Coronary artery disease (ischemic heart disease): causes, symptoms and treatment

Coronary artery disease is the formation of plaque in the coronary arteries (the arteries that supply blood to the heart muscle). Coronary artery disease results in myocardial ischemia and can cause – depending on the severity and degree of myocardial ischemia – chronic coronary syndromes (stable angina) and acute coronary syndromes (heart attacks). Coronary heart disease prevention is based on the prevention of atherosclerosis, which is the most common cause of coronary heart disease.

What is coronary artery disease? What is ischemic heart disease?

Coronary heart disease (CAD) is a term that includes all conditions of myocardial ischemia, regardless of the cause. The absolutely most common (> 98% of cases) cause of ischemic heart disease is coronary atherosclerosis (see figure), or coronary artery disease . In coronary artery disease, plaque develops in the artery for many years (see What is atherosclerosis? ). As it grows, less and less blood flows to the heart muscle, which causes its ischemia and hypoxia.

Ischemic disease can also (rarely) be caused by, among others:

1. coronary artery spasm – variant angina (Prinzmetal’s), induced by drugs, e.g. after withdrawal of nitrates
2. coronary embolism – in the course of sepsis or bacterial endocarditis
3. coronary arteritis – polyarteritis nodosa , Takayasu’s disease, Kawasaki’s disease , systemic lupus erythematosus , syphilis
4. changes in the coronary arteries in the course of metabolic disorders – mucopolysaccharidosis, amyloidosis, Fabry disease, homocystinuria
5. arterial thrombosis due to haemostatic disorders – thrombocythemia, intravascular coagulation syndrome, polycythemia true states of increased blood coagulation, especially antiphospholipid syndrome
6. reduced oxygen supply in relation to the demand (not related to changes in the arteries) – aortic stenosis – all forms, hypertrophic cardiomyopathy, aortic valve insufficiency, carbon monoxide poisoning, decompensated hyperthyroidism , anemia.

Depending on how quickly coronary artery disease develops and how much oxygen deficiency is, two main forms are distinguished:

1. chronic coronary syndromes , i.e. a condition in which ischemia occurs most often due to an increase in the load on the heart muscle (e.g. during exercise, stress) or is mild, and the disease progresses relatively slowly.
2. acute coronary syndromes in which oxygen deficiency is severe, often the blood supply to the heart is almost completely interrupted, and ischemia increases rapidly and is a direct threat to life. Heart attacks belong to this group .

What is angina?

Angina is a symptom of ischemic heart disease. In angina, there is pain in the chest (or its equivalent, i.e. other symptoms with the same cause and significance) due to myocardial ischemia. Pain is usually caused by exercise or stress (but can occur spontaneously) and is not related to necrosis of myocardial cells. Angina symptoms are an expression of insufficient oxygen supply in relation to the myocardial demand. More: Angina pectoris

Who Has Coronary Heart Disease? What are the causes of coronary artery disease?

The incidence of coronary artery disease in Poland is 20–40 / 1000. It usually occurs after the age of 40 in men and in the age of 50 in women. The incidence of angina increases in both sexes with age (5-7% and 10-12% in women, and 4-7% and 12-14% in men, aged 45-64 and 65-84 years, respectively) ).

The likelihood of having coronary heart disease is increased by the presence of risk factors, such as:

1. genetic predisposition (early – in men under 55 years of age, in women under 60 years of age – a family history of ischemic heart disease or diseases of other arteries based on atherosclerosis)
2. age (men from 45 years of age, women from 55 years of age)
3. Gender (higher risk in males than in premenopausal females)
4. improper nutrition
5. little physical activity
6. increased concentration of LDL cholesterol (LDL-C) in plasma
7. increased levels of triglycerides (TG)
8. pre-diabetes or diabetes
9. overweight and obesity
10. hypertension
11. smoking
12. the presence of atherosclerosis of the cerebral or peripheral arteries
13. changes in your resting (routine) ECG
14. abnormal function of the left ventricle on echocardiography.

What are the symptoms of coronary artery disease?

Coronary artery disease may take the form of chronic coronary syndromes or acute coronary syndromes. Read more: Acute coronary syndromes and  Stable angina

In chronic coronary syndromes, the set of symptoms that appear when myocardial ischemia worsens (usually with exercise) is called angina . They manifest slightly differently in each person, but the most common symptom is chest pain, which:

• it is oppressive, choking or crushing (it is almost never sharp or prickly)
• usually located behind the breastbone, it can radiate to the neck, lower jaw, upper abdomen or arms (usually left); it can also be located in the upper abdomen
• it is triggered by exercise and resolves at rest. Emotional stress is the second most important factor in causing pain, apart from exercise
• the intensity of pain is often greater in the morning, it also depends on weather conditions – it is favored by cold air and windy weather
• it usually lasts a few minutes and does not change depending on body position or breath phase (it is the same during inhalation and exhalation)
• disappears after sublingual intake of nitroglycerin, usually within 1-3 minutes
• typical angina is more common in men than in women. In women, pain is more often associated with unpleasant emotions and lasts longer than a few minutes
• pain can also be caused by lying down and occur at night. This type of pain occurs especially in elderly people with limited physical activity
• A heavy meal may also be conducive to the onset of angina.

