Coronary artery disease

Coronary artery disease (CAD) also known as

atherosclerotic heart disease,[1] atherosclerotic cardiovascular disease,[2] coronary heart disease,[3] or ischemic heart disease (IHD),[4] is the most common type
of heart disease and cause of heart attacks.[5] The disease
is caused by plaque building up along the inner walls of
the arteries of the heart, which narrows the lumen of arteries and reduces blood ow to the heart.

forms, are also eective in relieving symptoms but are

not known to reduce the chances of future heart attacks.
Many other more eective treatments, especially of the
underlying atheromatous disease, have been developed.

Angina that changes in intensity, character or frequency

is termed unstable. Unstable angina may precede
myocardial infarction. In adults who go to the emergency
with an unclear cause of pain, about 30% have pain due
While the symptoms and signs of coronary artery disease to coronary artery disease.[10]
are noted in the advanced state of disease, most individuals with coronary artery disease show no evidence of disease for decades as the disease progresses before the rst 2 Risk factors
onset of symptoms, often a sudden heart attack, nally
arises. Symptoms of stable ischaemic heart disease inCoronary artery disease has a number of well determined
clude angina (characteristic chest pain on exertion) and
risk factors. The most common risk factors include
decreased exercise tolerance.
smoking, family history, hypertension, obesity, diabetes,
Unstable IHD presents itself as chest pain or other symp- lack of exercise, stress, and hyperlipidemia.[11] Smoktoms at rest, or rapidly worsening angina. The risk ing is associated with about 54% of cases and obesity
of artery narrowing increases with age, smoking, high 20%.[12] Lack of exercise has been linked to 712% of
blood cholesterol, diabetes, high blood pressure, and is cases.[12][13]
more common in men and those who have close relatives
Job stress appears to play a minor role accounting for
with CAD. Other causes include coronary vasospasm,[6] a
about 3% of cases.[12] In one study, women who were
spasm of the blood vessels of the heart, it is usually called
free of stress from work life saw an increase in the diPrinzmetals angina.[7]
ameter of their blood vessels, leading to decreased proDiagnosis of IHD is with an electrocardiogram, blood gression of atherosclerosis.[14] Contrastingly, women who
tests (cardiac markers), cardiac stress testing or a had high levels of work-related stress experienced a decoronary angiogram. Depending on the symptoms and crease in the diameter of their blood vessels and signifrisk, treatment may be with medication, percutaneous icantly increased disease progression.[14] Also, having a
coronary intervention (angioplasty) or coronary artery type A behavior pattern, a group of personality characbypass surgery (CABG).
teristics including time urgency, competitiveness, hostil[15]
is linked to an increased risk of
It was as of 2012 the most common cause of death in ity, and impatience
[16]
[8]
[9] coronary disease.
the world, and a major cause of hospital admissions.
There is limited evidence for population screening, but Risk factors can be classied as: xed (such as age, sex,
prevention (with a healthy diet and sometimes medica- family history) and modiable (such as smoking, hypertion for diabetes, cholesterol and high blood pressure) is tension, diabetes mellitus, obesity, etc.)
used both to prevent IHD and to decrease the risk of complications.
Hypercholesterolemia (specically, serum LDL
concentrations) HDL(high density lipoprotein)has
a protective eect over development of coronary
artery disease.[17]
1 Signs and symptoms
Type A Behavioural Patterns, TABP.Type A behaviour is associated with competitive drive, restlessness,hostility & a sense of impatience. Added
in 1981 as an independent risk factor after a majority of research into the eld discovered that TABPs
were twice as likely to exhibit CAD as any other personality type (very controversial due to tobacco industry funding of these researches).

Angina (chest pain) that occurs regularly with activity, after heavy meals, or at other predictable times is
termed stable angina and is associated with high grade
narrowings of the heart arteries. The symptoms of
angina are often treated with betablocker therapy such
as metoprolol or atenolol. Nitrate preparations such as
nitroglycerin, which come in short-acting and long-acting
1

4 DIAGNOSIS
Hemostatic factors:[18] High levels of brinogen and
coagulation factor VII are associated with an increased risk of CAD. Factor VII levels are higher
in individuals with a high intake of dietary fat. Decreased brinolytic activity has been reported in patients with coronary atherosclerosis.

heart muscle death and later myocardial scarring without heart muscle regrowth. Chronic high-grade stenosis of the coronary arteries can induce transient ischemia
which leads to the induction of a ventricular arrhythmia,
which may terminate into ventricular brillation leading
to death.

