespie, N, Darbar, D. Infarcts After Surgery. Symptoms of Coronary Artery Disease Predict Risks of Surgery." BMJ. 311(7005):628-9. Sep 2, 1995.

Gold, S, Wong, WF, Schatz, IJ, Blanchette, PL. "Invasive Treatment for Coronary Artery Disease in the Elderly." Arch Intern Med. 151(6):1085-8. Jun 1991.

Hertog, MG, et al. "Dietary Antioxidant Flavonoids and Risk of CHD," Lancet, 342(8878):1007, 1993.

Ko, W, Gold, JP, Lazzaro, R, Zelano, JA, Lang, S, Isom, OW, Krieger, KH. "Survival Analysis of Octogenarian Patients with Coronary Artery Disease Managed by Elective Coronary Artery Bypass Surgery versus Conventional Medical Treatment." Circulation. 85 (5 Suppl): II 191-197. 1992.

Malloy, MJ, Kane, JP. "Aggressive Medical Therapy for the Prevention and Treatment of Coronary Artery Disease." Adv Intern Med. 42():1-38. 1997.

Matsumura, Y, Takata, J, Yabe, T, Furuno, T, Chikamori, T, Doi, YL. "Atherosclerotic Aortic Plaque Detected by Transesophageal Echocardiography: Its Significance and Limitation as a Market for Coronary Artery Disease in the Elderly." Chest. 112(1): 81-86. 1997.

O'Brien, T, Nguyen, TT, Hallaway, BJ, Hodge, D, Bailey, K, Holmes, D, Kottke, BA. "The Role of Lipo-Protein A-I and Lipoprotein A-I/A-II in Predicting Coronary Artery Disease." Arterioscler Thromb Vasc Biol. 15(2): 228-231. 1995.

Ornish, D. et al. "Can Lifestyle Changes Reverse Coronary Artery Disease?" Lancet, 336:129, 1990.

Renaud. S. et al. "Cretan Mediterranean Diet for Prevent of CHD," Am. J. Clin. Nutrition, 61(Suppl): 1360S, 1995.

Rimm, EB et al. "Vegetable, Fruit, and Cereal Fiber Intake and Risk of CHD in Men," JAMA, 275:447, 1996.

Rimm, EB, et al. "Vitamin E Consumption and Risk of Coronary Heart Disease in Men," NEJM, 328:1450, 1993.

Stampfer, MJ et al. "Vitamin E Consumption and Risk of Coronary Disease in Women," NEJM, 328:1444, 1993.

Vogel, RA. "The Spectrum of Treatment for Coronary Artery Disease: Medical Regression to High-Risk Angioplasty." Md Med J. 40(3):219-21. Mar 1991.

Woodside, J. et al. "Effect of Vitamin Supplementation on Cardiovascular Risk," J. of Inheritable and Metabolic Dis., 19(Suppl 1):26, 1996.

Zamarra JW et al. "Usefulness of TM in the Treatment of Patients with CAD," Am. J. Cardiology, 77:867, 1996.

 

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