Let's Talk About Coronary Artery Disease (CAD)
All your vessels are important, but the ones that bring blood to heart? Those are major—and keeping them healthy is crucial.by Matt McMillen Health Writer
There are many different types of heart disease, but coronary artery disease, or CAD for short, is the most common. You might also hear it referred to as coronary heart disease or ischemic heart disease, but no matter what you call it, more than 18 million American adults have it, according to the Centers for Disease Control (CDC). And it’s not just a concern for older folks. It’s the number-one killer of both men and women, a sobering 20% of them younger than 65. But there are things you can do, right now, to lower your risk of CAD. We’ll tell you how.
Our Pro Panel
We went to some of the nation’s top experts in coronary artery disease (CAD) to bring you the most up-to-date information possible.
Guy Mintz, M.D.
Director of Cardiovascular Health & Lipidology
Sandra Atlas Bass Heart Hospital
Michael Goyfman M.D., MPH
Director of Clinical Cardiology
Long Island Jewish Forest Hills
David Friedman, M.D.
Director of Heart Failure Services
Northwell Health’s LIJ Valley Stream
Long Island, NY
Worry is a strong word—so let’s just say: Be proactive. CAD symptoms don’t often begin until the plaque buildup has narrowed an artery by 70%. However, plaque can rupture, which causes heart attacks, and this commonly occurs when a blockage is only a 50% obstruction. If you have any CAD risk factors, discuss them with your doctor.
While chest pain and shortness of breath are hard to ignore, it can be difficult to decide what’s important if you have vague symptoms like nausea. In most cases, after all, nausea is NOT due to CAD. But if you have known risk factors for heart disease and are worried that you may be having a heart attack, call 911 immediately.
Lifestyle modification is the cornerstone therapy for halting the progression of CAD. The most beneficial? Exercise. Regular workouts get your heart pumping; reduce inflammation, cholesterol and blood pressure; improve the health of your blood vessels; lower stress; and make you feel—and even look—good, too.
If you have heart disease, you’re at higher risk of depression. That makes addressing mental health one of the most important things you can do for CAD. If you’re not doing well emotionally, you’ll be less likely to take your medications as directed, and you might find it harder to stick to a healthy diet and a regular exercise routine. Talk to your doctor if you feel anxious or depressed.
What Is Coronary Artery Disease (CAD), Exactly?
Coronary artery disease develops when your heart’s all-important arteries become damaged. This damage, which happens in a number of ways we’ll soon explain, causes your arteries to dangerously narrow, which can then cause blockages that prevent blood and oxygen from reaching your heart and the rest of your body. (And you probably don’t need a website to tell you that’s not good.)
Before we get into the nitty-gritty of what causes all those problems, let’s do a quick review of how the circulatory system works:
You have arteries throughout your body. Along with your veins and capillaries, they comprise a 60,000-mile-long system of blood vessels.
Your arteries deliver oxygen-rich blood from your heart to every cell in the rest of your body.
Along the way, the blood transfers nutrients and picks up waste products from cells via tiny capillaries, and then it heads back to heart by way of the veins.
Once there, it enters the pulmonary circulatory system. The heart pumps it over to the lungs, where it unloads carbon dioxide and stocks up on a fresh supply of oxygen.
Then it's back over to the heart to do the whole thing again.
Your entire blood supply—more than a gallon of the life-sustaining stuff—cycles throughout your body roughly every 30 seconds. Pretty amazing, right?
What’s more, your heart has its own network of arteries to support this critical work. Here are the main players:
The aorta is the body’s largest artery and main supplier of blood. Branching off from the aorta are the heart’s two main arteries: the right coronary artery and the left coronary artery (often referred to as the left main coronary artery).
Further and progressively smaller arteries branch off from there, delivering blood to your heart muscle. Your heart’s veins carry depleted blood to the lungs for its oxygen refresh.
In a healthy heart, blood flows unobstructed through the many arteries, providing all that your ticker needs to keep on pumping—and keep you alive. But when CAD develops, serious heart complications can result, including:
So, What Causes Coronary Artery Disease?