High levels of Lipoprotein(a),[19][20][21] a compound Typically, coronary artery disease occurs when part of
formed when LDL cholesterol combines with a sub- the smooth, elastic lining inside a coronary artery (the
arteries that supply blood to the heart muscle) develops
stance known as Apoliprotein (a).
atherosclerosis. With atherosclerosis, the arterys lining
[22]
becomes hardened, stiened, and swollen with all sorts of
Men over 45; Women over 55
gunge - including calcium deposits, fatty deposits, and
abnormal inammatory cells - to form a plaque. Deposits
Low hemoglobin[23]
of calcium phosphates (hydroxyapatites) in the muscular
High blood triglycerides may play a role.[24]
layer of the blood vessels appear to play not only a signicant role in stiening arteries but also for the induction of
an early phase of coronary arteriosclerosis. This can be
seen in a so-called metastatic mechanism of calciphylaxis
3 Pathophysiology
as it occurs in chronic kidney disease and haemodialysis (Rainer Liedtke 2008). Although these patients suffer from a kidney dysfunction, almost fty 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
ow. Patients with coronary artery disease might have
just one or two plaques, or might have dozens distributed
throughout their coronary arteries. However, there is a
term in medicine called cardiac syndrome X, which describes chest pain (Angina pectoris) and chest discomfort in people who do not show signs of blockages in the
larger coronary arteries of their hearts when an angiogram
(coronary angiogram) is being performed.[25]

Illustration depicting atherosclerosis in coronary artery.

No one knows exactly what causes cardiac syndrome X.

One explanation is microvascular dysfunction.[26] It is not
completely clear why women are more likely than men to
have it; however, hormones and other risk factors unique
to women may play a role.[27]

4 Diagnosis
For symptomatic patients, stress echocardiography can
be used to make a diagnosis for obstructive coronary
artery disease.[28] The use of echocardiography is not recommended on individuals who are exhibiting no symptoms and are otherwise at low risk for developing coronary disease.[28]

Illustration depicting coronary artery disease

Limitation of blood ow to the heart causes ischemia (cell

starvation secondary to a lack of oxygen) of the myocardial cells. Myocardial cells may die from lack of oxygen
and this is called a myocardial infarction (commonly
called a heart attack). It leads to heart muscle damage,

CAD has always been a tough disease to diagnose without the use of invasive or stressful activities. The development of the Multifunction Cardiogram (MCG) has
changed the way CAD is diagnosed. The MCG consists
of a 2 lead resting EKG signal is transformed into a mathematical model and compared against tens of thousands
of clinical trials to diagnose a patient with an objective
severity score, as well as secondary and tertiary results
about the patients condition. The results from MCG

4.1

Stable angina

3
of coronary artery disease:
Baseline electrocardiography (ECG)
Exercise ECG Stress test
Exercise radioisotope test (nuclear stress test, myocardial scintigraphy)
Echocardiography (including stress echocardiography)
Coronary angiography
Intravascular ultrasound
Magnetic resonance imaging (MRI)

Coronary angiogram of a man

The diagnosis of coronary disease underlying particular

symptoms depends largely on the nature of the symptoms. The rst investigation is an electrocardiogram
(ECG/EKG), both for stable angina and acute coronary
syndrome. An X-ray of the chest and blood tests may be
performed.

4.1 Stable angina

Main article: Angina pectoris
In stable angina, chest pain with typical features occurring at predictable levels of exertion, various forms of
cardiac stress tests may be used to induce both symptoms and detect changes by way of electrocardiography
(using an ECG), echocardiography (using ultrasound of
the heart) or scintigraphy (using uptake of radionuclide
by the heart muscle). If part of the heart seems to receive
an insucient blood supply, coronary angiography may
be used to identify stenosis of the coronary arteries and
suitability for angioplasty or bypass surgery.
Coronary angiogram of a woman

4.2 Acute coronary syndrome

tests have been validated in 8 clinical trials which resulted in a database of over 50,000 patients where the system has demonstrated accuracy comparable to coronary
angiography (90% overall sensitivity, 85% specicity).
This level of accuracy comes from the application of advanced techniques in signal processing and systems analysis combined with a large scale clinical database which allows MCG to provide quantitative, evidence-based results
to assist physicians in reaching a diagnosis. The MCG
has also been awarded a Category III CPT code by the
American Medical Association in the July 2009 CPT update .
The diagnosis of Cardiac Syndrome X - the rare coronary artery disease that is more common in women, as
mentioned, an exclusion diagnosis. Therefore, usually
the same tests are used as in any patient with the suspicion

Main article: 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 nonST elevation MI (NSTEMI). If there is no evidence of
damage, the term unstable angina is used. This process usually necessitates admission to hospital, and close
observation on a coronary care unit for possible complications (such as cardiac arrhythmias irregularities in the
heart rate).

