Coronary Artery Disease

What is Coronary Artery Disease (CAD)?

Coronary artery disease is the narrowing or blockage of the coronary arteries caused by atherosclerosis.

Atherosclerosis occurs due to cholesterol and plaque build up in the walls of the arteries. Plaque build up can restrict blood flow to the heart muscle and deprive the heart of the oxygen and nutrients that it needs.

How does coronary artery disease occur?

At a young age, fat can start to deposit within the blood vessel walls. Fat builds up over the years that can cause injury to the blood vessel walls.

Not only fat, but a number of other substances in blood like inflammatory cells, cellular waste products, proteins, and calcium begin sticking to the inside of vessel wall. All of these substances collectively form what is called Plaque.

Many of the plaque deposits have a soft inner center and hard exterior. If the hard outer surface breaks or tears, the soft inner center will become exposed to our body’s platelets.

The platelets will come to the area of breakage and form a clot around the plaque. This causes the artery to narrow even more.

A clot may dislodge and permit blood flow again, but the dislodging of a clot can also be dangerous.

Animation of the development of atherosclerosis

What are the symptoms of coronary artery disease?

Some people may have no signs or symptoms at all. This is known as Silent Coronary Artery Disease, which is seen more often in diabetic patients. Silent coronary artery disease can lead to sudden heart attack, congestive heart failure, or arrhythmia.

When there are symptoms, the following may be noticed:

  • Chest pain (Angina) – Angina is the most common symptom of coronary artery disease. It can be described as chest pain, discomfort, heaviness, tightness, pressure, aching, burning, numbness, fullness, or squeezing. This can be mild or severe. Angina is usually felt in the chest, but can also be felt in the left shoulder, arms, neck, back, and jaw. This can be similar to a heart attack, though angina pain usually lasts for only a few minutes and relieved on rest. If not relieved after a few minutes or on rest, call 9-1-1 for help.
  • Shortness of breath
  • Palpitations
  • Faster heartbeat
  • Dizziness
  • Nausea
  • Extreme weakness
  • Sweating

If you are not in an emergency situation, call Dr. Jamnadas and inform him of any symptoms you are experiencing.
If you have been prescribed Nitroglycerin and experience angina: Stop what you are doing and rest. Take one nitroglycerin tablet sublingually and wait 5 minutes. If you still have angina after 5 minutes, call 9-1-1 for emergency assistance.

For patients diagnosed with Chronic Stable Angina:

  • If you experience angina, take 1 nitroglycerin tablet sublingually.
  • Wait 5 minutes
  • If you are still experiencing angina, take another tablet.
  • Wait 5 minutes
  • If angina still persists, take a final sublingual tablet.
  • Wait 5 minutes
  • After a total of 3 nitroglycerin tablets and a total of 15 minutes of angina, call 9-1-1 for emergency help.

What causes coronary artery disease?

  • Smoking
  • High blood pressure
  • High cholesterol
  • Diabetes

What are the risk factors?

Non-modifiable risk factors:

  • Age: Old age
  • Sex: Men have a greater risk of coronary artery disease than women. The risk increases in woman after menopause due to less hormone production of estrogen.
  • Race: African Americans have more severe high blood pressure than Caucasians therefore have a higher risk of heart disease.
  • Family history of heart disease.

Modifiable risk factors:

  • Smoking
  • Excessive alcohol consumption
  • High blood pressure
  • High blood cholesterol levels
  • Uncontrolled diabetes (HbA1c >7.0)
  • Sedentary lifestyle- lack of physical activity is associated with coronary artery disease.
  • Obesity
  • Obstructive sleep apnea
  • Chronic inflammation- even having the flu can be a risk because it is a form of inflammation. C-reactive protein is a marker of inflammation and high levels of this can show an increased risk of coronary artery disease.
  • Stress
  • Depression- loneliness can be a risk factor of coronary artery disease.
  • Homocysteine – is an amino acid in the body that helps make protein and maintain tissue. Elevated levels of this can increase the risk of coronary artery disease.
  • Fibrinogen- is a protein in the body that aids in blood clotting. An increase in this can increase platelet clumping leading to the formation of clots.

What are the complications of coronary artery disease?

