Coronary artery disease is the leading cause of heart attacks.
• Heart disease refers to various types of conditions that can affect heart function. These types include:
1. Coronary artery (atherosclerotic) heart disease that affects the arteries to the heart
2. Valvular heart disease that affects how the valves function to regulate blood flow in and out of the heart
3. Cardiomyopathy that affects how the heart muscle squeezes
4. Heart rhythm disturbances (arrhythmias) that affect the electrical conduction
5. Heart infections where the heart has structural problems that develop before birth
• Coronary artery disease is the most common type of heart disease in the US.
• Coronary arteries supply blood to the heart muscle, and coronary artery disease occurs when there is a buildup of cholesterol plaque inside the artery walls. Over time, this buildup of plaque may partially block the artery and decrease blood flow through it.
• A heart attack occurs when a plaque ruptures and forms a clot in the artery, causing a complete blockage. That part of the heart muscle that is denied blood supply starts to die.
• Classic signs and symptoms of coronary heart disease may include:
○ Chest pain (angina) – This pain may radiate or move to the arm, neck, or back.
○ Shortness of breath
○ Irregular heartbeat
• Not all people with coronary artery disease have chest pain as a symptom. Some may have signs and symptoms of indigestion or exercise intolerance, where they cannot perform activities normally.
• Coronary heart disease is initially diagnosed by patient history and physical examination. EKG blood tests and tests to image the arteries and heart muscle confirm the diagnosis.
• Treatment for coronary heart disease depends upon its severity. Many times lifestyle changes such as eating a heart-healthy diet, exercising regularly, stopping smoking, and controlling high blood pressure, high cholesterol, and diabetes may limit the artery narrowing.
• In some people, surgery or other procedures might be needed.
Women experience classic angina symptoms such as chest pain or pressure but more commonly, women experience:
• Chest tightness squeezing burning sense of discomfort
• While the pain often is described as coming from behind the chest bone, women are more likely than men to experience discomfort in the arms, neck, jaw, throat, or back.
• Women often have a hard time determining where the pain is exactly coming from.
• The pain may be accompanied by nausea or indigestion, sweating, lightheadedness fatigue.
• The classic symptoms of angina, or pain from the heart, are described as a crushing pain or heaviness in the chest’s center with radiation of the pain to the arm (usually the left) or jaw. There can be associated shortness of breath, sweating, and nausea.
• The symptoms tend to be brought on by activity and get better with rest.
• Some people may have indigestion and nausea while others may have upper abdominal, shoulder, or back pain.
• Unstable angina is the term used to describe symptoms that occur at rest, wake the patient from sleep, and not respond quickly to nitroglycerin or rest.
Not all pain from heart disease has the same signs and symptoms. The more we learn about heart disease, the more we realize that symptoms can be markedly different in different groups of people. Women, people who have diabetes, and the elderly may have different pain perceptions. They may complain of overwhelming fatigue and weakness or a change in their ability to perform routine daily activities like walking, climbing steps, or doing household chores. Some patients may have no discomfort at all.
Most often, cardiovascular disease symptoms become worse over time, as the narrowing of the affected coronary artery progresses over time, and blood flow to that part of the heart decreases. It may take less activity to cause symptoms to occur, and it may take longer for those symptoms to get better with rest. This change in exercise tolerance helps make the diagnosis.
Often the first signs and symptoms of heart disease may be a heart attack. This can lead to crushing chest pressure, shortness of breath, sweating, and sudden cardiac death.
There are risk factors that increase the potential to develop plaque within coronary arteries and narrow. Atherosclerosis (athero=fatty plaque + sclerosis=hardening) is the term that describes this condition. Factors that put people at increased risk for heart disease are:
• High blood pressure (hypertension)
• High cholesterol
• Family history of heart problems, especially heart attacks and strokes
Since cardiovascular disease, peripheral artery disease, and stroke share the same risk factors, a patient diagnosed with one of the three has an increased risk of developing the others.
