Coronary artery disease
), also called coronary heart disease
), ischemic heart disease
or simply heart disease
, involves the reduction of blood flow to the heart muscle
due to build-up of plaque (atherosclerosis
) in the arteries of the heart
It is the most common of the cardiovascular diseases
Types include stable angina
, unstable angina
, myocardial infarction
, and sudden cardiac death
A common symptom is chest pain
or discomfort which may travel into the shoulder, arm, back, neck, or jaw.
Occasionally it may feel like heartburn
. Usually symptoms occur with exercise or emotional stress
, last less than a few minutes, and improve with rest. Shortness of breath
may also occur and sometimes no symptoms are present.
In many cases, the first sign is a heart attack
Other complications include heart failure
or an abnormal heartbeat
Risk factors include high blood pressure
, lack of exercise, obesity
, high blood cholesterol
, poor diet, depression
, and excessive alcohol
A number of tests may help with diagnoses including: electrocardiogram
, cardiac stress testing
, coronary computed tomographic angiography
, and coronary angiogram
, among others.
In 2015, CAD affected 110 million people and resulted in 8.9 million deaths.
It makes up 15.6% of all deaths, making it the most common cause of death
The risk of death from CAD for a given age decreased between 1980 and 2010, especially in developed countries
The number of cases of CAD for a given age also decreased between 1990 and 2010.
In the United States in 2010, about 20% of those over 65 had CAD, while it was present in 7% of those 45 to 64, and 1.3% of those 18 to 45;
rates were higher among men than women of a given age.
Signs and symptoms
The narrowing of coronary arteries reduces the supply of oxygen-rich blood flowing to the heart, which becomes more pronounced during strenuous activities during which the heart beats faster.
For some, this causes severe symptoms while others experience no symptoms at all.
The most common symptom is chest pain
or discomfort that occurs regularly with activity, after eating, or at other predictable times; this phenomenon is termed stable angina
and is associated with narrowing
of the arteries
of the heart
. Angina also includes chest tightness, heaviness, pressure, numbness, fullness, or squeezing.
Angina that changes in intensity, character or frequency is termed unstable. Unstable angina
may precede myocardial infarction
. In adults who go to the emergency department with an unclear cause of pain, about 30% have pain due to coronary artery disease.
Angina, shortness of breath, sweating, nausea or vomiting, and lightheadedness are signs of a heart attack, or myocardial infarction, and immediate emergency medical services are crucial.
Symptoms in women
Symptoms in women can differ from those in men, and the most common symptom reported by women of all races is shortness of breath.
Other symptoms more commonly reported by women than men are extreme fatigue, sleep disturbances, indigestion, and anxiety.
However, some women do experience irregular heartbeat, dizziness, sweating, and nausea.
Burning, pain, or pressure in the chest or upper abdomen that can travel to the arm or jaw can also be experienced in women, but it is less commonly reported by women than men.
On average, women experience symptoms 10 years later than men. Women are less likely to recognize symptoms and seek treatment.
Coronary artery disease has a number of well determined risk factors. These include high blood pressure
, lack of exercise, obesity
, high blood cholesterol
, poor diet, depression
, family history
, and excessive alcohol
About half of cases are linked to genetics.
Smoking and obesity are associated with about 36% and 20% of cases, respectively.
Smoking just one cigarette per day about doubles the risk of CAD.
Lack of exercise has been linked to 7–12% of cases.
Exposure to the herbicide Agent Orange
may increase risk.
Rheumatologic diseases such as rheumatoid arthritis
, systemic lupus erythematosus
, and psoriatic arthritis
are independent risk factors as well.
Job stress appears to play a minor role accounting for about 3% of cases.
In one study, women who were free of stress from work life saw an increase in the diameter of their blood vessels, leading to decreased progression of atherosclerosis.
In contrast, women who had high levels of work-related stress experienced a decrease in the diameter of their blood vessels and significantly increased disease progression.
Having a type A behavior pattern
, a group of personality characteristics including time urgency, competitiveness, hostility, and impatience,
is linked to an increased risk of coronary disease.
Dietary cholesterol does not appear to have a significant effect on blood cholesterol and thus recommendations about its consumption may not be needed.
Saturated fat is still a concern.
- Endometriosis in women under the age of 40.
- Depression and hostility appear to be risks.
- The number of categories of adverse childhood experiences (psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill, suicidal, or incarcerated) showed a graded correlation with the presence of adult diseases including coronary artery (ischemic heart) disease.
- Hemostatic factors: High levels of fibrinogen and coagulation factor VII are associated with an increased risk of CAD.
- Low hemoglobin.
- In the Asian population, the b fibrinogen gene G-455A polymorphism was associated with the risk of CAD.