The culprit behind CAD is nearly always atherosclerosis. That mouthful of a name describes a process in which plaque builds up over time on the walls of one or more of your heart’s arteries. Plaque is a mixture of cholesterol, fat, calcium, and fibrin (a substance that helps your blood to clot), and it tends to collect within the arteries where damage has occurred.
But what damages arteries in the first place?
High blood pressure (HBP), which stresses the vessels
Cigarette smoke, which is loaded with harmful chemicals
Unhealthy levels of LDL, or ‘bad’, cholesterol, which sticks to the walls of your arteries, causing irritation
High blood sugar, which can increase inflammation in the arteries
So, it's like this: When the inside of your arteries get roughed up, it's easier for the plaque-forming compounds to gain a foothold. As it builds up, blood can’t flow as easily as it once did. The result? Coronary artery disease.
As CAD progresses, plaque continues to accumulate. Your arteries become increasingly narrow, and you edge closer and closer to heart attack territory. Why? Because heart attacks are caused by partial or complete blockages of blood flow to the heart.
And know this: You don’t need a complete blockage for plaque to be life-threatening. Even partially obstructed arteries are a major cause for concern. Why? Because:
Plaque can be soft and vulnerable to rupture, meaning a plaque buildup can burst.
Your immune system senses the disturbance and swings into action, forming a blood clot around the rupture in an attempt to “repair” it.
This causes further harm, since the blood clot itself can block even more blood flow.
Depending on the artery and the location of the clot, a heart attack or stroke (which occurs when a blockage is located in an artery leading to the brain) may then occur.
Are There Other Causes of Coronary Artery Disease?
Yes. While atherosclerosis is by far and away its most common cause, CAD can also be triggered by the rarer (but still possible) coronary artery spasm. This is also known as non-obstructive coronary artery disease.
Such spasms cause an artery to suddenly tighten, cutting off the flow of blood. They can be triggered by cocaine and nicotine use, or occasionally, severe cold or extreme emotional stress, according to the Mayo Clinic. While such spasms most often occur in people who already have CAD, they can also strike people whose arteries are healthy. For some, a spasm is an isolated event, but in others they occur more than once.
In addition, CAD can also be triggered by other, less-obvious culprits:
Endothelial dysfunction: This is when an artery does not expand to meet the need for increased blood flow, such as during exercise.
Birth defects: Some babies are born with structural damage to their hearts.
Coronary-artery dissection: This is a tear in the wall of one your coronary arteries, which traps blood between the arterial layers. Swelling results, which narrows or blocks the artery to potentially trigger an emergency situation like a heart attack. The reasons for such tears are unknown.
Autoimmune diseases: Conditions that cause chronic inflammation, such as lupus or Crohn’s disease, can lead to CAD because inflammation damages your arteries, which attracts plaque buildups.
Radiation therapy: This treatment can also cause damage to your arteries, leading to CAD.
What Are the Risk Factors for Coronary Artery Disease?
A whole host of risk factors bump up your likelihood of developing atherosclerosis and, as a result, your odds of being diagnosed with CAD, as well. The good news? For a substantial number of them, lifestyle changes can make a huge difference. And while some risk factors are unchangeable (like your age and family history), others are within your power to eliminate altogether. That’s because living a healthier lifestyle can help reduce your odds of getting CAD.
Let’s first examine the risk factors you can’t do anything about (and get 'em out of the way):
Your arteries become more damage-prone the older you get. It’s just part of the regular wear and tear of living. You're more likely to develop CAD after you turn 55 if you're male and after the age of 65 if you're female.
If a parent or sibling had CAD, especially at a younger age—55 for your dad or your brother, 65 for your mom or sister—your risk may be more than double that of people without a family history of heart disease, according to a 2019 study in the Journal of the American Heart Association. This can be due to lifestyle factors your family shared, such as smoking or a lack of exercise. Or it could be genetic.
For example, some people inherit a gene mutation that makes it likelier they will have high cholesterol, a contributor to CAD. Most often, this is caused by a mutation in the LDLR gene, which helps control the production of LDL (so-called “bad” cholesterol), which we’ll get into shortly.
Being a Guy
Men are more likely to develop CAD starting at an earlier age than women. For men, the risk tends to begin rising at about age 45. Women’s risk starts to climb about 10 years later, at age 55. Experts believe this is because the hormone estrogen, which women have in greater amounts before menopause, provides some protection against CAD.
