Coronary Artery Disease Podcast Transcript

Welcome to the National Heart, Lung, and Blood Institute podcast on Coronary Artery Disease. This podcast will discuss what coronary artery disease is and its causes, risk factors, and signs and symptoms. It also will discuss how coronary artery disease is diagnosed and treated, how it can be prevented, and how to care for yourself if you have coronary artery disease.

More information is available on the NHLBI Web site at www.nhlbi.nih.gov or by calling the NHLBI Health Information Center at 301–592–8573.

What Is Coronary Artery Disease?

Coronary artery disease is a condition in which plaque builds up inside the coronary arteries, which supply your heart muscle with oxygen-rich blood.

Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. When plaque builds up in the arteries, the condition is called atherosclerosis.

Plaque narrows the arteries and reduces blood flow to your heart muscle. It also makes it more likely that blood clots will form in your arteries. Blood clots can partially or completely block blood flow.

When your coronary arteries are narrowed or blocked, oxygen-rich blood can't reach your heart muscle. This can cause angina or a heart attack.

Angina is chest pain or discomfort that occurs when not enough oxygen-rich blood is flowing to an area of your heart muscle. Angina may feel like pressure or squeezing in your chest. The pain also may occur in your shoulders, arms, neck, jaw, or back.

A heart attack occurs when blood flow to an area of your heart muscle is completely blocked. This prevents oxygen-rich blood from reaching that area of heart muscle and causes it to die. Without quick treatment, a heart attack can lead to serious problems and even death.

Over time, coronary artery disease can weaken the heart muscle and lead to heart failure and arrhythmias. Heart failure is a condition in which your heart can't pump enough blood throughout your body, and arrhythmias are problems with the speed or rhythm of your heartbeat.

Coronary artery disease is the most common type of heart disease, and it’s the leading cause of death in the United States for both men and women. However, lifestyle changes, medicines, and/or medical procedures can effectively prevent or treat coronary artery disease in most people.

What Causes Coronary Artery Disease?

Research suggests that coronary artery disease starts when certain factors damage the inner layers of the coronary arteries. These factors include:

• Smoking,
• High amounts of certain fats and cholesterol in the blood,
• High blood pressure, and
• High amounts of sugar in the blood due to insulin resistance or diabetes

When damage occurs, your body starts a healing process. Excess fatty tissues release compounds that promote this process. This healing causes plaque to build up where the arteries are damaged.

The buildup of plaque in the coronary arteries may start in childhood. Over time, plaque can narrow or completely block some of your coronary arteries, reducing the flow of oxygen-rich blood to your heart muscle. Plaque also can crack, which causes blood cells called platelets to clump together and form blood clots at the site of the cracks. This narrows the arteries more and worsens angina or causes a heart attack.

Who Is At Risk for Coronary Artery Disease?

Coronary artery disease is the leading cause of death in the United States for both men and women. Each year, more than half a million Americans die from this disease.

Certain traits, conditions, or habits, known as risk factors, may raise your chance of developing coronary artery disease. You can control most risk factors and help prevent or delay coronary artery disease, but some risk factors can’t be controlled.

There are many risk factors for coronary artery disease, and the more you have, the greater your chance of developing the disease. They include:

• Unhealthy blood cholesterol levels. This includes high LDL cholesterol, which is sometimes called bad cholesterol, and low HDL cholesterol, which is sometimes called good cholesterol.
• High blood pressure. Blood pressure is considered high if it stays at or above 140/90 millimeters of mercury over a period of time.
• Smoking. This can damage and tighten blood vessels, raise cholesterol levels, and raise blood pressure. Smoking also doesn't allow enough oxygen to reach the body's tissues.
• Insulin resistance. This condition occurs when the body can't use its own insulin properly. Insulin is a hormone that helps move blood sugar into cells where it's used.
• Diabetes. This is a disease in which the body's blood sugar level is high because the body doesn't make enough insulin or doesn't use its insulin properly.
• Overweight or obesity. Overweight is having extra body weight from muscle, bone, fat, and/or water. Obesity is having a high amount of extra body fat.
• Metabolic syndrome. This is the name for a group of risk factors linked to overweight and obesity that raise your chance for heart disease and other health problems, such as diabetes and stroke.
• Lack of physical activity. Lack of activity can worsen other risk factors for coronary artery disease.
• Age. As you get older, your risk for coronary artery disease increases. Genetic or lifestyle factors cause plaque (plak) to build up in your arteries as you age. By the time you’re middle-aged or older, enough plaque has built up to cause signs or symptoms. The risk for coronary artery disease increases in men after age 45 and in women after age 55.
• Family history of early heart disease. Your risk increases if your father or a brother was diagnosed with coronary artery disease before 55 years of age, or if your mother or a sister was diagnosed with coronary artery disease before 65 years of age.