Illustration depicting coronary artery disease
Limitation of blood flow to the heart causes ischemia
(cell starvation secondary to a lack of oxygen) of the heart's muscle cells
. The heart's muscle cells may die from lack of oxygen
and this is called a myocardial infarction
(commonly referred to as a heart attack). It leads to damage, death, and eventual scarring of the heart muscle without regrowth of heart muscle cells. Chronic high-grade narrowing
of the coronary arteries can induce transient ischemia
which leads to the induction of a ventricular arrhythmia
, which may terminate into a dangerous heart rhythm known as ventricular fibrillation
, which often leads to death.
Typically, coronary artery disease occurs when part of the smooth, elastic lining inside a coronary artery
(the arteries that supply blood to the heart muscle) develops atherosclerosis
. With atherosclerosis, the artery's lining becomes hardened, stiffened, and accumulates deposits of calcium, fatty lipids, and abnormal inflammatory cells
– to form a plaque
. Calcium phosphate (hydroxyapatite) deposits in the muscular layer of the blood vessels appear to play a significant role in stiffening the arteries and inducing the early phase of coronary arteriosclerosis
. This can be seen in a so-called metastatic mechanism of calciphylaxis
as it occurs in chronic kidney disease
(Rainer Liedtke 2008). Although these people suffer from a kidney dysfunction, almost fifty percent of them die due to coronary artery disease. Plaques can be thought of as large "pimples" that protrude into the channel of an artery, causing a partial obstruction to blood flow. People with coronary artery disease might have just one or two plaques
, or might have dozens distributed throughout their coronary arteries
. A more severe form is chronic total occlusion
(CTO) when a coronary artery is completely obstructed for more than 3 months.
Coronary angiogram of a man
Coronary angiogram of a woman
For symptomatic people, stress echocardiography
can be used to make a diagnosis for obstructive coronary artery disease.
The use of echocardiography
, stress cardiac imaging, and/or advanced non-invasive imaging is not recommended on individuals who are exhibiting no symptoms and are otherwise at low risk for developing coronary disease.
The diagnosis of "Cardiac Syndrome X" – the rare coronary artery disease that is more common in women, as mentioned, is a diagnosis of exclusion. Therefore, usually, the same tests are used as in any person with the suspected of having coronary artery disease:
Stable coronary artery disease (SCAD) is also often called stable ischemic heart disease (SIHD).
A 2015 monograph explains that "Regardless of the nomenclature, stable angina is the chief manifestation of SIHD or SCAD."
There are U.S. and European clinical practice guidelines
Acute coronary syndrome
Diagnosis of acute coronary syndrome
generally takes place in the emergency department
, where ECGs may be performed sequentially to identify "evolving changes" (indicating ongoing damage to the heart muscle). Diagnosis is clear-cut if ECGs show elevation of the "ST segment
", which in the context of severe typical chest pain is strongly indicative of an acute myocardial infarction
(MI); this is termed a STEMI (ST-elevation MI) and is treated as an emergency with either urgent coronary angiography
and percutaneous coronary intervention
(angioplasty with or without stent
insertion) or with thrombolysis
("clot buster" medication), whichever is available. In the absence of ST-segment elevation, heart damage is detected by cardiac markers
(blood tests that identify heart muscle damage). If there is evidence of damage (infarction
), the chest pain is attributed to a "non-ST elevation MI" (NSTEMI). If there is no evidence of damage, the term "unstable angina" is used. This process usually necessitates hospital admission and close observation on a coronary care unit
for possible complications (such as cardiac arrhythmias
– irregularities in the heart rate). Depending on the risk assessment, stress testing or angiography may be used to identify and treat coronary artery disease in patients who have had an NSTEMI or unstable angina.
There are various risk assessment systems for determining the risk of coronary artery disease, with various emphasis on different variables above. A notable example is Framingham Score
, used in the Framingham Heart Study
. It is mainly based on age, gender, diabetes, total cholesterol, HDL cholesterol, tobacco smoking and systolic blood pressure. When it comes to predicting risk in younger adults (18–39 years old), Framingham Risk Score remains below 10-12% for all deciles of baseline-predicted risk.
is another way of risk assessment. In one study the relative risk of incident coronary events was 91% higher among participants at high genetic risk than among those at low genetic risk.
Most guidelines recommend combining these preventive strategies. A 2015 Cochrane Review found some evidence that counselling and education in an effort to bring about behavioral change might help in high-risk groups. However, there was insufficient evidence to show an effect on mortality or actual cardiovascular events.
Secondary prevention is preventing further sequelae of already established disease. Effective lifestyle changes include:
, like walking, jogging, or swimming, can reduce the risk of mortality from coronary artery disease.
