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Coronary Heart Disease

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Coronary Heart Disease

Symptoms

No symptoms in the early stages of CHD.

Chest pain (angina), or milder pressure, tightness, squeezing, burning, aching, or heaviness in the chest, lasting from 30 seconds to 5 minutes. The pain or discomfort is usually located in the center of the chest just under the breastbone, and may radiate down the arm (usually the left arm), up into the neck, or along the jaw line. The pain is generally brought on by exertion or stress and stops with rest. The amount of exertion required to produce angina is reproducible and predictable.

Shortness of breath, dizziness, or a choking sensation, accompanying chest pain.

A sudden increase in the severity of angina, or angina at rest, is a sign of unstable angina that requires immediate medical attention because a heart attack may shortly occur.

When To Call Your Doctor

Call an ambulance if you experience crushing chest pain with or without nausea, vomiting, profuse sweating, shortness of breath, weakness, or intense feelings of dread.

Call an ambulance if chest pain from previously diagnosed angina does not subside after 10 to 15 minutes.

Call an ambulance the first time you experience intense chest pain.

See your doctor if attacks of previously diagnosed angina become more frequent or more severe or occur at rest.


What Is It?

Coronary heart disease (CHD), the leading cause of death in the United States, is a narrowing of the coronary arteries, the blood vessels that supply blood and oxygen to the heart. This arterial narrowing limits the supply of oxygenated blood to the heart, and can lead to angina (chest pain) or a heart attack.

Coronary heart disease is generally due to the buildup of plaques in the arterial walls, a process known as atherosclerosis. Plaques are composed of cholesterol-rich fatty deposits, collagen and other proteins, and excess smooth muscle cells. Atherosclerosis, which usually progresses very gradually over a lifetime, thickens and narrows the arterial walls, impeding the flow of blood. Blood clots form more easily on arterial walls roughened by plaque deposits. The clots may block the narrowed coronary artery completely and cause a heart attack. Arteries may also narrow suddenly as a result of an arterial spasm. Spasms are most commonly triggered by smoking.

Symptoms of CHD usually develop insidiously. In the early stages of the disease, there are generally no symptoms. As the disease progresses, angina may develop during periods of physical activity or emotional stress, because the narrowed arteries cannot supply the heart with the increased amount of blood and oxygen necessary at those times. Angina usually subsides quickly with rest, but over time, symptoms arise with less exertion, and CHD may eventually lead to a heart attack. However, in a third of CHD cases, angina never develops, and a heart attack can occur suddenly with no prior warning.

Although CHD can be a life-threatening condition, the outcome of the disease can be managed. Damage to the arteries can be slowed or halted with lifestyle changes, including smoking cessation, dietary modifications, and regular exercise, or by medications to lower blood pressure and cholesterol levels. Additional goals of treatment, which may involve medication and sometimes surgery, are to relieve symptoms, improve blood circulation, and prolong life.

What Causes It?

Smoking promotes the development of plaque in the arteries. It also increases the likelihood of angina by increasing the amount of carbon monoxide in the bloodstream and decreasing the amount of oxygen available to the heart.

High blood cholesterol levels lead to CHD. Low density lipoprotein (LDL) cholesterol enters the lining of the arterial walls where, after being chemically altered, it is incorporated into plaque.

High blood pressure increases the risk of CHD.

People with diabetes are at greater risk for atherosclerosis.

Obesity may promote atherosclerosis.

Lack of exercise (a sedentary lifestyle) may encourage atherosclerosis.

Men are at greater risk than women for CHD, although the risk for postmenopausal women approaches that of men as estrogen production decreases with menopause.

Women over age 35 who take oral contraceptives and smoke cigarettes have a higher risk of atherosclerosis.

A family history of premature heart attacks (before age 55 in men and before age 65 in women) is associated with greater CHD risk.

A spasm of the muscular layer of the arterial walls may cause an artery to contract and produce angina. Spasms may be induced by smoking, extreme emotional stress, or exposure to cold air.

Prevention

Don’t smoke.

Eat a diet low in saturated fat, cholesterol, and salt.

Pursue a program of moderate aerobic exercise for at least 30 minutes, three days a week. People over age 50 who have led a sedentary lifestyle should check with a doctor before beginning an exercise program.