Although age and a family history of early heart disease are risk factors, it doesn't mean that you will develop coronary artery disease if you have one or both.

Making lifestyle changes and/or taking medicines to treat other risk factors can often lessen genetic influences and prevent coronary artery disease from developing, even in older adults.

Scientists continue to study other possible risk factors for coronary artery disease.

High levels of a protein called C-reactive protein, or CRP, in the blood may raise the risk for coronary artery disease and heart attack. High levels of CRP are proof of inflammation in the body. Inflammation is the body's response to injury or infection. Damage to the arteries' inner walls seems to trigger inflammation and help plaque grow.

Research is under way to find out whether reducing inflammation and lowering CRP levels also can reduce the risk of developing coronary artery disease and having a heart attack.

High levels of fats called triglycerides in the blood also may raise the risk of coronary artery disease, particularly in women.

Other factors also may contribute to coronary artery disease. These include:

• Sleep apnea. This is a disorder in which your breathing stops or gets very shallow while you're sleeping. Untreated sleep apnea can raise your risk for high blood pressure, diabetes, and even a heart attack or stroke.
• Stress. Research shows that the most commonly reported trigger for a heart attack is an emotionally upsetting event—particularly one involving anger.
• Alcohol. Heavy drinking can damage the heart muscle and worsen other risk factors for heart disease. Men should have no more than two drinks containing alcohol a day. Women should have no more than one drink containing alcohol a day.

What Are the Signs and Symptoms of Coronary Artery Disease?

A common symptom of coronary artery disease is angina. Angina is chest pain or discomfort that occurs when your heart muscle doesn't get enough oxygen-rich blood.

Angina may feel like pressure or a squeezing pain in your chest. You also may feel it in your shoulders, arms, neck, jaw, or back. This pain tends to get worse with activity and go away when you rest. Emotional stress also can trigger the pain.

Another common symptom of coronary artery disease is shortness of breath. This symptom happens if coronary artery disease causes heart failure. When you have heart failure, your heart can't pump enough blood throughout your body. Fluid builds up in your lungs, making it hard to breathe.

The severity of these symptoms varies. The symptoms may get more severe as the buildup of plaque continues to narrow the coronary arteries.

Some people who have coronary artery disease have no signs or symptoms. This is called silent coronary artery disease. It may not be diagnosed until a person show signs and symptoms of a heart attack, heart failure, or an arrhythmia, which is an irregular heartbeat.

A heart attack happens when an area of plaque in a coronary artery breaks apart, causing a blood clot to form.

The blood clot cuts off most or all blood to the part of the heart muscle that's fed by that artery. Cells in the heart muscle die because they don't receive enough oxygen-rich blood. This can cause lasting damage to your heart.

The most common symptom of heart attack is chest pain or discomfort. Most heart attacks involve discomfort in the center of the chest that lasts for more than a few minutes or goes away and comes back. The discomfort can feel like pressure, squeezing, fullness, or pain. It can be mild or severe. Heart attack pain can sometimes feel like indigestion or heartburn.

Heart attacks also can cause upper body discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath or fatigue often may occur with or before chest discomfort. Other symptoms of heart attack are nausea, or feeling sick to your stomach; vomiting; lightheadedness or fainting; and breaking out in a cold sweat.