Heart or cardiovascular disease is the leading cause of death in the United States. It can often be attributed to the lifestyle factors that increase atherosclerosis or narrowing of arteries. Smoking, along with poorly controlled hypertension (high blood pressure) and diabetes, causes inflammation and irritation of the inner lining’s coronary arteries. Over time, cholesterol in the bloodstream can collect in the inflamed areas and begin forming a plaque. This plaque can grow, and as it does, the diameter of the artery narrows. If the artery narrows by 40% to 50%, blood flow decreases enough to cause angina symptoms potentially.
In some circumstances, the plaque can rupture or break open, leading to blood clot formation in the coronary artery. This clot can completely occlude or block the artery. This prevents oxygen-rich blood from being delivered to the heart muscle beyond that blockage. That part of the heart muscle begins to die. This is a myocardial infarction or heart attack. If the situation is not recognized and treated quickly, the muscle’s affected part cannot be revived. It dies and is replaced by scar tissue. Long term, this scar tissue decreases the heart’s ability to pump effectively and efficiently and may lead to ischemic cardiomyopathy.
Heart muscle that lacks adequate blood supply also becomes irritable and may not conduct electrical impulses usually. This can lead to abnormal electrical heart rhythms, including ventricular tachycardia and ventricular fibrillation. These are the heart arrhythmias associated with sudden cardiac death.
The diagnosis of cardiovascular disease begins by taking the patient’s history. The health-care professional needs to understand the patient’s symptoms, and this may be difficult. Often, health-care professionals ask about chest pain. Still, the patient may deny having pain because they perceive their symptoms as pressure or heaviness. Words also may have different meanings for different people. The patient may describe their discomfort as sharp, meaning intense. At the same time, the health-care professional may understand that term to mean stabbing. For that reason, the patient must be allowed to take the time to describe the symptoms in their own words and have the health-care professional try to clarify the terms being used.
The health-care professional may ask questions about the quality and quantity of pain, where it is located, and where it might travel or radiate. It is essential to know about the associated symptoms, including shortness of breath, sweating, nausea, vomiting, indigestion, and malaise or fatigue.
The circumstances surrounding the symptoms are also critical.
• Does activity bring on the symptoms?
• Do they get better with rest?
• Since symptoms began, does less movement provoke the onset of the symptoms?
• Do the symptoms wake the patient?
These are questions that may help decide whether the angina is stable, progressing, or becoming unstable.
• With stable angina, the activity that is required to initiate the symptoms does not fluctuate. For example, a patient may state that their symptoms are brought on by climbing up two flights of stairs or walking one mile.
• Progressive angina would find the patient stating that the symptoms are brought on by less activity than previously.
• In the case of unstable angina, symptoms may arise at rest or wake the patient from sleep.
Risk factors for cardiovascular disease should be assessed, including the presence of high blood pressure, diabetes, high cholesterol, smoking history, and family history of cardiovascular disease. A history of stroke or peripheral artery disease is also a significant risk factor to be assessed.
Physical examination may not necessarily help make the diagnosis of heart disease. Still, it can help decide whether other underlying medical problems may cause the patient’s symptoms.
Some physical exam clues suggest the presence of narrowed arteries to the heart and coronary artery disease; for example, the doctor may:
Check for high blood pressure.
Palpate. (feel) for the pulses in the wrists and feet to see if they are present and normal in their amplitude and force. Lack of pulses may signal a narrowed or blocked artery in the arm or leg. If one artery is narrowed, perhaps others, like the coronary arteries in the heart, also may be narrowed
Auscultating or listening to the neck, abdomen, and groin for bruits. A bruit is a sound produced within a narrowed artery due to turbulence caused by decreased blood flow across the narrowed area. Bruits can be heard easily with a stethoscope in the carotid artery in the neck, the abdominal aorta, and the femoral artery. Check sensation in the feet for numbness, decreased sensation, and peripheral neuropathy.
Moreover, many other necessary conditions may need to be considered as the cause of symptoms. Examples include those arising from the lung (pulmonary embolus), the aorta (aortic dissection), the esophagus (GERD), and the abdomen (peptic ulcer disease, gallbladder disease).
