Coronary Artery Disease

The coronary arteries are the blood vessels that supply your heart with blood. Your heart needs this blood to work properly. Every day, your heart pumps about 3,000 gallons of blood through your body.

What is coronary artery disease?

Coronary artery disease is the narrowing or blockage of the coronary arteries. This condition is usually caused by atherosclerosis. Atherosclerosis (sometimes called hardening or clogging of the arteries) is the buildup of cholesterol and fatty deposits (called plaques) on the inner walls of the arteries. These plaques can restrict blood flow to the heart muscle by clogging the artery or by causing damage to the arteries.

If the heart does not get enough blood, it cannot get the oxygen and nutrients it needs to work properly. This can cause chest pain called angina. If the blood supply to an area of the heart muscle is completely blocked, or if the heart can't work as hard as it needs to because it lacks blood, you can have a heart attack.

What causes the coronary arteries to narrow?

Healthy coronary arteries are smooth and elastic. The insides of these muscular hollow tubes are lined with a layer of cells called the endothelium. The endothelium helps protect the vessel walls and keep the arteries working properly. Blood can flow freely.

Coronary artery disease starts when you are very young. Before your teen years, the blood vessel walls start to show streaks of fat. As you get older, the fat builds up, causing minor damage to your blood vessel walls. With time, other substances that move through your bloodstream, such as inflammatory cells, cellular waste products, proteins and calcium, stick to the vessel walls. These substances combine with the fat to form plaque.

Plaque deposits of different sizes collect inside the arteries. Many are soft on the inside with a hard, fibrous cap covering the outside. If the hard surface cracks or tears, the soft, fatty inside is exposed. Platelets (disc-shaped particles in the blood that help form clots) move to the area, and blood clots form around the plaque. The endothelium can also become irritated and stop working properly, which causes the artery to squeeze at the wrong times. This causes the artery to narrow even more.

Sometimes, the blood clot breaks apart and blood can flow through the area again. Other times, the blood clot (coronary thrombus) suddenly blocks the blood supply to the heart muscle (coronary occlusion), causing one of three serious conditions known as an acute coronary syndrome.

What are acute coronary syndromes?

• Unstable angina: This may be a new symptom or a change from stable angina. The angina may occur more often, happen more easily when you are resting, feel more severe, or last longer. Medication can often help relieve symptoms of unstable angina. However, the condition can lead to a heart attack. If you have unstable angina, you will likely need more intense medical treatment or a procedure to correct the problem.
• Non-ST segment elevation myocardial infarction (NSTEMI): This is a type of heart attack, or MI, that does not cause major changes on an electrocardiogram (ECG). But, a blood test will show that the heart muscle has been damaged. The damage is usually minimal or moderate in size, as the blockage is often partial or temporary.
• ST segment elevation myocardial infarction (STEMI): This type of heart attack, or MI, happens when a part of the heart goes without blood for an extended period of time. It affects a large area of the heart muscle, and causes changes on an ECG and blood test results.

Some people have symptoms before they develop an acute coronary syndrome, but it is possible to not have symptoms until the condition occurs. Some patients never have any symptoms.

If you have an acute coronary syndrome, you need to get emergency treatment!

Collateral circulation

As the blockage in a coronary artery gets bigger and if it occurs slowly, new blood vessels may form to reroute blood around the blockage. This is called collateral circulation. These new blood vessels may not be able to carry enough blood to the heart when there is extra activity or stress.

What is ischemia?

Ischemia is described as cramping of the heart muscle. It is similar to a cramp in the leg after exercising a long time. The muscles in the legs cramp up because they need oxygen and nutrients. Your heart, which is also a muscle, needs oxygen and nutrients to keep working. If the heart muscle can't get enough blood because the coronary artery is too narrow, it causes ischemia. When this happens, you may feel chest pain or other symptoms.

Ischemia happens most often when the heart needs extra oxygen, such as when you are active, eating, excited, stressed, exposed to cold.

If rest or medications relieve symptoms of ischemia within 10 minutes and your symptoms are not getting worse, you may be told you have stable coronary artery disease or stable angina. However, the problem can get worse and you may have symptoms even when you are resting.

It is possible to have ischemia, or even a heart attack, without having any symptoms. This is called silent ischemia. Although anyone with heart disease can have silent ischemia, it is more common in people with diabetes.

What are the symptoms of coronary artery disease?

