Coronary Artery Disease

Coronary artery disease is a common heart condition affecting millions of people worldwide, where the arteries supplying blood to the heart become narrowed or blocked, potentially leading to serious complications like heart attacks.

Table of contents

• What Is Coronary Artery Disease?
• Signs and Symptoms
• Causes and Development
• Risk Factors
• Diagnosis and Testing
• Treatment Options
• Prevention and Lifestyle Changes
• Living With Coronary Artery Disease

coronary heart disease, CHD, ischemic heart disease, IHD, CAD

• Heart
• Coronary arteries
• Aorta
• Blood vessels

What Is Coronary Artery Disease?

Coronary artery disease is the most common type of heart disease and a leading cause of death in the United States and worldwide^[1][2]. The condition occurs when the arteries that supply oxygen-rich blood to your heart muscle become narrowed or blocked^[3]. These blood vessels, called coronary arteries (the main blood vessels that deliver blood to the heart), branch off from the aorta just after it leaves the heart^[1][6].

Over 18 million adults in the United States have coronary artery disease^[2]. In 2021, coronary artery disease killed 375,500 people in the U.S., and in 2022, it caused 371,506 deaths^[2][3]. The disease is sometimes called coronary heart disease or ischemic heart disease^[1][3].

There are two main forms of coronary artery disease. Stable ischemic heart disease is the chronic form where your coronary arteries gradually narrow over many years. You may feel some symptoms, but you’re able to live with the condition day to day^[2]. Acute coronary syndrome is the sudden form that’s a medical emergency. The plaque in your coronary artery suddenly ruptures and forms a blood clot that blocks blood flow to your heart, causing a heart attack^[2].

Signs and Symptoms

Many people may have no symptoms of coronary artery disease for a long time. Plaque buildup takes many years, even decades^[2][5]. You might have the disease for many years and not have any symptoms until you experience a heart attack. That’s why coronary artery disease is often called a “silent killer”^[2].

As your arteries narrow, you may notice mild symptoms. These symptoms mean your heart is pumping harder to deliver oxygen-rich blood to your body^[2]. The main symptoms of coronary artery disease include^[5]:

• Chest pain or angina (a feeling of pressure, squeezing, or discomfort in the chest)
• Shortness of breath
• Pain in your neck, shoulders, jaw, or arms
• Feeling faint
• Feeling sick to your stomach

Stable angina (temporary chest pain or discomfort) is the most common symptom. It comes and goes in a predictable pattern. You’ll usually notice it during physical activity or emotional stress. It goes away when you rest or take nitroglycerin (medicine that treats angina)^[2]. Some people feel short of breath during light physical activity^[2].

For many people, the first clue that they have coronary artery disease is a heart attack. About 1 in 20 adults aged 20 and older have coronary artery disease, but many people don’t know they have the disease until they have chest pain, a heart attack, or their heart suddenly stops pumping blood^[3]. Half of the time, the first symptom a person has is actually a heart attack, and half of these heart attacks are fatal^[9].

Symptoms of a heart attack may include^[23]:

• Pain or discomfort in the center or left side of the chest
• Pain or discomfort in the upper body, including the arms, back, shoulders, neck, jaw, or upper stomach
• Shortness of breath or trouble breathing
• Feeling sick to your stomach or throwing up
• Stomachache or feeling like you have heartburn
• Feeling dizzy, lightheaded, or unusually tired
• Breaking out in a cold sweat

Causes and Development

Coronary artery disease is almost always due to the gradual buildup of cholesterol and other fatty materials in the wall of a coronary artery^[6]. This buildup of fatty deposits is called plaque or atheroma, and the process is known as atherosclerosis (literally “hardening of the arteries”)^[1][2].

Over time, the walls of your arteries can become furred up with these fatty deposits. As plaque collects along your artery walls, your arteries become narrow and stiff^[2][5]. Plaque consists of cholesterol, waste products, calcium, and fibrin (a substance that helps your blood clot)^[2].