Heart failure is a condition in which your heart can't pump enough blood to your body. Heart failure doesn't mean that your heart has stopped or is about to stop working. It means that your heart can't fill with enough blood or pump with enough force, or both.

This causes you to have shortness of breath and fatigue that tends to increase with activity. Heart failure also can cause swelling in your feet, ankles, legs, and abdomen.

An arrhythmia is a problem with the speed or rhythm of the heartbeat. When you have an arrhythmia, you may notice that your heart is skipping beats or beating too fast. Some people describe arrhythmias as a fluttering feeling in their chests. These feelings are called palpitations.

Some arrhythmias can cause your heart to suddenly stop beating. This condition is called sudden cardiac arrest. Sudden cardiac arrest can make you faint, and it can cause death if it’s not treated right away.

For more information about heart attacks, heart failure, and arrhythmia, see the articles on these topics at the DCI Web site at www.nhlbi.nih.gov/health/dci.

How Is Coronary Artery Disease Diagnosed?

Your doctor will diagnose coronary artery disease based on your medical and family histories, your risk factors, the results of a physical exam, and diagnostic tests and procedures

No single test can diagnose coronary artery disease. If your doctor thinks you have this disease, he or she will likely use one or more tests, such as:

• An electrocardiogram, or EKG,
• A stress test,
• Echocardiography,
• A chest x ray,
• Blood tests,
• Electron-beam computed tomography, or EBCT, and
• Coronary angiography and cardiac catheterization.

An EKG is a simple test that detects and records the electrical activity of your heart. An EKG shows how fast your heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of your heart. Certain electrical patterns that the EKG detects can suggest whether coronary artery disease is likely. An EKG also can show signs of a previous or current heart attack.

During a stress test, you exercise to make your heart work hard and beat fast while heart tests are performed. If you can't exercise, you're given medicine to speed up your heart rate.

When your heart is beating fast and working hard, it needs more blood and oxygen. Arteries narrowed by plaque can't supply enough oxygen-rich blood to meet your heart's needs. A stress test can show possible signs of coronary artery disease, such as:

• Abnormal changes in your heart rate or blood pressure,
• Symptoms such as shortness of breath or chest pain, and
• Abnormal changes in your heart rhythm or your heart's electrical activity.

During the stress test, if you can't exercise for as long as what's considered normal for someone your age, it may be a sign that not enough blood is flowing to your heart. But other factors besides coronary artery disease can prevent you from exercising long enough—for example, lung diseases, anemia, or poor general fitness.

Some stress tests use a radioactive dye, sound waves, positron emission tomography, or cardiac magnetic resonance imaging to take pictures of your heart when it's working hard and when it's at rest. These imaging stress tests can show how well blood is flowing in the different parts of your heart. They also show how well your heart pumps blood when it beats.

Echocardiography uses sound waves to create a moving picture of your heart. This test provides information about the size and shape of your heart and how well your heart chambers and valves are working.

Echocardiography also can identify areas of poor blood flow to the heart, areas of heart muscle that aren't contracting normally, and previous injury to the heart muscle caused by poor blood flow.

A chest x ray takes a picture of the organs and structures inside the chest, including your heart, lungs, and blood vessels. A chest x ray can reveal signs of heart failure, as well as lung disorders and other causes of symptoms that aren't due to coronary artery disease.

Blood tests check the level of certain fats, cholesterol, sugar, and proteins in your blood. Abnormal levels may show that you have risk factors for coronary artery disease.

Electron-beam computed tomography, or EBCT, finds and measures calcium deposits, called calcifications, in and around the coronary arteries. The more calcium detected, the more likely you are to have coronary artery disease. EBCT isn't routinely used to diagnose coronary artery disease, because its accuracy isn't yet known.

Your doctor may ask you to have coronary angiography if other tests or factors show that you're likely to have coronary artery disease. This test uses dye and special x rays to show the insides of your coronary arteries.

To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization. A long, thin, flexible tube called a catheter is put into a blood vessel in your arm; groin, or upper thigh; or neck. The tube is then threaded into your coronary arteries, and the dye is released into your bloodstream. Special x rays are taken while the dye is flowing through your coronary arteries.