While you can’t do anything to change the above, there’s plenty you can do to change the risk factors below. Want some additional motivation? Improving a single risk factor often improves or even eliminates others.
Being sedentary, a.k.a. couch potato syndrome, contributes to many CAD risk factors, including HBP, obesity, diabetes, high cholesterol levels, and high triglycerides, a type of fat found in your bloodstream that’s linked to atherosclerosis. When you’re physically fit, your heart works more efficiently. That can improve your blood pressure. It can also help you achieve and maintain a healthy weight, which eases the burden on your heart. Plus, exercise reduces stress hormones, such as cortisol and adrenaline, that can otherwise strain your heart. And, it helps keep your cholesterol at healthy levels. Working out is basically magic for your whole body.
Lighting up damages your blood vessels. The toxic chemicals in tobacco smoke, such as carbon monoxide, may injure the walls of your arteries, and that in turn may trigger plaque buildups. Smoking also causes your blood vessels to constrict, which raises your blood pressure. Oh, and it may also thicken your blood, increasing your risk of clots by making clot-forming platelets stickier. If exercise is magic, cigarettes are kryptonite.
Does that mean you should switch to vaping? No way! E-cigarette vapor contains many toxic chemicals linked to heart disease, according to the AHA, which recently published a report that showed how vaping may harm your blood vessels in much the same way smoking cigarettes does.
Fortunately, the benefits of being smoke-free start the moment you quit. To help kick your smoking habit, check out the AHA’s smoking cessation resources.
High Blood Pressure (HBP)
Hypertension, a.k.a. high blood pressure (HBP), stresses your arteries, causing them to harden and thicken, which makes it more difficult for blood to flow through them. The stress from HBP can also damage the lining of your arteries, and that damage may attract plaque buildups.
Obesity or Being Overweight
Carrying too many pounds increases your chances of diabetes, a major cause of heart disease. Excess weight also makes your heart work harder. That can raise your blood pressure, which then damages the inner lining of your arteries. If this seems like a chain reaction, it's because it often is. But what's important to remember? It goes the other way, too. Losing even a modest amount of weight can lower your blood sugar and your pressure.
You know the drill here: Diets high in saturated fat (like butter or beef) or trans fat (found in processed foods like cookies, crackers, and margarine), and refined carbs (like processed breads, pizza dough, pastries, and some breakfast cereals) really aren't great for your heart. Saturated and trans fats increase your “bad” cholesterol and decrease your “good” cholesterol. Meanwhile, refined carbs boost your blood sugar levels. Over time, that elevated blood sugar can lead to type 2 diabetes, a known risk factor for heart disease.
High Cholesterol Levels
High cholesterol means you have elevated levels of low-density lipoprotein (LDL), or “bad”, cholesterol and low levels of high-density lipoprotein (HDL), or “good”, cholesterol. LDL cholesterol circulates throughout your body and can build up on the walls of your arteries, which makes them hard and stiff. This often happens when you don’t have enough HDL at the ready; this blood fat actually sweeps up the excess LDL and takes it to liver to be processed as waste.
This sleep disorder causes repeated interruptions to your breathing throughout the night and has been linked to obesity and HBP, both major risk factors for CAD. Sleep apnea impacts blood pressure by causing frequent drops in blood oxygen levels during moments of interrupted breathing—forcing your heart to work harder.
Your immune response can be triggered by plaque buildups in your arteries, leading to inflammation. Over time, low levels of chronic inflammation irritates your blood vessels and may make a plaque buildup more vulnerable to rupture.
What Are the Symptoms of Coronary Artery Disease?
Plaque buildup that leads to CAD often moves slowly, over many, many years. In fact, it can begin as early as childhood. But you won’t necessarily know that you have it. Usually, symptoms of CAD don’t begin until you’re well into middle age or nearing retirement.
For some people, the first symptom of CAD will be a heart attack. This makes it critical to discuss your CAD risk factors with your doctor to determine the state of your heart health.
Symptoms of CAD include:
This is also known by its fancier name, angina. It occurs when your heart doesn’t get enough oxygen-rich blood. You may feel pain, pressure, or a squeezing sensation in your chest. It frequently goes away when you rest.
