Coronary Artery Disease

One of the most frequent reasons patients are seen by a cardiologist is to evaluate them for the presence of coronary artery disease. The heart is a muscle which needs oxygen and nutrients to function properly. These are provided to the heart through arteries which run on the heart's outer surface. These arteries are known as the coronary arteries because they surround the heart in the same way a crown (corona) surrounds the head. When cholesterol plaques form in the inner walls of these arteries they begin to choke off the heart's blood supply. This may result in

Factors Which Increase Your Risk of Developing Coronary Artery Disease:

1. Cholesterol High LDL ("bad cholesterol") cholesterol increases your risk. If you have diabetes or already have blockages in your coronary arteries or other arteries in the body your LDL should be 99 or less. If you already have vascular disease or diabetes you should be on a Statin medication regardless of your cholesterol level. You can learn more about these medicines by reading Statins: Lower Your Cholesterol. If you have no evidence of arterial blockage and no diabetes your LDL cholesterol goal is 129 or less.

2. High Blood Pressure? Here's What You Can Do Your blood pressure should be no more than 135/85. If you have diabetes or already have arterial blockages your blood pressure goal is 130/80 or less.

3. Smoking. Tobacco smoke damages the inner walls of the coronary arteries and increases your risk. To find out more about our Smoking Cessation programs call our Health Education Department at 307-2210.

4. Family History. If a parent or sibling has developed coronary artery disease, especially if it occurred early in life (before age 50) your risk is increased. If you have a family history of coronary artery disease it is especially important to control the other risk factors mentioned above.

Symptoms of Coronary Artery Disease:

The most frequent symptom of coronary artery disease is chest discomfort known as angina pectoris. When the heart needs extra oxygen during exercise or heightened emotional states (fear, anger, excitement), the arterial blockage may prevent enough oxygen rich blood from reaching the heart muscle cells which are downstream from the blockage. When this happens, angina may result. Angina usually consists of a dull pain or burning or a pressure sensation deep in the chest. Sometimes it feels very similar to indigestion. The discomfort (it may not be described as a pain) may radiate to your jaw, shoulders or down your arms. It may be associated with nausea, vomiting, shortness of breath or sweating. Some people will have only shortness of breath or only arm pain. Diabetic patients may not have normal function of the nerves and so their symptoms may be quite mild.

Tests for Coronary Artery Disease:

There are a number of tests which allow us to determine whether or not someone has coronary artery disease. In general we begin with noninvasive tests (tests which do not require placing tubes in the heart). We can often determine if someone has a blockage by a simple stress test or a stress test with images taken of the heart either with ultrsound (echocardiography) or with a nuclear medicine (adenosine thallium testing). You can find out more about stress testing by clicking on

Stress Tests on the Department of Cardiology Home Page.

Cardiac Catheterization:

Sometimes it is very useful to actually see the coronary arteries and to get a picture of the blockages. When we need to do this we order a Cardiac Catheterization. Cardiac means heart and a catheter is a tube. Cardiac catheterization means to place a tube in the heart. This test is done by puncturing an artery with a needle, usually in the groin area but sometimes the wrist or forearm area is used. A local anesthetic numbs the area before the needle punctures the artery. You will remain awake during the procedure. This is the same kind of anesthetic you might be accustomed to from routine dental work. Once the area is numb, there should be no pain or only minor discomfort. Once the needle is in the artery, a thin wire is threaded through the needle and the needle is removed. The catheter (a long flexible hollow plastic tube) is then inserted over the wire and the wire is then removed leaving the catheter in the artery. The catheter is advanced into the opening of the coronary arteries and dye is injected. The dye fills the artery and a moving picture is taken which shows any blockages which might be present. In this way we get a very detailed x ray picture of all of the coronary arteries. By knowing where the blockages are, how many are present and how bad they are, we can determine what the best therapy is in each situation.

Medical therapy for Coronary Artery Disease:

All patients with coronary artery disease should be taking an Aspirin daily. If a patient cannot take aspirin because of an allergy or other problems taking apsirin, an alternative medicine clopidegril (plavix) should be taken. These medicines prevent the blockages from getting worse.

All patients with coronary artery disease should be taking a Statin medication daily unless there is a reason not to. These medicines help lower cholesterol but they also help patients with coronary artery disease with normal cholesterol levels live longer healthier lives.

There are a number of other medications which are very helpful. Beta blocking medications (atenolol, metoprolol, carvedilol) help patients who have suffered a heart attack live longer. They also limit the chest pain (angina) symptoms of some patients with coronary blockages. Nitroglyerin is a small tablet which patients put under their tongue when an acute attack of angina (chest pain) occurs. I tell my patients with angina that they should take a nitroglycerin if chest pain lasts 5 minutes of more. A nitro can be taken every five minutes to relieve the pain. If three nitro are necessary to relieve the angina I tell patients to come to the Emergency Room for an evaluation. Nitroglycerin can also be taken in a sustained release form either by tablet or a patch and this can be very helpful in preventing angina.

Invasive Therapy for Coronary artery Disease:

Often medical therapy is not sufficient by itself to adequately treat the coronary blockages which occur. In this case we may need to relieve the blockage either by inserting a catheter with a small balloon which can open up a blockage or by performing coronary artery bypass surgery. The balloon technique, Angioplasty, is done when the cardiac catheterization is performed. After the arterial blockage is opened up by inflating the angioplasty balloon a small sleeve called a Stent is placed in the artery to keep it from reoccluding.

At times the blockages are best treated by Coronary Artery Bypass Grafts. This is open heart surgery. A cardiovascular surgeon takes an artery from inside the chest and also sometimes a vein from the leg and constructs a channel to carry blood around the blockages.

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