The most common symptom of coronary artery disease is angina. Angina is often referred to as chest pain. It is also described as chest discomfort, heaviness, tightness, pressure, aching, burning, numbness, fullness, or squeezing. It can be mistaken for indigestion or heartburn. Angina is usually felt in the chest, but may also be felt in the left shoulder, arms, neck, back or jaw.

Other symptoms of coronary artery disease include:

• Shortness of breath
• Palpitations (irregular heartbeats, skipped beats or a flip-flop feeling in your chest)
• A faster-than-normal heartbeat
• Dizziness
• Nausea
• Extreme weakness
• Sweating

If you have symptoms of coronary artery disease, it is important to call your doctor, especially if they are new symptoms or have become worse or more frequent.

Symptoms in women

Women often have different symptoms of coronary artery disease than men. For example, many women who have a heart attack have:

• Pain or discomfort in the chest, left arm or back
• A very fast heartbeat
• Shortness of breath
• Nausea or fatigue

If any of these symptoms occur, it is important to get medical help right away. Call 999 or have someone take you to the nearest emergency room.

What you should do if you have symptoms

If you or someone you are with has pain in the chest, left arm or back that lasts more than five minutes, with one or more symptoms of a heart attack or coronary artery disease, call 999. DO NOT WAIT to get help. Quick treatment during a heart attack is very important to minimize heart damage. If you are a smoker, it is very important that you DO NOT smoke to relieve your stress. Smoking can make symptoms of a heart attack worse.

Aspirin: The 999 dispatcher may tell you to chew one full (325 mg) aspirin slowly, if you do not have a history of aspirin allergy or bleeding. Aspirin is most effective if taken within 30 minutes after the start of symptoms. Do NOT take an aspirin if you have symptoms of a stroke.

Call your doctor if:

• This is the first time you have had these symptoms. Make an appointment to be evaluated.
• You have new symptoms or if symptoms get worse or occur more often.
• Your symptoms stop completely in five minutes. Let your doctor know about your symptoms.

Learn to recognize your symptoms and the situations that cause them.

If you have a prescription for Nitroglycerin

If you have symptoms of angina and you have a prescription for Nitroglycerin, stop what you are doing and rest. Take one dose (dissolve one tablet under your tongue or spray under your tongue). Wait five minutes. If you still have symptoms, call 999.

If you have chronic stable angina and you have symptoms, take one dose of nitroglycerin. Wait five minutes. If symptoms continue, take another dose. You can take three doses within 15 minutes. If symptoms continue after three doses, call 999.

Do not wait to get help

If you think you are having a heart attack, call 999! Do not wait for your symptoms to stop.

The earlier you get treatment, the less damage will happen to your heart.

What's the difference between angina and a heart attack?

Angina is a warning symptom of heart disease but it is not a heart attack. The symptoms of a heart attack (also called myocardial infarction or MI) are similar to angina.

Angina	Heart Attack
Caused by a temporary brief period of poor blood supply to the heart muscle	Caused by a lack of blood supply to the heart muscle over time. The blockage is often due to a clot in a coronary artery
Does not cause permanent damage to the heart	Causes permanent damage to the heart muscle
Symptoms last a few minutes and usually stop if you rest or take medication. Symptoms include chest pain or discomfort, shortness of breath, palpitations, fast heartbeat, dizziness, nausea, extreme weakness and sweating	Symptoms usually last more than a few minutes and can come and go. Symptoms include chest pain or discomfort; pain or discomfort in other areas of the upper body; trouble breathing or shortness of breath; sweating or cold sweat; feeling full, like you are choking, or indigestion; nausea or vomiting; light-headedness; extreme weakness; anxiety; fast or irregular heartbeat
Symptoms usually stop if you rest or take medication	Symptoms do not stop if you rest or take medication
Emergency medical attention is not needed. Call your doctor if you have not had symptoms before or if your symptoms have gotten worse or happen more often	Emergency medical attention is needed if symptoms last longer than 5 minutes

How is coronary artery disease diagnosed?

If you have symptoms that could be caused by coronary artery disease, your doctor will review your medical history and risk factors, do a complete exam, and order some tests. These can include blood work, an electrocardiogram (ECG/EKG), exercise stress tests, cardiac catheterization and coronary computed tomography angiogram (CTA). Testing is needed to find out how severe the disease is, how it is affecting your heart, and to help plan the best treatment for you.

Who is affected by coronary artery disease?