Cardiac catheterization is usually done in a hospital. You're awake during the procedure. It usually causes little to no pain, although you may feel some soreness in the blood vessel where your doctor put the catheter.

How Is Coronary Artery Disease Treated?

Treatment for coronary artery disease may include lifestyle changes, medicines, and medical procedures. The goals of treatments are to:

• Relieve symptoms,
• Reduce risk factors in an effort to slow, stop, or reverse the buildup of plaque,
• Lower the risk of blood clots forming, which can cause a heart attack,
• Widen or bypass clogged arteries, and
• Prevent complications of coronary artery disease.

Making lifestyle changes can often help prevent or treat coronary artery disease. For some people, these changes may be the only treatment needed.

One important lifestyle change is following a heart healthy eating plan. This can prevent or reduce high blood pressure and high blood cholesterol and help you maintain a healthy weight.

Your doctor may recommend the Therapeutic Lifestyle Changes, or TLC, program if you have high cholesterol. TLC is a three-part program that includes a healthy diet, physical activity, and weight management.

With the TLC diet, less than 7 percent of your daily calories should come from saturated fat. This kind of fat is mainly found in meat and poultry, including dairy products. No more than 25 to 35 percent of your daily calories should come from all fats, including saturated, trans, monounsaturated, and polyunsaturated fats.

You also should have less than 200 mg a day of cholesterol. The amounts of cholesterol and the different kinds of fat in prepared foods can be found on the Nutrition Facts label.

Foods high in soluble fiber also are part of a healthy eating plan. They help block the digestive track from absorbing cholesterol. These foods include:

• Whole grain cereals such as oatmeal and oat bran,
• Fruits such as apples, bananas, oranges, pears, and prunes, and
• Legumes such as kidney beans, lentils, chick peas, black-eyed peas, and lima beans.

A diet high in fruits and vegetables can increase important cholesterol-lowering compounds in your diet. These compounds, called plant stanols or sterols, work like soluble fiber.

Fish are an important part of a heart healthy diet. They're a good source of omega-3 fatty acids, which may help protect the heart from blood clots and inflammation and reduce the risk for heart attack. Try to have about two fish meals every week. Fish high in omega-3 fats are salmon, canned or fresh tuna, and mackerel.

You also should try to limit the amount of sodium, or salt, that you eat. This means choosing low-sodium and low-salt foods and "no added salt" foods and seasonings at the table or when cooking. The Nutrition Facts label on food packaging shows the amount of sodium in the item.

Try to limit alcoholic drinks. Too much alcohol will raise your blood pressure and triglyceride level. Triglycerides are a type of fat found in the blood. Alcohol also adds extra calories, which will cause weight gain. Men should have no more than two alcoholic drinks a day. Women should have no more than one alcoholic drink a day.

For more information on TLC, see the "Your Guide to Lowering Your Cholesterol With TLC" booklet on NHLBI’s Web site at www.nhlbi.nih.gov.

If you have high blood pressure, your doctor may recommend the Dietary Approaches to Stop Hypertension eating plan. This also is called the DASH eating plan. The plan focuses on fruits, vegetables, whole grains, and other foods that are heart healthy and lower in salt/sodium.

DASH is low in fat and cholesterol. It also focuses on fat-free or low-fat milk and dairy products, fish, poultry, and nuts. The DASH eating plan is reduced in red meat—including lean red meat—sweets, added sugars, and sugar-containing beverages. It's rich in nutrients, protein, and fiber.

The DASH eating plan is a good heart healthy eating plan, even for those who don't have high blood pressure.

For more information on DASH, see the "Your Guide to Lowering Your Blood Pressure With DASH" booklet on NHLBI’s Web site at www.nhlbi.nih.gov.

For more information on heart healthy eating, see NHLBI’s Aim for a Healthy Weight Web site, which you can access by clicking on "Health Information and Publications" on the NHLBI Web site at www.nhlbi.nih.gov. The Aim for a Healthy Weight Web site provides practical tips on healthy eating, physical activity, and controlling your weight.