Shortness of Breath
Panting or struggling to get enough air can occur from restricted blood flow in your heart’s arteries and the reduced amount of oxygen that results, often during or after physical activity.
Feeling exhausted after your normal activities or your usual exercise routine can also result from restricted blood flow and reduced oxygen-rich blood.
Neck, Jaw, Shoulder, and/or Back Pain
Pain in other parts of the body such as the neck, jaw, shoulder, and back may occur because some nerves in the heart are connected to these areas, so symptoms can be felt in these more distant places. It’s not clear why this happens, but it may be due to the way your heart and brain are wired. When the brain sends out pain signals during a heart attack, those signals may activate nerves in a network in and around the heart.
Are Heart Attack Symptoms Different in Women?
The answer? Sometimes, yes. In fact, women are 50% more likely to report having a heart attack without obvious signs like chest pain, although it does remain their most common symptom, especially after age 65, when they no longer enjoy the protective effect of estrogen.
Among women, other common symptoms include:
Dizziness: This can be attributed to a drop in blood pressure and decreased blood flow to the brain caused by the blockage.
Fatigue: This exhaustion does not go away with rest.
Nausea and vomiting: Feeling nauseated possibly occurs because of stimulation of the vagus nerve or other nearby nerves. Such stimulation can upset your stomach.
Chest pressure or tightness: This symptom occurs even at rest. Women are also likely to feel pain in their neck and throat.
It’s thought the difference in heart attack symptoms between men and women may be a result of men having more plaque ruptures—which occur suddenly and cause classic, chest-clutching symptoms—while women experience more plaque erosions, which happen slowly over days or even weeks, causing what are known as atypical symptoms, such as nausea, weakness, and light-headedness.
How Do Doctors Diagnose Coronary Artery Disease?
Your doctor will begin by reviewing your symptoms and taking a detailed health history, including your family history of heart disease. You’ll also be asked to describe your daily habits that affect your health, such as diet and exercise. Your physical exam will include blood pressure measurements and blood tests, including cholesterol, triglycerides, blood sugar, and more.
Further testing likely will include:
Electrocardiogram (EKG or ECG)
This test records the electrical activity inside your heart and shows whether or not it’s beating normally. An EKG also reveals whether your heart is receiving an adequate amount of blood.
Your heart will be monitored via EKG while you walk on a treadmill or ride a stationary bike. This will determine whether your heart gets enough blood and oxygen during exertion. If you can’t exercise, you will be given a nuclear stress test. A small amount of radioactive tracer gets injected into your bloodstream. Using special cameras, a doctor can track its movement through your heart, revealing areas that get insufficient blood flow.
This test uses sound waves to produce images of the heart that allow doctors to evaluate your heart’s strength and how well it functions.
A thin tube called a catheter is inserted into a blood vessel near your groin and threaded through to your coronary arteries. A special type of ink will be injected into your arteries. The ink will show your doctor, via x-ray images, where your blockages are located. Catheterization is considered the gold standard for diagnosis. You will be awake but mildly sedated during this procedure.
Coronary Calcium Scan
A computed tomograpy (CT) scan measures the amount of calcium in your arteries. Why calcium? It’s a component of the plaque buildup that’s blocking your artery.
What Are the Best Treatments for Coronary Artery Disease?
Treatment for CAD has several goals: to ease the heart’s workload, to improve blood flow, and to slow or reverse plaque buildup in the arteries—all of which can help extend your life. There are a menu of treatment approaches to accomplish this, including:
What works best for you will depend on your individual health history, ability to change any unhealthy habits you might have, and what your doctor prescribes based on screening tests.
Lifestyle Changes for Coronary Artery Disease
A critical part of any treatment plan, this part’s largely up to you to focus on and continue over your lifetime. Medications and procedures may help—they might even save your life—but to be the healthiest you can be, you must do the heavy lifting.
Your goal: at least 150 minutes of moderate exercise, such as walking, each week. That breaks down to 30 minutes, five times a week. Before you start, ask your doctor what type of exercise program would be best for you. Often, the best way start is to put one foot in front of the other. You know: Take a walk.