Cardiovascular disease (CVD) causes one in every five deaths in the United Arab Emirates. One in every four people have modifiable risk factors, such as high blood pressure, high cholesterol, smoking and unhealthy eating habits. In addition, 81 percent of people in the United Arab Emirates do not get enough exercise to stay healthy. Cardiovascular disease is a problem around the world, but can be prevented in large part by making lifestyle changes.

What are the risk factors for coronary artery disease?

There are several risk factors for coronary artery disease, including some you can't control (non-modifiable). But, you do have control over many other risk factors (modifiable) The more risk factors you have, the greater your chance of heart disease. Your doctor can help you understand your individual risk factors and what you can do to lower your risk.

Non-Modifiable risk factors include:

• Male gender: Men have a higher risk of a heart attack than women, and they also have heart attacks earlier in life. This risk evens out after age 70.
• Age: You are more likely to have coronary artery disease as you get older, especially after age 65.
• Family history: If your parents have/had heart disease (especially before age 50), your risk of heart disease is higher. Ask your doctor when you should start regular preventive checks for heart disease.

Modifiable risk factors include:

• Tobacco use and exposure to smoke
• High blood cholesterol and high triglycerides. Ask your doctor about goals for your cholesterol and triglyceride levels.
• High blood pressure
• Uncontrolled diabetes
• Being inactive
• Being overweight (body mass index [BMI] 25-29) or obese (BMI >30). The way you carry your weight is also important. The risk of heart disease is higher if your waist is more than 88 centimeters (women) or 101 centimeters (men). Your waist should be measured around your body, just above your belly button.
• Uncontrolled stress or anger
• Diet high in saturated fat and cholesterol
• Drinking too much alcohol

What treatments are available for patients with coronary artery disease?

Your doctor will talk to you about the best treatment plan for you. Following your treatment plan will help reduce your risk of problems like heart attack and stroke.

Reduce your risk factors

The first step in treatment for coronary artery disease is reducing your risk factors. This involves making changes in your lifestyle.

• Don't smoke. If you smoke or use tobacco products, quit. Talk to your doctor about ways to help you stop smoking, including medications.
• Manage health problems like high cholesterol, high blood pressure and diabetes.
• Eat a heart-healthy diet. Talk to your doctor or a registered dietitian about ways to change your diet to reduce your risk of heart disease.
• Limit alcohol use. Daily limits are one drink per day for women, two drinks per day for men.
• Increase your activity level. Exercise helps you lose weight, improve your physical condition and relieve stress. Most people can reduce their risk of heart attack by doing the equivalent of 30 minutes of walking five times per week or walking 10,000 steps per day it is important to talk to your doctor before you start any exercise program.

Medications

Your doctor may prescribe medication as part of your treatment plan for coronary artery disease. These can include medications to lower cholesterol levels and blood pressure or treat other health conditions you have. It is important to take all medications as prescribed. Ask your doctor if you have any questions about which medications you should take or how to take them.

Interventional procedures

Interventional procedures are not considered surgery. A cardiologist (not a surgeon) performs these procedures to reduce plaque build-up in the arteries and prevent blockages. Common procedures are balloon angioplasty (PTCA) and stenting. During an interventional procedure, a long, thin tube called a catheter is inserted into an artery through a small incision. The catheter is guided to the blocked area of the artery, and the plaque build-up is cleared. Your doctor will give you more information if you need an interventional procedure as part of your treatment.

Coronary artery bypass graft (CABG) surgery

Coronary artery bypass graft (CABG) surgery involves creating a new path for blood to flow when there is a blockage in the coronary arteries. In most cases, the surgeon removes blood vessels from the patient's chest, arm or leg, and creates the new pathway to deliver oxygen-rich blood to the heart. Your doctor will give you more information if you need CABG surgery.

Other treatment options

If traditional treatment options are not successful, your doctor may recommend other treatment options, such as:

• Enhanced external counterpulsation (EECP): Inflatable cuffs (like blood pressure cuffs) are used to squeeze the blood vessels in your lower body. This helps improve blood flow to the heart by helping create natural bypasses around blocked coronary arteries. The bypasses are called collaterals and are made up of small branches of blood vessels. Enhanced external counterpulsation is a possible treatment for patients with chronic stable angina who cannot have an invasive procedure or bypass surgery and do not get relief from medication.

Important Note: These procedures increase blood supply to your heart, but they do not cure coronary heart disease. You still need to follow the other parts of your treatment plan to help prevent your condition from getting worse.

Follow-up care

Regular visits with your cardiologist, along with any needed tests, are important. Follow-up care lets your doctor know how your treatment is working and if changes are needed.