Another important lifestyle change is regular physical activity. Regular physical activity can lower many coronary artery disease risk factors, including LDL, or "bad," cholesterol, high blood pressure, and excess weight. Physical activity also can lower your risk for diabetes and raise your levels of HDL cholesterol—the "good" cholesterol that helps prevent coronary artery disease.

Check with your doctor about how much and what kinds of physical activity are safe for you. Unless your doctor tells you otherwise, try to get at least 30 minutes of moderate-intensity activity on most or all days of the week. You can do the activity all at once or break it up into shorter periods of at least 10 minutes each.

Moderate-intensity activities include brisk walking, dancing, bowling, bicycling, gardening, and housecleaning.

More intense activities, such as jogging, swimming, and various sports, also may be appropriate for shorter periods.

For more information on physical activity, see the "Your Guide to Physical Activity and Your Heart" booklet on NHLBI’s Web site at www.nhlbi.nih.gov.

Maintaining a healthy weight is another lifestyle change that can decrease risk factors for coronary artery disease. If you're overweight, aim to reduce your weight by 7 to 10 percent during your first year of treatment. This amount of weight loss can lower your risk for coronary artery disease and other health problems.

After the first year, you may have to continue to lose weight so you can lower your body mass index, or BMI, to less than 25.

BMI measures your weight in relation to your height and gives an estimate of your total body fat. A BMI between 25 and 29 is considered overweight. A BMI of 30 or more is considered obese. A BMI of less than 25 is the goal for preventing and treating coronary artery disease.

You can calculate your BMI using the NHLBI's online calculator at www.nhlbisupport.com/bmi, or your health care provider can calculate your BMI.

For more information on losing weight and maintaining your weight, see the DCI Overweight and Obesity article at www.nhlbi.nih.gov/health/dci.

Another important lifestyle change is quitting smoking or using tobacco. Smoking can damage and tighten blood vessels and raise your risk for coronary artery disease. Talk to your doctor about programs and products that can help you quit. The U.S. Department of Health and Human Services also has information on how to quit smoking at www.surgeongeneral.gov/tobacco. You also should avoid exposure to secondhand smoke.

Reducing and coping with stress is another lifestyle change that can lower your risk for coronary artery disease. Research shows that the most commonly reported "trigger" for a heart attack is an emotionally upsetting event—particularly one involving anger. Also, some of the ways people cope with stress, such as drinking, smoking, or overeating, aren't heart healthy.

Physical activity can help relieve stress and reduce other coronary artery disease risk factors. Many people also find that meditation or relaxation therapy helps them reduce stress.

You may need medicines to treat coronary artery disease if lifestyle changes aren't enough. Medicines can:

• Decrease the workload on your heart and relieve coronary artery disease symptoms,
• Decrease your chance of having a heart attack or dying suddenly,
• Lower your cholesterol and blood pressure,
• Prevent blood clots, and
• Prevent or delay the need for a special procedure such as angioplasty or coronary artery bypass grafting.

Medicines used to treat coronary artery disease include anticoagulants, aspirin and other antiplatelet medicines, ACE inhibitors, beta blockers, calcium channel blockers, nitroglycerin, glycoprotein IIb-IIIa, statins, and fish oil and other supplements high in omega-3 fatty acids.

You may need a medical procedure to treat coronary artery disease. Both angioplasty and coronary artery bypass grafting are used as treatments.

Angioplasty opens blocked or narrowed coronary arteries. During angioplasty, a thin tube with a balloon or other device on the end is threaded through a blood vessel to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque outward against the wall of the artery. This widens the artery and restores the flow of blood.

Angioplasty can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. Sometimes a small mesh tube called a stent is placed in the artery to keep it open after the procedure.

In coronary artery bypass grafting, arteries or veins from other areas in your body are used to bypass—that is, go around—your narrowed coronary arteries. This surgery can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack.

You and your doctor can discuss which treatment is right for you.

Your doctor may prescribe cardiac rehabilitation, or rehab, for angina or after coronary artery bypass grafting, angioplasty, or a heart attack. Cardiac rehab, when combined with medicine and surgical treatments, can help you recover faster, feel better, and develop a healthier lifestyle. Almost everyone with coronary artery disease can benefit from cardiac rehab.