Angina symptoms are an expression of insufficient oxygen supply in relation to the myocardial demand. The typical symptoms of angina are angina, but an attack of angina can also be a so-called angina attack. equivalents to which belong:

1. Exercise dyspnea – this means that when the patient undertakes physical exertion (eg, walking), he has a feeling of lack of air and must stop to “draw in” it. This symptom can accompany or replace pain – especially in people with diabetes or the elderly, who often have impaired pain perception.
2. Severe upper abdominal pain or nausea and vomiting – these symptoms are not typical of angina, but are possible symptoms that may occur especially in the elderly, in women, in patients with diabetes, kidney failure or  dementia . Some people who suffer from this may feel that this is a serious indigestion. They may or may not be associated with the other symptoms listed.
3. Strong dizziness
4. Palpitations
5. Considerable weakness

More about angina here: Stable angina

Acute coronary syndromes are ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndrome (NSTEMI) – non-ST segment elevation myocardial infarction and unstable angina. More: Acute coronary syndromes

In acute coronary syndromes, chest pain occurs that is similar to pain in angina or its equivalents. Contrary to stable coronary artery disease, pain does not subside within 5 minutes after the effects of its triggers has ceased or nitroglycerin has been ingested under the tongue, but it lasts longer and may also appear at rest. In patients with diabetes, renal failure, the elderly, with dementia, and more often in women, unusual or mild symptoms may occur.

In ST segment elevation myocardial infarction, the symptoms may be more severe and the chest pain may be accompanied by other symptoms. Read more: Heart attack with ST segment elevation

What to do in the event of symptoms of coronary artery disease?

People diagnosed with coronary artery disease can usually judge for themselves whether the symptoms are disturbing or not. If there is anything disturbing about the symptoms you experience, for example the pain is stronger and longer than usual, contact your doctor as soon as possible!If you experience sudden severe pain in the chest, especially if it is accompanied by weakness or other distressing symptoms, you should call an ambulance service ( 

999 or 

112 ) as soon as possible. Similar ailments can also occur for other life-threatening reasons. Do not delay the decision to call an ambulance or seek medical help on your own.While waiting for medical assistance, allow the patient to stay in a comfortable position and provide access to fresh air. In case of unconsciousness, the patient should be placed in the recovery position.In the event of symptoms of sudden cardiac arrest, first aid should be provided immediately in accordance with the management of a person in cardiac arrest.

Keep in mind that a heart attack may be the first symptom of coronary artery disease.

How does a doctor diagnose coronary artery disease?

The diagnosis of unstable coronary artery disease and myocardial infarction, due to the riskiness of these conditions, is usually carried out in a hospital, most often in the Hospital Emergency Department (!). In the case of stable coronary artery disease, a number of additional tests are performed, such as:

• laboratory tests (cholesterol, triglycerides (lipidogram), glucose , morphology, thyroid hormones, creatinine , etc.)
• echocardiography or stress scintigraphy of the heart
• Resting echocardiography (including transesophageal echocardiography ) – to assess the resting function of the heart
• electrographic exercise test and resting ECG
• a chest x-ray to look for other causes of chest discomfort and / or signs of heart failure
• coronary angiography (invasive angiography) of the coronary arteries – to assess the anatomy of the coronary arteries
• angio-CT of the heart – in exceptional cases
• MRI of the heart – usually in patients who cannot perform echocardiography
• PET (positron emission tomography) – very accurate, but also very expensive and difficult to access examination.

Coronary heart disease prophylaxis

Coronary artery disease is most often caused by atherosclerosis. So, the prevention of coronary heart disease is the prevention of atherosclerosis. Read here: Atherosclerosis

How Long Can You Live With Coronary Heart Disease?

It is impossible to answer this question unequivocally. It depends on many factors, including on how advanced the coronary artery disease is, on the general condition of the patient, their heart and circulatory system, and on what causes the coronary artery disease. In most cases, coronary artery disease is caused by atherosclerosis. Therefore, the prevention of atherosclerosis is very important. More here: Atherosclerosis
Proper management may slow down its development and prevent complications, such as a heart attack.