- J. Clay Hays, Jr., M.D.

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4 What Causes CAD? Coronary arteries supply blood to sustain the heart. The arteries know when to expand and contract because they are signaled by a sensitive coating inside the blood vessels (endothelium). Arteries expand and contract to adjust to different levels of work needed by the heart. For instance, when you walk up a flight of stairs, the heart s workload is greater than when you are sitting down watching TV; arteries constantly adjust. Normally, we are born with healthy coronary arteries that have smooth inner linings. But, by the time we become teenagers, the inside lining of the coronary arteries may already show streaks of fat deposits. This build-up continues throughout life, with the rate of fatty build-up varying widely between people. It depends on many factors. As we grow older, fat deposits, along with other substances, continue to build up, stick together and form plaque. The build-up of plaque in the blood vessels is called atherosclerosis the leading cause of CAD. This causes blood vessels to become progressively narrowed until it is hard for blood to pass through. If an artery is completely blocked it causes a life-threatening loss of blood flow. This leads to chest pain (known as angina) or a heart attack. A heart attack can occur as a result of a clot that forms in the narrowed artery causing the blood supply to be cut off. If the coronary vessel narrows and a blood clot forms that breaks away and travels it is called a coronary thrombus. As it moves, the blood flow may be restored temporarily. But, if the clot suddenly lodges in an artery that leads to the heart, it can cause a sudden blockage of blood supply to the heart muscle called a coronary occlusion.

5 Blood supply to the heart involves not only the large coronary arteries but smaller arteries that are referred to collectively as collateral circulation. For those people who exercise frequently, the number and size of these arteries is greater. This can become especially important when a large artery is blocked, and smaller arteries help supply blood to the heart muscle. Any condition that causes a sudden reduction (or complete blockage) of blood flow to the heart is called acute coronary syndrome (or ACS) and can cause damage to the heart muscle. This can be lifethreatening and requires immediate emergency evaluation and treatment. Long-term CAD can also cause the heart muscle to weaken, which can contribute to heart failure. Coronary artery spasm is another type of coronary artery problem. It is a temporary, sudden narrowing of one of the coronary arteries caused by squeezing of the muscles in the artery wall. This spasm can slow or stop blood flow to the heart, often causing symptoms of angina. This can happen without having cardiac risk factors or atherosclerosis. And, it can be silent with no symptoms, or it can cause chest pain, angina or a heart attack. Coronary microvascular disease: When CAD happens inside of very small arteries, it is known as coronary microvascular disease. Researchers believe women are more likely to have this type of CAD because of lowered estrogen levels after menopause. Broken Heart Syndrome? Broken heart syndrome, also called stress cardiomyopathy, was first medically identified in 1990 in Japan and was named Takotsubo cardiomyopathy. Since then, interest in this condition has grown and cardiologists continue to observe and document this syndrome. Basically, the symptoms are similar to a heart attack with chest pain and shortness of breath. An EKG also may show abnormalities, and the pumping chamber of the heart (left ventricle) has an unusual shape during contraction. Most patients go to the emergency room because they think they are having a heart attack.

6 Interestingly, this can occur in patients whose arteries are not narrowed nor have severe plaque buildup present. In 85% of cases the attack is triggered by an emotionally or physically stressful event. Emotional causes might include grief from the death of a loved one, fear (from such events as a violent attack, threats or stage fright) or life stressors such as serious arguments, divorce, job loss or financial problems. Physical stressors might include serious health problems such as stroke, chemotherapy, an asthma attack or surgery. Usually, the stressor or stressors leading up to the attack can be identified, but not always. It is unknown whether or not chronic stressors (rather than one major event) might cause this syndrome. With medical diagnosis and treatment, the vast majority of patients survive such an attack and few (less than 5%) will have a repeat episode. Treatment for this syndrome includes diagnostic tests and medication. Some patients may need to be in the hospital until they are stable. Typically, complications are relatively rare and recovery is quick and complete. So, a perfectly, healthy person can truly have a broken heart with actual heart attack symptoms, but when promptly diagnosed and treated, symptoms can most often be reversed without complications or long term effects. What are the Symptoms of CAD? Early CAD may not cause any symptoms. The most common problem caused by CAD is ischemia (lack of oxygen and blood to the heart muscle). When ischemia occurs in the heart, the symptom or pain that is felt is known as angina pectoris, commonly called angina. The pain is usually severe and is felt under the chest bone (sternum) or left side of the chest and can spread to the neck, shoulder or arm. A person may faint/lose consciousness during an episode of chest pain. Types of angina include: Stable angina: Happens when the heart works harder and has a regular pattern. Treatment typically is effective for this type of angina. Unstable angina: The most dangerous type that does not follow a pattern. It can happen at any time, whether the heart is working harder or not. It may not go away with rest or medication. It also may be a sign of an impending heart attack. Variant angina: A rare type that happens when you are at rest and is often helped by medication.