TREATMENT

fatty acid supplementation in preventing cardiovascular

disease (including myocardial infarction and sudden
cardiac death).[40][41] There is tentative evidence that
menaquinone (Vitamin K2 ), but not phylloquinone
(Vitamin K1 ), intake may reduce the risk of CAD
mortality.[42]

5.2 Secondary prevention

Depending on the risk assessment, stress testing or angiography may be used to identify and treat coronary
Secondary prevention is preventing further sequelae of
artery disease in patients who have had an NSTEMI or
already established disease. Lifestyle changes that have
unstable angina.
been shown to be eective to this goal include:

4.3

Risk assessment

There are various risk assessment systems for determining the risk of coronary artery disease, with various emphasis on dierent 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.[29]

Prevention

Prevention involves: exercise, decreasing obesity, treating hypertension, a healthy diet, decreasing cholesterol
levels, and stopping smoking. Medications and exercise
are roughly equally eective.[30]
In diabetes mellitus, there is little evidence that very tight
blood sugar control improves cardiac risk although improved sugar control appears to decrease other problems
like kidney failure and blindness. The World Health Organization (WHO) recommends low to moderate alcohol intake to reduce risk of coronary artery disease although this remains without scientic cause and eect
proof.[31]

5.1

Weight control
Smoking cessation
Avoiding the consumption of trans fats (in partially
hydrogenated oils)
Exercise. In people with coronary artery disease,
aerobic exercise, like walking, jogging, or swimming, can reduce the risk of mortality.[43] Aerobic
exercise can help decrease blood pressure and the
amount of blood cholesterol (LDL) over time. It
also increases HDL cholesterol which is considered
as good cholesterol.[44][45] Separate to the question of the benets of exercise; it is unclear whether
doctors should spend time counseling patients to exercise. The U.S. Preventive Services Task Force,
found insucient evidence to recommend that
doctors counsel patients on exercise, but it did not
review the evidence for the eectiveness of physical activity to reduce chronic disease, morbidity
and mortality, it only examined the eectiveness of
the counseling itself.[46] The American Heart Association, based on a non-systematic review, recommends that doctors counsel patients on exercise.[47]
Decrease psychosocial stress.[48]

Diet

Main article: Diet and heart disease

6 Treatment

There are a number of treatment options for coronary

A diet high in fruits and vegetables decreases the risk of artery disease:[49]
cardiovascular disease and death.[32] Vegetarians have a
lower risk of heart disease,[33][34] possibly due to their
1. Lifestyle changes
greater consumption of fruits and vegetables.[35] Evidence also suggests that the Mediterranean diet[36] and
2. Medical treatment - drugs (e.g. cholesterol lowering
a high ber diet lower the risk.[37]
medications, beta-blockers, nitroglycerin, calcium
antagonists, etc.);
The consumption of trans fat (commonly found in
hydrogenated products such as margarine) has been
3. Coronary interventions as angioplasty and coronary
shown to cause a precursor to atherosclerosis[38] and instent;
[39]
crease the risk of coronary artery disease.
Evidence does not support a benecial role for omega-3

4. Coronary artery bypass grafting (CABG)

6.1

Medications

Statins, which reduce cholesterol, reduce risk of

coronary disease[50]
Nitroglycerin
ACE inhibitors, which treat hypertension and may
lower the risk of recurrent myocardial infarction
Calcium channel blockers and/or beta-blockers
Aspirin
6.1.1

Aspirin

In those with no other heart problems aspirin decreases

the risk of a myocardial infarction in men but not women
and increases the risk of bleeding, most of which is
from the stomach. It does not aect the overall risk of
death in either men or women.[51] It is thus only recommended in adults who are at increased risk for coronary
artery disease[52] where increased risk is dened 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)
are at increased risk for heart disease and may wish to
consider aspirin therapy'. More specically, high-risk
persons are 'those with a 5-year risk 3%'.