  • Chest pain (Angina) – this is due to the narrow arteries limiting oxygen enriched blood from supplying the heart muscle. The demand is greater during physical activity and exercise leading to chest pain and shortness of breath.
  • Heart attack- this is due to the rupture of plaque and formation of a blood clot completely obstructing an artery.
  • Congestive heart failure- when the heart muscle is chronically deprived from oxygen and the blood flow it needs, the heart muscle can become too weak to pump adequately.
  • Arrhythmia- abnormal heart rhythm that can cause inadequate blood pressure and black outs or sudden death.
  • Pericarditis- is inflammation of a layer of the heart
  • Stroke- occurs when a dislodged clot gets taken to the brain and blocks part of an artery in the brain.
  • Peripheral artery disease- can occur due to the weak blood supply to the peripheries or a dislodged clot blocking off the blood supply.
  • Aneurysm- is a weakening in the wall of an artery causing a dilatation or sac within the artery.
  • Mitral regurgitation
  • Cardiogenic Shock – Low blood pressure as a result of poor heart contraction.

What is the prevalence?

Heart disease is the leading cause of death in the United States.

The American Heart Association (AHA) estimates about every 34 seconds an American will have a heart attack.

How is coronary artery disease diagnosed?

Dr. Jamnadas will have a better idea if you have coronary artery disease by:

  • Discussing with you about your symptoms, medical and family history, and risk factors.
  • Physical examination
  • Blood tests- to measure your lipid profile

Performing diagnostic tests including:

  • Electrocardiogram (EKG) – records the electrical activity of the heart. This may involve you to wear a 24 hour holter monitor which records the electrical events of the heart during your normal daily activities. It is important to accurately record your activities and symptoms so Dr. Jamnadas can compare them to the holter monitor findings.
  • Echocardiogram (ECHO) – shows the images of the heart which determines whether the heart walls and pumping activity are normal or performing weakly.
  • Stress test– helps access the blood flow to the heart at rest and during stress. Will detect if any areas receiving less blood flow.
  • Chest x-ray– reveals signs of congestive heart failure.
  • Coronary Angiogram– allows Dr. Jamnadas to locate the exact anatomical site of blockage by injecting a dye within the coronary arteries showing the amount of blood flow to an area, and the number, size, and location of any blockages.
  • Computerized tomography (CT) – helps visualize your arteries. Sometimes an electron beam computerized tomography (EBCT) is offered to detect calcium within fatty deposits in narrowed arteries.
  • Magnetic resonance angiogram (MRA) – this is an MRI used with a dye to check for areas of narrowing or blockage in the arteries.

How is coronary artery disease treated?

The goal of treatment is for you to get back to a full and active lifestyle.

Treatment depends on many factors including your age, heart function, and other health problems.

Lifestyle changes

  • First treatment is diet changes, exercise, and weight management.
  • Eat foods high in fiber such as whole grain cereals, oatmeal, and figs. Eat plenty of fruits such as apples, bananas, prunes, oranges, and pears. Include fish and legumes such as beans or chickpeas.
  • Lower your salt intake.
  • Avoid fatty foods including bad saturated fat that is found in some meats, dairy products, chocolates, baked goods, and deep-fried food.
  • Maintain a healthy weight with a BMI below 25.
  • No smoking.
  • Limit alcohol to one glass a day if you chose to drink.
  • Be more physically active.
  • Relax and reduce stress.

For some people these changes may be the only treatment needed.

Medications

If lifestyle changes are not enough to control your heart disease, medications may be prescribed to you including:

  • Cholesterol lowering medications– these act by decreasing the amount of cholesterol in blood, especially Lowering your low density lipoprotein (LDL- your Lousy cholesterol) and keep your high density lipoprotein (HDL- your Healthy cholesterol) High.
  • Aspirin – prevents platelets clumping together. This thins the blood and reduces the chances of a blood clot narrowing or obstructing the arteries. This is not appropriate for all patients including patients with bleeding disorders or already taking a blood thinner.
  • Beta blockers- slow your heart rate and reduce blood pressure which decreases the oxygen demand of the heart.
  • Angiotensin converting enzyme (ACE) inhibitors and Angiotensin receptor blockers (ARBs) – help relax the blood vessels and lower the blood pressure so the heart does not have to work as hard and improve the lining of arteries.
  • Calcium Channel Blockers- medication that helps relax the muscles surrounding the coronary arteries and cause the vessels to open leading to an increase in blood flow to the heart and lowering blood pressure.
  • Nitroglycerin- either a sublingual tablet, spray, or patch which is used to control chest pain.