The cardiac rehab team may include doctors, nurses, exercise specialists, physical and occupational therapists, dietitians, and psychologists or other behavioral therapists.

Rehab has two parts: exercise training and education, counseling, and training.

Exercise training helps you learn how to exercise safely, strengthen your muscles, and improve your stamina. Your exercise plan will be based on your individual abilities, needs, and interests.

Education, counseling, and training help you understand your heart condition and find ways to reduce your risk for future heart problems. The cardiac rehab team will help you learn how to cope with the stress of adjusting to a new lifestyle and with your fears about the future.

For more information on cardiac rehab, see the DCI Cardiac Rehabilitation article at www.nhlbi.nih.gov/health/dci.

How Can Coronary Artery Disease Be Prevented or Delayed?

Taking action to control your risk factors can help prevent or delay coronary artery disease. Your chance of developing coronary artery disease goes up with the number of risk factors you have.

Making lifestyle changes and taking prescribed medicines are important steps. Listen to the treatment section of the podcast for information on heart healthy eating plans, physical activity, maintaining a healthy weight, and medicines.

Know your family history of health problems related to coronary artery disease. If you or someone in your family has coronary artery disease, be sure to tell your doctor. Also, let your doctor know if you smoke.

Living With Coronary Artery Disease

Coronary artery disease can cause serious complications. However, if you follow your doctor's advice and change your habits, you can prevent or reduce the chances of:

• Dying suddenly from heart problems,
• Having a heart attack and permanently damaging your heart muscle,
• Damaging your heart because of reduced oxygen supply, and
• Having arrhythmias, which are irregular heartbeats.

Doing physical activity regularly, taking prescribed medicines, following a heart healthy eating plan, and watching your weight can help control coronary artery disease.

See your doctor regularly to keep track of your blood pressure and blood cholesterol and blood sugar levels. A cholesterol blood test will show your levels of LDL, or "bad," cholesterol; HDL, or "good," cholesterol; and triglycerides. A fasting blood glucose test will check your blood sugar level and show if you're at risk for or have diabetes. These tests will show whether you need more treatments for your coronary artery disease.

Talk to your doctor about how often you should schedule office visits or blood tests. Between those visits, call your doctor if you develop any new symptoms or if your symptoms worsen.

Coronary artery disease raises your risk for heart attack. Learn the symptoms of heart attack and arrhythmia. These include:

• Chest discomfort or pain, including uncomfortable pressure, squeezing, fullness, or pain in the center of the chest that can be mild or strong. This discomfort or pain lasts more than a few minutes or goes away and comes back,
• Upper body discomfort in one or both arms, the back, neck, jaw, or stomach, and
• Shortness of breath, which may occur with or before chest discomfort.

Call 9–1–1 if you have any of these symptoms for more than 5 minutes.

It's important to know the difference between angina and a heart attack. During a heart attack, the pain is usually more severe than angina, and it doesn't go away when you rest or take medicine. If you don't know whether your chest pain is angina or a heart attack, call 9–1–1.

Let the people you see regularly know you're at risk for a heart attack. They can seek emergency care if you suddenly faint, collapse, or develop other severe symptoms.

You may feel depressed or anxious if you've been diagnosed with coronary artery disease and/or had a heart attack. You may worry about heart problems or making lifestyle changes that are necessary for your health. Your doctor may recommend medicines, professional counseling, or relaxation therapy if you have depression or anxiety.

Physical activity can improve mental well-being, but you should talk to your doctor before starting any fitness activities. It's important to treat any anxiety or depression that develops because it raises your risk of having a heart attack.

Links to Other Information About Coronary Artery Disease

For more information about coronary artery disease and to access the "Your Guide" publication series, go to the NHLBI Web site at www.nhlbi.nih.gov.

You can download or order copies of NHLBI publications from the Web site. To speak with a health information specialist or to order print copies of publications, call the NHLBI Health Information Center at 301–592–8573.