Lose weight if you are overweight.

See your doctor regularly to have your blood pressure and cholesterol measured.

Your doctor may advise you to take a low dose of aspirin every day if you are at risk for CHD. Aspirin reduces the tendency of the blood to clot, thereby decreasing the risk of heart attack. However, such a regimen should only be initiated under a doctor’s recommendation.

Diagnosis

Patient history and physical examination. If you suffer a heart attack, diagnosis will often be made immediately upon examination by a doctor or emergency medical technician.

An electrocardiogram (ECG) may be performed to measure changes in the electrical activity of the heart resulting from abnormalities in the flow of blood or a prior heart attack. In some cases your doctor may provide you with a portable ECG device, known as a Holter monitor, in order to record the electrical activity of the heart over a 24-hour period.

Chest x-rays.

Blood tests.

Exercise stress testing. Blood pressure, heartbeat, and breathing rates are measured by ECG while you walk on a treadmill. If you cannot exercise adequately, a medication may be injected to mimic the effect of exercise on the heart.

An injection of a radioisotope such as thallium may be given after an exercise stress test to gauge blood flow to the heart.

An echocardiogram, which uses ultrasound waves to create moving images of the heart, may be performed.

Coronary angiography may be performed to determine the presence of narrowing in the coronary arteries. In this procedure a tiny catheter is inserted into an artery in the groin and threaded up into the coronary arteries. A contrast material is then injected from the end of the catheter into the coronary arteries, and x-rays are taken.

Treatment

Emergency treatment and immediate hospitalization is necessary if a heart attack occurs—commonly signaled by crushing, persistent chest pain.

Follow prevention tips for a heart-healthy lifestyle, including a low-fat diet and regular physical exercise. Avoid excessive alcohol consumption, nasal decongestants, and diet pills, all of which may raise blood pressure.

Rapidly acting nitrates, such as nitroglycerin, or longer-acting nitrates like isosorbide dinitrate may be prescribed to dilate blood vessels and relieve or prevent symptoms of angina. A nitroglycerin tablet placed under the tongue (sublingually) at the onset of an angina attack usually relieves the pain within minutes. Sublingual nitroglycerin may also be taken just prior to activities that commonly provoke angina. However, for any given angina attack, you should not take more than three nitroglycerin tablets at five-minute intervals—pain lasting longer than this may signal a heart attack. Intravenous nitrates may be administered in patients with unstable angina. Nitrates may also be prescribed in the form of patches or ointments for continuous protection.

Beta-blockers such as propranolol or metoprolol are prescribed to reduce the heart’s oxygen demand by slowing the heart rate and lowering blood pressure.

ACE inhibitors such as enalapril may be prescribed to reduce blood pressure and dilate blood vessels.

Calcium channel blockers such as verapamil, diltiazem, or nifedipine may be prescribed to reduce the heart’s oxygen demands and to increase blood flow to the heart.

Anticoagulants such as heparin or warfarin are administered to reduce the risk of blood clots in patients with unstable angina.

Vasodilators such as captopril, enalapril, or hydralazine may be prescribed to expand blood vessels, thus reducing blood pressure and facilitating blood flow.

An obstructed coronary artery may be opened by percutaneous transluminal coronary angioplasty (PTCA). In this procedure a small balloon is inserted into an artery in the groin via a catheter and guided to the site of the arterial blockage. The balloon is then inflated, compressing the plaque; this widens the passageway and improves blood flow. PTCA usually requires an overnight hospital stay.

Coronary bypass surgery may be performed to improve blood flow to the heart. A mammary artery or a vein taken from the leg is grafted onto the damaged coronary artery to circumvent a narrowed or blocked portion.

A heart transplant may be advised in severe cases in which the heart muscle has been badly damaged. The survival rate for heart transplant is 85 percent after one year and 65 percent after five years.

 

From Johns Hopkins Symptoms and Remedies, the complete home medical reference. You can order this book now on our secure server.

 

 

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2005
WHITE PAPERS
Coronary Heart Disease

The Coronary Heart Disease White Paper from The Johns Hopkins White Papers series is an annual, in-depth report written by Johns Hopkins physicians.


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