As an atheroma grows, it may bulge into the artery, narrowing the interior and partially blocking blood flow. With time, calcium accumulates in the atheroma^[6]. The plaque can partly or completely block blood flow in the arteries of the heart. When this happens, the heart muscle might not get enough blood to continue working properly^[14].

The blood supply is more likely to be inadequate during exertion, when the heart muscle requires more blood. An inadequate blood supply to the heart muscle is called myocardial ischemia^[6]. An atheroma, even one that is not blocking very much blood flow, may rupture suddenly. The rupture of an atheroma often triggers the formation of a blood clot. The clot further narrows or completely blocks the artery, causing acute myocardial ischemia^[6].

Risk Factors

Anyone can get coronary artery disease, but certain traits, conditions, or habits may raise your risk. Some risk factors you can’t control, while others you can^[23].

Risk factors you cannot control include^[1][23]:

• Age (being a woman over age 55 or a man over age 45)
• Family history of heart disease, especially if your father or brother had heart disease before age 55, or your mother or sister had it before age 65
• Sex at birth (men have higher death rates between ages 35 and 55)

Risk factors you can control include^[4][5]:

• Smoking tobacco
• High cholesterol levels
• High blood pressure (hypertension)
• Diabetes or high blood sugar levels
• Being overweight or having obesity
• Physical inactivity
• Unhealthy eating habits
• Regularly drinking excessive amounts of alcohol

Atherosclerosis can be caused by lifestyle factors, such as smoking and regularly drinking excessive amounts of alcohol. You’re also more at risk of getting atherosclerosis if you have conditions like high cholesterol, high blood pressure, or diabetes^[5].

Diagnosis and Testing

If a doctor feels you’re at risk of coronary heart disease, they may carry out a risk assessment. They’ll ask you about your medical and family history and your lifestyle, and they’ll take a blood test^[5].

If you’re at high risk for heart disease or already have symptoms, your doctor can use several tests to diagnose coronary artery disease^[4]:

• ECG or EKG (electrocardiogram): Measures the electrical activity, rate, and regularity of your heartbeat
• Echocardiogram: Uses ultrasound (special sound waves) to create a picture of the heart
• Exercise stress test: Measures your heart rate while you walk on a treadmill to determine how well your heart is working when it has to pump more blood
• Chest X-ray: Uses x-rays to create a picture of the heart, lungs, and other organs in the chest
• Cardiac catheterization: Checks the inside of your arteries for blockage by inserting a thin, flexible tube through an artery in the groin, arm, or neck to reach the heart
• Coronary angiogram: Monitors blockage and flow of blood through the coronary arteries using X-rays to detect dye injected via cardiac catheterization
• Coronary artery calcium scan: A computed tomography (CT) scan that looks at calcium buildup in the arteries

Treatment Options

Coronary heart disease cannot be cured, but treatment can help manage the symptoms and reduce the chances of problems such as heart attacks^[5]. Treatment for coronary artery disease depends on how serious your symptoms are and any other health conditions you have^[10].

Treatment may include heart-healthy lifestyle changes, medicines, or procedures to prevent a heart attack or other health problems^[10]. All patients should be started on a statin (cholesterol-lowering medicine) unless contraindicated^[15]. Daily low-dose aspirin is recommended for all patients with stable coronary artery disease, unless contraindicated^[15].

Many different medicines are used to treat coronary artery disease. They usually aim to reduce blood pressure, widen your arteries, or prevent blood clots^[12]. Common medications include:

• Blood-thinning medicines like low-dose aspirin and clopidogrel to help reduce the risk of a heart attack
• Statins to slow down the production of cholesterol in your liver
• Beta blockers to slow down your heartbeat and improve blood flow
• Nitrates to widen your blood vessels and lower blood pressure
• ACE inhibitors to reduce blood pressure
• Calcium channel blockers to relax the muscles in the artery walls and reduce blood pressure

Antianginal medications (medicines to treat chest pain) should be added in a stepwise approach beginning with a beta blocker. Calcium channel blockers, nitrates, and ranolazine are used as adjunctive or second-line therapy when beta blockers are ineffective or contraindicated^[15].