7 Angina that is caused by atherosclerosis usually occurs when the heart is working harder than usual, during exertion such as exercising or walking. People describe angina pain in different ways but usually say that it is chest discomfort, heaviness, tightness, crushing, constricting, pressure, aching, burning, numbness, fullness or squeezing. Only about 2% of angina is caused by coronary artery spasms. It is more common among those who smoke, have high blood pressure or have high cholesterol. It can be related to alcohol withdrawal, a high level of stress, exposure to cold, some medications (vasoconstrictors that cause contracting of blood vessels) or stimulant drugs such as amphetamines and cocaine. If angina is caused by coronary artery spasms it may be somewhat different, usually happening at night or the same time each day, usually between midnight and 8 AM. Pain is typically temporary, lasting from 5 to 30 minutes. It may also occur at rest. What Is the Difference Between Angina and a Heart Attack? The symptoms are similar and angina can be a warning that a heart attack may be near. In addition to pain, other symptoms of CAD include: Shortness of breath Palpitations (irregular heartbeat, skipped beats or a flipflop feeling) A faster than usual heartbeat Dizziness Nausea Extreme weakness Sweating Differences between men and women: There is increasing evidence that men and women experience the symptoms differently. Women have heart attack symptoms that include: Pain or discomfort in the chest, left arm or back Unusually rapid heartbeat Shortness of breath Nausea or fatigue If you experience any of these symptoms, get help immediately. Call 911 or have someone drive you to the nearest emergency room. Do not wait.

8 What else can I do? Take Aspirin. If you feel symptoms suggestive of a heart attack, take 325 mg of aspirin (one regular size aspirin tablet). This will help the threat of blood clots that may be forming in your heart. - J. Clay Hays, Jr., How Is CAD Diagnosed? The cardiologists at Jackson Heart Clinic will complete a medical history and physical exam and may order tests to diagnose CAD. Diagnostic tests can tell whether or not you have CAD, but can also indicate how advanced it is. Tests will also give your cardiologist information about how to best treat your particular case. Blood tests: Certain blood tests will give your cardiologist an indication that coronary artery disease is present. Your levels of cholesterol and other specific measures will also be helpful to diagnose CAD. Chest X-ray: An X-ray of the chest gives a picture of your heart, lungs and other organs in the chest. Echocardiogram: Creates a picture of your heart using ultrasound. CAC (coronary artery calcium score): This test shows great promise in predicting those at high risk of a heart attack. The procedure creates an image that shows the degree of calcium deposits in the coronary arteries. Both are advanced forms of imaging technology electron beam tomography or CT scan. EKG (Electrocardiogram): An EKG records electrical impulses produced by your heart. This is done using electrodes that are attached to your arm, chest and leg. The electrode wires are attached to a device that records the electrical impulses for the doctor to interpret. The EKG can measure any damage present in the heart, the heart rate and whether or not the heart is beating normally. In addition, the EKG can be used to determine the effects of drugs or devices that affect the heart. It can also indicate the size and position of heart chambers. Exercise stress test: This test shows how your heart performs with increased workload and whether or not your heart is getting ample blood supply. Similar to a simple EKG, electrodes are placed on your body and are connected to a device that monitors your heart and blood pressure as you exercise on a treadmill. The test will also show how quickly your heart recovers after working hard.

9 An X-ray of the chest gives a picture of your heart, lungs and other organs in the chest. Nuclear stress test: This test is similar to the exercise stress test except that you will receive an IV nuclear medication that can show how the blood travels in the heart during exercise. It helps to diagnose heart disease or can show if disease has grown worse. Coronary computed tomography angiogram: This is a procedure that requires a cardiologist to pass a thin catheter through an artery into your heart. As the catheter moves along, X-rays are taken to help position the catheter. Then a contrast material is injected into the catheter that allows x-rays to show any blockages in blood flow to the heart. This test is particularly helpful to diagnose specific conditions of the coronary arteries and heart. It can show how many coronary arteries are blocked, where they are blocked and how severe the blockages are. The test is a bit more risky than some tests but very safe when done by an experienced cardiac team. In summary, the information above provides a brief description of possible tests that we might order to facilitate your care. You will be given more detailed information if you are scheduled for any of these tests.