Aerobic exercise can help decrease blood pressure and the amount of blood cholesterol (LDL) over time. It also increases HDL cholesterol which is considered "good cholesterol".
Although exercise is beneficial, it is unclear whether doctors should spend time counseling patients to exercise. The U.S. Preventive Services Task Force
found "insufficient evidence" to recommend that doctors counsel patients on exercise but "it did not review the evidence for the effectiveness of physical activity to reduce chronic disease, morbidity and mortality", only the effectiveness of counseling itself.
The American Heart Association
, based on a non-systematic review, recommends that doctors counsel patients on exercise.
Psychological symptoms are common in people with CHD, and while many psychological treatments may be offered following cardiac events, there is no evidence that they change mortality, the risk of revascularization procedures, or the rate of non-fatal myocardial infarction.
There are a number of treatment options for coronary artery disease:
It is recommended that blood pressure typically be reduced to less than 140/90 mmHg.
The diastolic blood pressure however should not be lower than 60 mmHg.[vague]
Beta blockers are recommended first line for this use.
In those with no previous history of heart disease, aspirin decreases the risk of a myocardial infarction but does not change the overall risk of death.
It is thus only recommended in adults who are at increased risk for coronary artery disease
where increased risk is defined as "men older than 90 years of age, postmenopausal
women, and younger persons with risk factors for coronary artery disease (for example, hypertension, diabetes, or smoking) who are at increased risk for heart disease and may wish to consider aspirin therapy". More specifically, high-risk persons are "those with a 5-year risk ≥ 3%".
plus aspirin (dual anti-platelet therapy) reduces cardiovascular events more than aspirin alone in those with a STEMI
. In others at high risk but not having an acute event, the evidence is weak.
Specifically, its use does not change the risk of death in this group.
In those who have had a stent, more than 12 months of clopidogrel plus aspirin does not affect the risk of death.
Revascularization for acute coronary syndrome
has a mortality benefit.
Percutaneous revascularization for stable
ischaemic heart disease does not appear to have benefits over medical therapy alone.
In those with disease in more than one artery, coronary artery bypass grafts
appear better than percutaneous coronary interventions
Newer "anaortic" or no-touch off-pump coronary artery revascularization techniques have shown reduced postoperative stroke rates comparable to percutaneous coronary intervention.
Hybrid coronary revascularization has also been shown to be a safe and feasible procedure that may offer some advantages over conventional CABG though it is more expensive.
Deaths due to ischaemic heart disease per million persons in 2012
As of 2010, CAD was the leading cause of death globally resulting in over 7 million deaths.
This increased from 5.2 million deaths from CAD worldwide in 1990.
It may affect individuals at any age but becomes dramatically more common at progressively older ages, with approximately a tripling with each decade of life.
Males are affected more often than females.
It is estimated that 60% of the world's cardiovascular disease burden will occur in the South Asian subcontinent despite only accounting for 20% of the world's population. This may be secondary to a combination of genetic predisposition and environmental factors. Organizations such as the Indian Heart Association
are working with the World Heart Federation
to raise awareness about this issue.
Coronary artery disease is the leading cause of death for both men and women and accounts for approximately 600,000 deaths in the United States every year.
According to present trends in the United States, half of healthy 40-year-old men will develop CAD in the future, and one in three healthy 40-year-old women.
It is the most common reason for death of men and women over 20 years of age in the United States.
Society and culture
Other terms sometimes used for this condition are "hardening of the arteries" and "narrowing of the arteries".
In Latin it is known as morbus ischaemicus cordis
Industry influence on research
Research efforts are focused on new angiogenic
treatment modalities and various (adult) stem-cell therapies
. A region on chromosome 17
was confined to families with multiple cases of myocardial infarction.
Other genome-wide studies have identified a firm risk variant on chromosome 9
However, these and other loci
are found in intergenic segments and need further research in understanding how the phenotype
A more controversial link is that between Chlamydophila pneumoniae
infection and atherosclerosis.
While this intracellular organism has been demonstrated in atherosclerotic plaques, evidence is inconclusive as to whether it can be considered a causative factor.
Treatment with antibiotics in patients with proven atherosclerosis has not demonstrated a decreased risk of heart attacks or other coronary vascular diseases.
Since the 1990s the search for new treatment options for coronary artery disease patients, particularly for so called "no-option" coronary patients, focused on usage of angiogenesis
and (adult) stem cell
therapies. Numerous clinical trials were performed, either applying protein
(angiogenic growth factor
) therapies, such as FGF-1
, or cell therapies using different kinds of adult stem cell
populations. Research is still going on – with first promising results particularly for FGF-1
and utilization of endothelial progenitor cells
Dietary changes can decrease coronary artery disease. For example, data supports benefit from a plant-based diet and aggressive lipid lowering to improve heart disease.[needs update]
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