Supplements

Food and supplements rich in omega 3 fatty acids help reduce inflammation throughout the body, lower blood pressure, and the risk of heart attack.

  • Fish and Fish Oil- are high in omega 3 fatty acids, especially in fish like salmon, herring, and tuna. Fish oil supplements are also high in omega 3 fatty acids.
  • Flax and flaxseed oil- contain omega 3 fatty acids and fiber.
  • Greensoul- is a natural supplement that helps to maintain a healthy cholesterol level, supports the body’s immunity, and the ability to fight free radicals.
  • Coenzyme Q10- helps maintain a healthy cholesterol level, boosts immunity, and energy.
  • Perfusion SR- helps enhance blood flow, maintain a normal blood pressure, and enhance the elasticity of large arteries.

Procedures to restore blood flow

  • Angioplasty and stent or drug eluting stent placement: Most coronary blockages are treated with balloon angioplasty and coronary stenting. Angioplasty is the stretching of an artery to widen it, followed by stent placement.

This procedure is considered non-surgical because it is done by Dr. Jamnadas, who accesses the heart by inserting a long, thin tube (catheter) into the narrowed part of your artery.

A wire with a deflated balloon is passed through the catheter to the narrow area. The balloon is then inflated, compressing the plaque against the artery walls so it no longer restricts blood flow. Following this a stent may be placed to prevent restenosis.

There are two types of stents, bare metal stents and most of them today are drug coated called drug eluting stents.

Angioplasty and stent or drug eluting stent placement procedure

Bare metal stents act as a scaffolding to keep an artery open, but suffer from a 30-40% re-stenosis rate. This is due to a process called intimal hyperplasia which is attributed to a keloid. A keloid is an overgrowth of the inner lining of the blood vessel that covers over the stent.

However, this reparative process lasts no more than 6 months. After 6 months, if an artery has not re-narrowed at the site of the stent, it is unlikely to re-narrow.

Drug eluting stents have a less aggressive reparative process and therefore the narrowing rate within the stent is less than 5%.

Drug eluting stents are one of the marvels of modern cardiology. Typically if a year has gone by with no evidence of re-narrowing, then that portion of the artery that has been stented will remain patent indefinitely in 99% of patients.

If symptoms of angina reoccur after one year, it is usually due to NEW blockage in a DIFFERENT part of the artery, therefore risk factor modification is needed to prevent new blockages. ** Many people have the misguided understanding that patients who have received multiple stents over the course of years have had stent failures. In the vast majority of these cases, it is a stent in a New location that was needed.

Following stent placement in addition to atherosclerosis risk factor modification, patients need to be put on two antiplatlet therapies. Brilinta, Plavix or Effient + Aspirin are recommended for one uninterrupted year of antiplatlet therapy.

It is important to know that a Plavix sensitivity test is done for those who have a drug eluting stent to assess patients responsive to Plavix. Those who are sensitive and have the drug eluting stent will require Plavix therapy up to 1 year until the stent is covered by the natural lining of the blood vessel wall. This also helps in preventing blood clots from forming.

For those with a bare metal stent applied, 1 month of Plavix therapy is required.

  • Coronary artery bypass surgery: This is done in patients with one or more blocked coronary arteries that are bypassed by a blood vessel graft to restore normal blood flow to the heart. In those whom stent replacement is not feasible or if there is left main artery stenosis, a graft is usually taken from another area of your body either in the chest, arm, or leg. This will go around the clogged artery or arteries to create a new pathway for blood to flow to the heart.
  • Enhanced external counterpulsation (EECP): This is for patients who have angina (chest pain) and have already exhausted the standard treatments without successful results or for those who do not qualify for the other treatment regimens. This is a non-invasive procedure which promotes the formation of collaterals to bypass the clogged arteries as another means of getting oxygen rich blood to those areas of the heart that are not getting it. This is carried out in our office daily for 7 weeks.

How can I prevent coronary artery disease?

Healthy lifestyle habits can prevent coronary artery disease from developing.

Taking action in leading a healthy lifestyle can help keep your arteries strong, elastic, and free of plaque build up to ensure maximum blood flow.

These healthy habits include:

  • NO Smoking
  • Limiting alcohol
  • Controlling high blood pressure, cholesterol, and diabetes.
  • Eating a healthy diet
  • Keep physically active with the right kind of exercise.
  • Maintain a healthy weight with a BMI <25
  • Get an annual flu shot
  • Reduce stress!