10 What Are the Treatments for CAD? If you have been diagnosed with CAD, your questions will probably include Why me? and What s next? Remember that treating CAD can increase your quality of life and potentially reduce your risk of a heart attack. Why me? The reality is that you have probably had CAD for some time and probably also have risk factors that have led to the development of CAD. What are the risk factors? Risk factors for CAD include anything that increases your chance of having it. This includes risk factors that you cannot change, as well as those that you can change. Sometimes CAD develops in a person who has no known risk factors. Risk factors that you cannot change include: Gender: Men are at greater risk than women and tend to have heart attacks earlier in life. But, after age 70 the risk is even between men and women. Women tend to have Coronary Heart Disease about 10 years later than men, but it still is the #1 killer of women in the United States. Although death rates from CAD have dropped over the years, they have not dropped for women as much as for men. Age: Everyone over age 65 is at greater risk of CAD. Family history of heart disease: If your parent had heart disease, your risk is greater, especially if they were diagnosed before age 50. Race: African Americans tend to have higher blood pressure and also a greater risk of heart disease. Mexican Americans, American Indians, native Hawaiians and some Asians also have a higher risk. In general, higher risk is related to greater levels of obesity and diabetes in these populations.

11 Even though you can t change your inherited risk, you can work on modifiable risk factors- things that you can change to improve your health and help minimize your overall risk for cardiovascular events in the future. For instance, don t add to your risk by smoking, becoming overweight, or not exercising. And be sure to monitor your blood pressure and have simple blood tests to check your cholesterol and blood sugar levels. These steps can have a positive impact on your health now and in the future! - Philip L. Chustz, Risk factors that can be controlled include: Smoking or tobacco use of any kind; exposure to secondhand smoke High blood pressure High triglycerides Uncontrolled diabetes Physical inactivity Overweight Uncontrolled stress or anger Diet high in saturated fat and cholesterol Drinking too much alcohol Researchers continue studying other factors that are related to CAD. There is evidence that sleep apnea may be related to the development of CAD. In addition, lack of sleep or too much sleep may also be related. The roles of C-reactive protein (a body protein that may be higher with inflammation), high triglycerides (a type of fat/lipid in the blood), homosysteine (an amino acid in the body) and lipoprotein (a) are also being explored to see if they are related to having CAD. What s Next? Options for treating CAD are better than ever before! Your cardiologist will address your risk factors and will develop a treatment plan especially designed for you. Often, risk factors can be reduced by making lifestyle changes. However, medication may be used to reduce levels of cholesterol and help keep the blood flowing. If you need help with these changes, your cardiologist will offer more detail and support.

12 In addition to slowing the progress of the disease, treatment is also aimed at lowering your risk of heart attack and death from CAD. The treatment recommended by your cardiologist depends on your age, overall health and the degree of your CAD. Treatments of CAD May Include One or More of the Following: 1. Lifestyle changes: Symptoms of CAD may get better when life style changes are made. Similarly, the changes can help keep it from becoming worse. Don t Smoke: Blood vessels constrict when any type of nicotine is used. If you need help with this, ask your cardiologist for recommendations. Exercise: Your cardiologist will advise you about what level of exercise is recommended in your particular case. An exercise or rehabilitation plan may be ordered by your cardiologist as an important part of your CAD treatment plan. Your diet: A heart-healthy diet that is low in saturated fat and high in essential nutrients can help slow down the progress of CAD. If started earlier in life, it can even act to prevent CAD. Your cardiologist can provide additional information about a healthy diet. Weight loss: If you need to lose weight, a heart healthy diet will help. If you have problems with this, ask your cardiologist for help or a consultation with a dietary expert. 2. Medication: Your cardiologist may prescribe different types of medications for CAD for the treatment of high blood pressure, high cholesterol, irregular heartbeat or poor blood flow. Aspirin or other drugs may be prescribed to help prevent blood clots. Treating CAD can improve a patient s quality of life and functional status and potentially reduce his/her risk of death. - Philip L. Chustz,

13 3. Surgical Procedures: Generally, surgery is not needed to treat CAD, except in advanced cases when blood flow to your heart is interfering with heart function. In such cases, surgery can be life-saving. Your cardiologist may recommend a surgical procedure when one or more of your coronary arteries is blocked and if other treatments have not helped. The recommendation for surgery always comes as a result of careful evaluation of your specific situation and your preferences, in order to give you the best possible options and outcomes. If your cardiologist recommends any of these procedures, you will receive extensive information and preparation to guide your decision making. Angioplasty or stent procedure: A balloon angioplasty procedure involves the insertion of a thin catheter with a plastic bulb into the blocked artery. Then, a tiny balloon at the end of the catheter is inflated to open the artery. Sometimes a thin, mesh tube (called a stent) is left in place to keep the artery open. The stent may contain medication that helps keep the artery open over time. Not every blockage can be treated with angioplasty. Bypass surgery (also known as coronary artery bypass grafting or CABG): A procedure to create a new passage for blood to get to the heart. This is done by removing a blood vessel from another part of your body and then reattaching it above and below a blocked artery. This re-routes the blood around the blockage and gives the heart the blood supply that it needs. Minimally invasive bypass surgery: This procedure has the same goals as a traditional by-pass surgery but is done without stopping the heart or using a heart-lung machine during the procedure. It is known as off pump coronary artery bypass, or OPCAB.

