Coronary Artery Disease

Coronary artery disease is basically plaque buildup or fatty deposits causing a blockage or narrowing in the coronary arteries. The role of the heart is to pump blood to the body but it also has to pump blood to itself through the coronary arteries and if there is a narrowing or a blockage that occurs progressively in these vessels, over the course of the years, patients can develop atherosclerotic heart disease that can result in disability and/or death from heart attacks. This narrowing of the arteries decreases perfusion of the heart downstream to the obstruction, resulting in lack of oxygen to the tissue when there is a demand placed on the heart for example.

Patients may complain of having symptoms of chest pain on exertion due to a simple mechanism when the supply does not meet the demand supply called a mismatch. If placing a load on the heart by physical exertion such as an exercise routine for example, the heart pumps faster to maintain the stroke volume so that it can perfuse the body with blood and deliver oxygen. It also does this by pumping blood through its own arteries called the coronary arteries. During a blockage or narrowing, perfusion will be reduced resulting in low supply which in turn causes symptoms such as chest pain. Other symptoms include:

• Shortness of breath, especially on exertion
• Feeling anxious
• Nausea
• Feeling dizzy
• Palpitations
• Neck pain
• Jaw pain
• Left arm pain

In patients who have uncontrolled diabetes, there may not be chest pain and many patients report feeling an impending sense of doom resulting in silent heart attacks. In men, sometimes there are symptoms of gastroesophageal reflux that may indicate Diagnostic tests include:

• Obtaining an electrocardiogram
• An electrocardiogram will reveal ST segment elevation or depressions, T wave inversions or even the presence of Q waves that reflect an old heart attack.
• Stress test

An exercise stress test where the patient gets on a treadmill to see if it results in decreased perfusion causing the patient to experience chest pain or other symptoms. For those patients who are unable to exercise for any reason, we can administer a chemical, and it’s called a pharmacological stress testing to see for the same results. Other labs that accompany these diagnostic tests that need to be interpreted appropriately are:

• Fasting cholesterol level
• Advanced imaging such as angiography where a dye is injected into the coronary arteries to see where the narrowing is where the blockages.
• Echocardiography is ordered to identify possible wall motion abnormalities.

Treatment for coronary artery disease is primarily aspirin, anywhere from 160 to 325 milligrams a day of aspirin can reduce mortality. Other medications that are prescribed ACE inhibitors, especially in patients who have increased risk factors such as diabetes or known coronary artery disease. If somebody has had a heart attack (MI) and they are post MI, adding beta blockers helps also to reduce mortality. Also controlling the cholesterol, with cholesterol lowering agents to reduce risk for plaque buildup in coronary vessels. Fish oils along with medications that can help elevate good cholesterol while lowering bad cholesterol levels. The role of the bad cholesterol is to take all the fats and put them right into our arteries where we do not want them to be causing a narrowing and blockages. The good cholesterol does just the opposite. It will take it away from our arteries and put it back into cells. We want our good cholesterol to be high, and medications that can help elevate good cholesterol levels include things like niacin, gemfibrozil, fenofibrate, etc.

This outpatient management of risk factors, become key in prevention by controlling cholesterol, smoking cessation, increasing good cholesterol through diet and exercise and controlling blood pressure. The goal is to keep it below 140/90 mmHg if the patient has diabetes and if there is any past medical history of kidney failure, then the goal is below 130/80 mmHg. Exercise about 30 minutes a week five to five days a week with two days of resistance training, prophylactic aspirin on a day to day basis, limit alcohol consumption, stress reduction, diet changes and weight loss are all measures that can be implemented in prevention of coronary artery diseases. With proper nutrition, exercise, smoking cessation, patients can lead healthier lifestyles and prevent these unfortunate events, resulting disability or death.

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