After the history and physical examination are complete, the health-care professional may require more testing if heart disease is considered a potential diagnosis. There are different ways to evaluate the heart anatomy and function; the type and timing of a test need to be individualized to each patient and their situation.
Most often, the health-care professional, perhaps in consultation with a cardiologist, will order the least invasive test possible to determine whether coronary artery disease is present. Although heart catheterization is the gold standard to define the heart’s anatomy and to confirm heart disease diagnosis (either with partial or complete blockage or no blockage), this is an invasive test and not necessarily indicated for many patients.
Electrocardiogram (EKG, ECG)
The heart is an electrical pump. Electrodes on the skin can capture and record the impulses generated as electricity travels throughout the heart muscle. Heart muscle that has decreased blood supply conducts electricity differently from normal muscle. These changes can be seen on the EKG.
A normal EKG does not exclude cardiovascular disease and coronary artery blockage; there may be narrowing of the coronary arteries that have yet to cause heart muscle damage. An abnormal EKG may be a “normal” variant for that patient. The result has to be interpreted based on the patient’s circumstances.
If possible, an EKG should be compared to previous tracings looking for changes in the electrical conduction patterns.
It would make sense that during exercise, the heart is asked to work harder. If the heart could be monitored and evaluated during that exercise, a test might uncover heart function abnormalities. That exercise may occur by asking the patient to walk on a treadmill or ride a bicycle. At the same time, an electrocardiogram is being performed. Medications (adenosine, Persantine, dobutamine) can stimulate the heart if the patient cannot exercise because of poor conditioning, injury, or underlying medical condition.
An ultrasound examination of the heart to evaluate the heart valves’ anatomy, the muscle, and a cardiologist may perform its function. This test may be ordered alone or combined with a stress test to look at heart function during exercise.
A radioactive tracer that is injected into a vein can be used to assess blood flow to the heart indirectly. Technetium or thallium can be injected while a radioactive counter is used to map out how heart muscle cells absorb the radioactive chemical, and how it is distributed in heart muscle cells may help determine indirectly whether a blockage exists. An area of the heart with no uptake would suggest that the area is not getting enough blood supply. This test may also be combined with an exercise test.
Cardiac computerized tomography (CT) and magnetic resonance imaging (MRI)
Using these scans, the coronary arteries’ anatomy can be evaluated, including how much calcium is present in the artery walls and whether blockage or artery narrowing is present. Each test has its benefits and limitations. The risks and benefits of considering a CT or MRI depend upon a patient’s situation.
Cardiac catheterization is the gold standard for coronary artery testing. A cardiologist threads a thin tube through an artery in the groin, elbow, or wrist into the coronary arteries. The dye is injected to assess the anatomy and whether blockages are present. This is called a coronary angiogram.
If a blockage exists, angioplasty may be performed. Using the same technique as the angiogram, a balloon is positioned at the obstructing plaque site. When the balloon is inflated, the plaque is squashed into the artery wall to re-establish blood flow. A stent may then be placed across the previously narrowed artery segment to prevent it from narrowing again.
The goal of treating cardiovascular disease is to maximize the patient’s quantity and quality of life. Prevention is the key to avoid cardiovascular disease and optimize treatment. Once plaque formation has begun, it is possible to limit its progression by maintaining a healthy lifestyle with routine exercise, diet, and lifetime control of high blood pressure, high cholesterol, and diabetes.
By reading this website, you acknowledge that you are responsible for your own health decisions. The information throughout this medical website is not intended to be taken as medical advice. The information provided is intended for general information regarding our cardiovascular clinic in Brooklyn, New York. If you experience chest pain, dizziness, nausea, or unusual shortness of breath, please stop and seek medical attention.
If you are interested in finding out more, please contact our Multi-Specialty Facility. Avoid worrisome self-diagnosis; the best cardiology doctors will properly diagnose your problem and refer you to a specialist if necessary. No information on this site should be used to diagnose, treat, prevent, or cure any disease or condition.