14 Remember These Important Facts Symptoms of CAD can be mistaken for something else, such as severe gas or indigestion. If you have CAD, your risk of heart attack, stroke and heart failure is greater than those who do not have this problem. If you have acute symptoms of a heart attack, call 911 or your local emergency number quickly. Do not try to drive yourself to the hospital! Do not wait! Your life may depend on it! In Summary This brochure has provided thorough information about CAD symptoms, diagnosis, and treatment. And, although CAD can be life-threatening, it can be treated so that your symptoms are manageable and the progress of the disease lessened. With your new knowledge of the problem, you can work with your cardiologist at Jackson Heart Clinic to develop a plan that works best for you and your unique needs. It is our goal for you to have the highest possible level of cardiovascular health and enjoy your life to the fullest degree possible! References: American Heart Association (2015) Coronary artery disease- coronary heart disease. Accessed 9/17/2015 from: Disease---The-ABCs-of-CAD_UCM_436416_Article.jsp Casey, T (July 6, 2015) Coronary artery calcification test predicts mortality over 15-year period. Cardiology Business. Accessed 9/18/2015. Centers for Disease Control and prevention (2015) Coronary artery disease CAD. Accessed 9/18/2015 from DHHS, NIH (National Heart, Lung & Blood Institute (2015) What is coronary heart disease?. Accessed 9/18/2015 from: Mayo Clinic Staff (2015) Coronary Artery Disease. Accessed 9/17/2015 from mayoclinic.org/diseases-conditions/coronary-artery-disease/basics/definition/con Sharkey, SW, Lesser, JR, & Maron, BJ (2011) Cardiology Patient Page. Takotsubo (Stress) Cardiomyopathy. American Heart Association. Accessed 10/7/2015 from: org/content/124/18/e460.full. University of Chicago Medical Center (2015) Coronary artery disease and chest pain. Accessed 9/17/2015 from: UpToDate Patient Information: Coronary Heart Disease. UpToDate. Accessed 9/17/2015 from

15 WebMD (2015) Coronary Artery Disease. Accessed 9/17/2015 from: heart-disease/guide/heart-disease-coronary-artery-diseasewebmd (2015) Coronary Artery Disease. Accessed 9/17/2015 from: Patient Resources: Explore these resources for more information about CAD. American Heart Association (Local) 4830 McWillie Circle Jackson, MS Phone: (601) Fax: (601) American Heart Association (National) Customer Service AHA-USA Center for Disease Control (CDC) Division for Heart Disease and Stroke Prevention For Coronary Artery Disease For General information: CDC/NCCDPHP/DHDSP 4770 Buford Hwy, NE Mail Stop F-72 Atlanta, GA Call: 800-CDC-INFO Fax: American College of Cardiology: Cardio smart CAD: Helping a Loved One National Institutes of Health National Heart, Lung, and Blood Institute, National Institutes of Health NHLBI At this website you will find links to information about every aspect of CAD. You can also write or call for hard copy of the information. DHHS, NIH (National Heart, Lung & Blood Institute (2015) What is coronary heart disease?. Accessed 9/18/2015 from: and for general information about other heart topics: Or write to: National Heart, Lung, and Blood Institute, National Institutes of Health - NHLBI Building 31, Room 5A52 31 Center Drive, MSC 2486 Bethesda, MD (Voice, Information Center) (FAX, Information Center) WebMD This site offers basic information about CAD and many links to related topics Jackson Heart Physicians: Jefferson Jefferson A. A. Fletcher, Fletcher, R. R. Harper Harper Stone, Stone, David David H. H. Mulholland, Mulholland, Jimmy Jimmy W. W. Lott, Lott, J. J. Clay Clay Hays, Hays, Jr., Jr., Richard Richard D. D. Guynes, Guynes, D. D. Russell Russell Young, Young, V. V. Reid Reid Cotten, Cotten, J. J. Gray Gray Bennett, Bennett, William William H. H. Crowder, Crowder, Douglas Douglas D. D. Harkins, Harkins, B. B. Judson Judson Colley Colley III, III,,, M.P.H. M.P.H. Philip Philip L. L. Chustz, Chustz, A. Gene Hutcheson, Brett A. Bennett,

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Coronary Artery Disease

Coronary Artery Disease This information is at http://www.nhlbi.nih.gov/health/dci/diseases/cad/cad_all.html and is provided by the NHLBI, one of the Institutes of the National Institutes of Health. To