Coronary artery disease
Also called: CAD, Ischaemic heart disease, Coronary heart disease
Fatty plaques (atherosclerosis) narrow the coronary arteries that feed the heart muscle. Reduced blood flow causes chest pain on exertion (angina) and, if a plaque ruptures, a heart attack. It is the single leading cause of death worldwide.
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Affects about 1 in 20 adults; risk rises steeply after 45 in men and after menopause in women.
What happens in the body
Cholesterol-rich LDL particles enter the damaged artery wall, provoke inflammation and build a plaque with a fibrous cap. Stable plaques limit flow during exercise (stable angina); an unstable plaque can crack, triggering a clot that blocks the artery (acute coronary syndrome).
Causes
- Atherosclerosis of the coronary arteries
- Rarely: coronary spasm, spontaneous coronary artery dissection, congenital anomalies, vasculitis
Risk factors
- Smoking
- High LDL cholesterol
- High blood pressure
- Diabetes
- Obesity and physical inactivity
- Family history of early heart disease
- Age and male sex
- Chronic kidney disease
- South Asian ancestry
Symptoms
- Chest pressure or tightness with exertion or stress, relieved by rest (angina)
- Pain spreading to the arm, neck, jaw or back
- Breathlessness on exertion
- Fatigue
- Some people — especially women, older adults and people with diabetes — have atypical or no symptoms
Diagnosis — tests and examinations
- Clinical history and risk assessment
- Resting ECG
- Blood tests: lipids, glucose/HbA1c, kidney function
- CT coronary angiography (first-line in many guidelines)
- Stress testing: exercise ECG, stress echocardiography, nuclear perfusion scan or stress MRI
- Invasive coronary angiography when revascularisation is being considered
Treatment
Medicines and medical treatment
- Aspirin (or clopidogrel) to prevent clots
- High-intensity statin to lower LDL; ezetimibe or PCSK9 inhibitors if needed
- Beta-blockers or calcium-channel blockers to control angina
- Glyceryl trinitrate (GTN) spray for attacks
- ACE inhibitors when there is diabetes, hypertension or reduced heart function
- Cardiac rehabilitation
Operations and procedures
- Percutaneous coronary intervention (PCI): balloon angioplasty with a drug-eluting stent
- Coronary artery bypass grafting (CABG) for left main or multivessel disease, especially with diabetes
Self-care, home remedies and lifestyle
- Stop smoking completely
- Mediterranean-style diet rich in vegetables, whole grains, legumes, fish and olive oil
- At least 150 minutes of moderate exercise per week as advised by the cardiac team
- Keep weight, blood pressure and blood sugar at target
- Limit alcohol
Possible complications
- Heart attack
- Heart failure
- Arrhythmias and sudden cardiac death
Prevention
- Not smoking
- Healthy diet and regular exercise
- Treating high blood pressure, cholesterol and diabetes
- Maintaining a healthy weight
Outlook
Chronic but very treatable: with medicines, lifestyle change and revascularisation when needed, most people live many years with good quality of life.
When to see a doctor
See a doctor for chest discomfort on exertion. Call emergency services for chest pain lasting more than a few minutes at rest, or pain with sweating, breathlessness or collapse.
Sources and further reading
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