In some cases, procedures or surgery may be necessary. Select patients with uncontrolled symptoms of stable coronary artery disease despite optimal medical management may benefit from coronary revascularization^[15]:

• Angioplasty: A procedure where balloons are used to open up clogged coronary arteries to restore blood flow, often followed by placement of a stent (a small, cage-like structure) to hold the cleared artery open^[14]
• Coronary artery bypass graft (CABG): Open-heart bypass surgery where surgeons create new routes for blood to flow around blocked arteries^[10][14]

Prevention and Lifestyle Changes

You can reduce your risk of getting coronary heart disease by making simple lifestyle changes^[5]. These changes include^[5][10]:

• Eating a healthy, balanced diet: Choose heart-healthy foods including fruits, vegetables, and whole grains. Limit saturated fats, sodium (salt), added sugars, and alcohol. Your healthcare provider may recommend following the DASH (Dietary Approaches to Stop Hypertension) eating plan^[10]
• Being physically active: Routine physical activity can help manage coronary heart disease risk factors such as high cholesterol, high blood pressure, or overweight and obesity. Aim for at least 30 to 60 minutes of activity daily^[19]
• Giving up smoking: Stopping smoking after a heart attack quickly reduces your risk of having a heart attack in the future^[12]. Smoking can damage and tighten your blood vessels^[10]
• Controlling blood cholesterol, blood pressure, and blood sugar levels: Keep these within healthy ranges through lifestyle changes and medications if needed^[5]
• Maintaining a healthy weight: Over 40% of Americans have obesity, making this a common risk factor for many health issues^[18]
• Managing stress: Find positive ways to cope with stress, as too much stress can be bad for your heart^[21]

Even if you haven’t been active for a while, you may need to slowly work your way up to these goals. But in general, the more active you are, the more you’ll benefit^[19]. One of the best things you can do for your heart is to stop smoking or using smokeless tobacco. Even if you’re not a smoker, be sure to stay away from secondhand smoke^[19].

Living With Coronary Artery Disease

Being told that you or a loved one has coronary artery disease can be upsetting. But you’re not alone. More people are living with the disease than ever before thanks to finding it early and better treatments^[21].

It is important to get routine medical care and take all medicines regularly as your healthcare provider prescribed. Follow your provider’s directions and do not change the amount of your medicine or skip a dose unless your provider tells you to^[16]. Be sure to tell your provider about over-the-counter medicines or supplements you take^[16].

Your provider may refer you for cardiac rehabilitation, which is a medically supervised exercise program for people recovering from heart problems. Studies show that cardiac rehabilitation lowers the risk of hospitalization and death. It can also improve your quality of life^[16].

Steps you can take to help prevent problems and feel better include^[21]:

• Make heart-healthy choices every day. Simple changes can make a big difference
• Find an exercise program that’s right for you. Talk with your health care team about what type of physical activity is best and how often you should be active
• Take your medications as prescribed. Medications don’t work the way they should if you don’t take the right dose at the right time
• Learn all you can about your condition. It will help you to ask the right questions and know how to manage it
• Keep routine appointments. Your heart team will want you to come in for routine visits and imaging tests to help track your condition
• Ask your family and friends to help you adopt and keep up with healthy habits
• Ask whether talking to a nutritionist or dietitian might be helpful
• Seek counseling or join a support group, especially if you feel depressed or anxious. Untreated depression or high stress is linked to worsening heart disease^[21]

Call 911 right away if you or someone else has signs of a heart attack. Don’t ignore any signs or feel embarrassed to call for help. Acting fast can save a life^[23].