Disability-adjusted life year for ischaemic heart disease per

100,000 inhabitants in 2004.[59]
no data
<350
350700
7001050
10501400
14001750
17502100
21002450
24502800
28003150
31503500
35004000
>4000

each decade of life.[8] Males are aected more often than

females.[8]

Coronary heart disease (CHD) is the leading cause of

death for both men and women and accounts for approximately 600,000 deaths in the United States every year.[61]
According to present trends in the United States, half of
6.1.2 Anti-platelet therapy
healthy 40-year-old males will develop CAD in the future, and one in three healthy 40-year-old women.[62] It
Clopidogrel plus aspirin reduces cardiovascular events
is the most common reason for death of men and women
more than aspirin alone in those with an STEMI. In othover 20 years of age in the United States.[63] The Maasai
ers at high risk but not having an acute event the evidence
of Africa have almost no heart disease.
is weak.[53] In those who have had a stent more than 12
months of clopidogrel plus aspirin does not aect the risk
of death.[54]

8 Research

6.2

Surgery

Revascularization for acute coronary syndrome has a

mortality benet.[55] Revascularization for stable ischaemic heart disease does not appear to have benets
over medical therapy alone.[56] In those with disease in
more than one artery coronary artery bypass grafts appear
better than percutaneous coronary interventions.[57][58]

Epidemiology

Further information: atheroma and atherosclerosis

Recent research eorts focus on new angiogenic treatment modalities (angiogenesis) and various (adult) stem
cell therapies.
A region on Chromosome 17 was conned to families
with multiple cases of myocardial infarction.[64]
A more controversial link is that between Chlamydophila
pneumoniae infection and atherosclerosis.[65] 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.[66]

CAD as of 2010 was the leading cause of death globally resulting in over 7 million deaths.[60] This is up from
5.2 million deaths in 1990.[60] It may aect individuals at
any age but becomes dramatically more common at progressively older ages, with approximately a tripling with Since the 1990s the search for new treatment options

REFERENCES

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K, Alfredsson L, Bjorner JB, Borritz M, Burr H, Casini A,
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vuo M, Koskinen A, Kouvonen A, Kumari M, Madsen
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10 External links
Risk Assessment of having a heart attack or dying of
coronary artery disease, from the American Heart
Association.
Risk Assessment Tool for Estimating 10-year Risk
of Developing Hard CHD using Framingham score
The InVision Guide to a Healthy Heart An interactive website on the development and function of the
cardiovascular system and cardiovascular diseases
and consequences. The website also features treatment options and preventative measures for maintaining a healthy heart.
A Mechanism of a Metabolic Induction of Coronary
Artery Disease in Chronic Kidney Disease, Rainer
K. Liedtke, MD

10

11

11
11.1

TEXT AND IMAGE SOURCES, CONTRIBUTORS, AND LICENSES

Text and image sources, contributors, and licenses

Text

Coronary artery disease Source: http://en.wikipedia.org/wiki/Coronary%20artery%20disease?oldid=642982585 Contributors: Sodium,

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11.2

Images

File:Blausen_0257_CoronaryArtery_Plaque.png Source:
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CoronaryArtery_Plaque.png License: CC BY 3.0 Contributors: Own work Original artist: BruceBlaus. When using this image in external
sources it can be cited as:
File:Blausen_0259_CoronaryArteryDisease_02.png Source: http://upload.wikimedia.org/wikipedia/commons/6/6d/Blausen_0259_
CoronaryArteryDisease_02.png License: CC BY 3.0 Contributors: Own work Original artist: BruceBlaus. When using this image in
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File:Coro_Man.jpg Source: http://upload.wikimedia.org/wikipedia/en/d/d2/Coro_Man.jpg License: CC-BY-3.0 Contributors: ? Original
artist: ?
File:Coro_Woman.jpg Source: http://upload.wikimedia.org/wikipedia/en/c/cf/Coro_Woman.jpg License: CC-BY-3.0 Contributors: ?
Original artist: ?
File:Ischaemic_heart_disease_world_map_-_DALY_-_WHO2004.svg Source: http://upload.wikimedia.org/wikipedia/commons/b/
b8/Ischaemic_heart_disease_world_map_-_DALY_-_WHO2004.svg License: CC BY-SA 2.5 Contributors:
Vector map from BlankMap-World6, compact.svg by Canuckguy et al. Original artist: Lokal_Prol

11.3

Content license

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