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Coronary Atherosclerosis (Coronary Heart Disease)
Coronary Artery Disease, CAD, Arteriosclerotic Heart Disease, ASHD, Chronic Ischemic Heart Disease
WHAT IS IT?
Atherosclerosis is the accumulation of fatty deposits in the walls of arteries. It can result in coronary artery disease (CAD), which is a major cause of disability and death. As the fatty deposits, called atheromas or plaques, slowly increase in size over the years, the result is areas of narrowing (stenosis) and reduced blood flow to the heart. The narrowing may become so tight that there is inadequate blood supply (myocardial ischemia) to meet the needs of the heart. Myocardial ischemia typically results in chest pain (angina pectoris), but may also be without symptoms (silent ischemia). CAD is also known as arteriosclerotic heart disease (ASHD) or chronic ische-mic heart disease.
Risk factors for atherosclerosis and coronary artery disease include male gender, age, a family history of symp-tomatic heart disease before age 50, high blood pressure, diabetes, high blood cholesterol, smoking, obesity, poor phy-sical fitness, and possibly emotional stress.
In general, males are at higher risk than females, but the risk increases for menopausal females who do not take estrogen or who have had both ovaries removed (bilateral oophorectomy) for other reasons.
HOW IS IT DIAGNOSED?
History may include a prior heart attack or angina (chest pain) with exertion that is relieved by rest.
Physical exam is usually not directly helpful in this diagnosis, but may reveal risk factors of high blood pressure and/or obesity. A fourth heart sound of congestive heart failure may be present.
Tests will include measurement of blood cholesterol, including low-density lipoprotein (LDL) and high density lipoprotein (HDL) because high total cholesterol and high LDL levels are associated with increased risk of coronary disease. An angiography may be needed. An EKG at rest may or may not indicate myocardial ischemia. A stress EKG will usually reveal more.The diagnosis may be discovered in asymptomatic individuals, when routine screening and physical exam detects one or more risk factors. Electrocardiography (EKG) and cardiac stress tests may then be performed, revealing the diagnosis.
HOW IS IT TREATED?
Risk factors should be treated whether symptoms are present or not. This helps prevent progression of coronary artery disease and, to some extent, can actually reverse it. Many of the risk factors are potentially treatable. Cessation of smoking is essential. Hypertension may be controlled by salt restriction, exercise, stress management, and medication. Diabetes can be managed by diet, exercise, and medication if necessary. Diet and exercise are also helpful in normalizing cholesterol levels. If this is not successful, cholesterol-lowering drugs can be added. A small daily dose of an anti-platelet drug helps inhibit blood clotting. And, for women after menopause, estrogen replacement may be recommended. Menopause may have occurred naturally or after both ovaries were removed.
COMPLICATIONS
Angina may remain stable for long periods. With progression of the disease, the anginal episodes may increase in severity and duration, become less responsive to medication, and/or be precipitated by less exertion. A worsening pattern of angina is referred to as unstable angina.A heart attack (myocardial infarction) can result if the obstruction in a coronary artery suddenly becomes complete. This is usually triggered by blood clotting (thrombosis) in a narrowed artery that may rapidly lead to complete blockage of the artery, or a clot may separate and be carried downstream (embolism) until it blocks a smaller artery. A heart attack then results, which is death of part of the heart muscle. Individuals who survive massive or repeated heart attacks may be left with so little functioning heart muscle that the heart can no longer pump effectively (congestive heart failure). Ischemic or damaged myocardium may also result in disturbances of heart rhythm (arrhythmias) such as atrial fibrillation or ventricular fibrillation. Atherosclerosis may also occur in other arteries throughout the body, causing impaired circulation in, for example, the legs.
PREDICTED OUTCOME
Asymptomatic disease usually does not result in disability. However, symptoms may eventually develop, depending on the extent to which risk factors can be modified. The prognosis of symptomatic CAD is discussed in the sections on angina pectoris, unstable angina, and myocardial infarction.
ALTERNATIVES
Other sources of chest pain besides include angina pectoris, spasm of the esophagus, chest wall pain, acute inflammation of the gall bladder, hiatal hernia, and panic attack.
APPROPRIATE SPECIALISTS
Cardiologist.
MEDICATIONS
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