Focus your food choices on fruits, vegetables, whole grains, and legumes such as beans, lean meat, and fish. Read food labels so you can avoid foods with saturated fats and/or trans fats as well as highly caloric foods loaded with sodium and/or sugar.
Your body mass index (BMI, a ratio of height to weight used to estimate body fat) should be in the normal range, between 19 and 25. Higher than that and you are overweight or, at 30 and above, obese. (Unless, that is, you're a serious gym bunny whose measurements in pure muscle defy regular BMI standards.) Start with small, achievable weight loss goals, because losing as little as five to ten pounds can pay dividends in health benefits, such as lower blood pressure.
It's true the more you smoke, the greater your health risks, but even light or part-time smokers should drop the habit. Women who are light smokers, for example, have a 500% higher risk of lung cancer than non-smokers. And light smoking may leave you with other forms of lung disease or cause a stroke, breast cancer, or cataracts, or … the list goes on and on.
No one likes being stressed out. But did you know that too much stress harms your heart? It can boost your blood pressure and make you more prone to give into unhealthy temptations, like smoking and overindulging in junk food or alcohol. The AHA recommends stress management, which you can get with the help of a therapist, at a cardiac rehab program, through regular exercise, or simply by breathing deeply.
Medications for Coronary Artery Disease
A variety of medications exist that can help reduce CAD symptoms such as chest pain as well as prevent the progression of the disease and prevent heart attacks.
High Blood Pressure Medications
Lowering blood pressure reduces your heart’s workload. Beta blockers llower blood pressure, and are very effective at slowing your heart rate and easing the force of your heart's contractions, giving your heart more time to relax between beats. Calcium channel blockers work by relaxing your blood vessels. Some also will slow your heart rate, and they may be used for chest pain.
These drugs (like aspirin) help prevent the formation of dangerous blood clots, which can develop around plaque buildups.
This treatment, which includes nitroglycerin, dilates, or widens, narrowed arteries from CAD to boost blood flow to your heart, which in turn eases chest pain. Nitrates also widen the veins, which helps ease the strain on your heart.
These medications, which include common brand names like Lipitor and Crestor, are used to control cholesterol levels. This reduces plaque buildup in your arteries. Statins may also help clear existing plaque buildups. Other cholesterol-lowering drugs are available if you can’t take statins.
This drug, often prescribed under the brand name Ranexa, helps ease chest pain (angina) if it persists despite the use of other therapies. It does this by improving blood flow, allowing the heart to work more efficiently.
Surgery for Coronary Artery Disease
When your arteries are severely blocked, you may require a procedure that opens them up to let a sufficient amount of blood flow to pass through. Such procedures include:
Coronary Artery Bypass Surgery
In this procedure, a surgeon takes an artery or vein from elsewhere in your body—often a leg, forearm, or your chest—and uses it to connect your aorta to the blocked artery, rerouting blood flow.
Angioplasty and Stenting
A cardiologist threads a catheter through a blood vessel to the point of the blockage. There, a small balloon is inflated, which flattens the plaque on the wall of your artery. Then, a stent is implanted at the site to hold the artery open. This allows blood to flow more freely and prevents the collapse of the artery.
What’s Life Like for People With Coronary Artery Disease?
Current treatments and earlier diagnosis are helping people live better lives with CAD, but a lot of the work is up to you. Cardiac rehabilitation will help.
Cardiac rehab, which typically consists of 36 sessions over 12 weeks, offers:
Supervised exercised programs
Heart-healthy diet counseling
Mental health services to help you with anxiety, depression, and other emotional burdens that may affect you after a heart disease diagnosis
Access to doctors, nurses, dietitians, mental health specialists, physical therapists, and more
The AHA recommends cardiac rehab for everyone with coronary artery disease—even if you haven’t suffered a heart attack. To participate, you will need a referral from your doctor. The AHA also suggests you initiate this discussion with your doctor. Don’t wait for your physician, who may be very busy with many patients that day, to bring it up—your heart health is too important for you to remain passive. So be your own best advocate. It just may save your life. People who attend cardiac rehab after a heart attack reduce their risk of dying by more than 50% compared to those who don’t attend, according to the CDC.
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