Coronary Artery Disease

Overview

What is coronary artery disease?

Coronary artery disease occurs when fatty deposits called plaque (say "plak") build up inside the coronary arteries. The coronary arteries wrap around the heart and supply it with blood and oxygen. When plaque builds up, it narrows the arteries and reduces the amount of blood that gets to your heart. This can lead to serious problems, including heart attack.

Coronary artery disease (also called CAD) is the most common type of heart disease. It is also the number one killer of both men and women in the United States.

It can be a shock to find out that you have coronary artery disease. Many people only find out when they have a heart attack. Whether or not you have had a heart attack, there are many things you can do to slow coronary artery disease and reduce your risk of future problems.

What causes coronary artery disease?

Coronary artery disease is caused by hardening of the arteries, or atherosclerosis. Atherosclerosis occurs when plaque builds up inside the arteries. (Arteries are the blood vessels that carry oxygen-rich blood throughout your body.) Atherosclerosis can affect any arteries in the body. When it occurs in the arteries that supply blood to the heart, it is called coronary artery disease.

Plaque is a fatty material made up of cholesterol, calcium, and other substances in the blood. To understand why plaque is a problem, compare a healthy artery with an artery with atherosclerosis:

• A healthy artery is like a rubber tube. It is smooth and flexible, and blood flows through it freely. If your heart has to work harder, such as when you exercise, a healthy artery can stretch to let more blood flow to your body’s tissues.
• An artery with atherosclerosis is more like a clogged pipe. Plaque narrows the artery and makes it stiff. This limits the flow of blood to the tissues. When the heart has to work harder, the stiff arteries can't flex to let more blood through, and the tissues don't get enough blood and oxygen.

See a picture of a normal artery and an artery narrowed by plaque.

When plaque builds up in the coronary arteries, the heart doesn't get the blood it needs to work well. Over time, this can weaken or damage the heart. If a plaque tears, the body tries to fix the tear by forming a blood clot around it. The clot can block blood flow to the heart and cause a heart attack. See a picture of how plaque causes a heart attack.

What are the symptoms?

Usually people with coronary artery disease don't have symptoms until after age 50. Then they may start to have symptoms at times when the heart is working harder and needs more oxygen, such as during exercise. Typical first symptoms include:

• Chest pain, called angina (say “ANN-juh-nuh” or “ann-JY-nuh”).
• Shortness of breath.
• Heart attack. Too often, a heart attack is the first symptom of coronary artery disease.

Less common symptoms include a fast heartbeat, feeling sick to your stomach, and increased sweating. Some people don't have any symptoms. In rare cases, a person can have a “silent” heart attack, without symptoms.

To find out your risk for a heart attack in the next 10 years, use this Interactive Tool: Are You at Risk for a Heart Attack?

How is coronary artery disease diagnosed?

To diagnose coronary artery disease, doctors start by doing a physical exam and asking questions about your past health and your risk factors. Risk factors are things that increase the chance that you will have coronary artery disease.

Some common risk factors are being older than 65; smoking; having high cholesterol, high blood pressure, or diabetes; and having heart disease in your family. The more risk factors you have, the more likely it is that you have coronary artery disease.

If your doctor thinks that you have coronary artery disease, you may have tests, such as:

• Electrocardiogram (EKG or ECG), which checks for problems with the electrical activity of your heart. An EKG can also show signs of an old or new heart attack.
• Chest X-ray.
• Blood tests.
• Exercise electrocardiogram, commonly called a "stress test." This test checks for changes in your heart while you exercise.

Your doctor may order other tests to look at blood flow to your heart. You may have a coronary angiogram if your doctor is considering a procedure to remove blockages, such as angioplasty or bypass surgery.

How is it treated?

Treatment focuses on taking steps to manage your symptoms and reduce your risk for heart attack and stroke. Some risk factors you can't control, such as your age and family history. Other risk factors you can control, such as high blood pressure, high cholesterol, and smoking. Lifestyle changes can help lower your risks. You may also need to take medicines or have a procedure to open your arteries.

Lifestyle changes are the first step for anyone with coronary artery disease. These changes may stop or even reverse coronary artery disease. To improve your heart health:

• Don't smoke. This may be the most important thing you can do. Quitting smoking can quickly reduce the risk of heart attack or death.
• Eat a heart-healthy diet that includes plenty of fish, fruits, vegetables, beans, high-fiber grains and breads, and olive oil. See a dietitian if you need help making better food choices.
• Get regular exercise on most, if not all, days of the week. Your doctor can suggest a safe level of exercise for you. Walking is great exercise that most people can do. A good goal is 30 minutes or more a day.
• Lower your stress level. Stress can hurt your heart.

Changing old habits may not be easy, but it is very important to help you live a healthier and longer life. Having a plan can help. Start with small steps. For example, commit to eating five servings of fruits and vegetables a day. Instead of having dessert, take a short walk. When you feel stressed, stop and take some deep breaths.

Medicines may be needed in addition to lifestyle changes. Medicines that are often prescribed for people with coronary artery disease include:

• Statins to help lower cholesterol.
• Beta-blockers or ACE inhibitors to lower blood pressure.
• Aspirin or other medicines to reduce the risk of blood clots.
• Nitrates to relieve chest pain.

Procedures may be done to improve blood flow to the heart.

• Angioplasty is used to open blocked arteries. It isn't major surgery. During angioplasty, the doctor guides a thin tube (called a catheter) into the narrowed artery and inflates a small balloon. This widens the artery to help restore blood flow. Often a small wire-mesh tube called a stent is placed to keep the artery open. See a picture of angioplasty with stent placement. The doctor may use a stent that is coated with medicine, called a drug-eluting stent. When the stent is in place, it slowly releases a medicine that prevents the growth of new tissue. This helps keep the artery open.
• Bypass surgery, which is major surgery, may be used if more than one coronary artery is blocked. It uses healthy blood vessels to create detours around narrowed or blocked arteries.

What else can you do?

To stay as healthy as possible, it is important to:

• See your doctor for regular follow-up appointments. This lets your doctor keep track of your risk factors and adjust your treatment as needed.
• Take your medicines exactly as prescribed. Do not stop or change medicines without talking to your doctor.
• Keep nitroglycerin with you at all times, if your doctor prescribed it for chest pain.
• Tell your doctor about any chest pain you have had, even if it went away.
• Get the support you need to succeed in making lifestyle changes. Ask family or friends to share a healthy meal or join a stop-smoking program with you. Or ask your doctor about a cardiac rehab program. In cardiac rehab, a team of health professionals provides education and support to help you make new, healthy habits.

Health Tools 

Health Tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	End of life: Should I stop treatment that prolongs my life?
	Heart attack: Should I take daily aspirin to prevent a heart attack or stroke?
	Heart disease risk: Should I have a coronary calcium scan?
	Heart disease: Should I have an angiogram?
	Heart disease: Should I have angioplasty for stable angina?
	Heart disease: Should I have bypass surgery?
	High blood pressure: Should I take medicine?
	High cholesterol: Should I take statins?
	Actionsets are designed to help people take an active role in managing a health condition.
	Heart disease: Eating a heart-healthy diet
	Heart disease: Exercising for a healthy heart
	Heart disease: Walking for a healthy heart
	Interactive tools are designed to help people determine health risks, ideal weight, target heart rate, and more.
	Interactive Tool: Are You at Risk for a Heart Attack?
	Interactive Tool: Are You Ready to Quit Smoking?
	Interactive Tool: How Does Smoking Increase Your Risk of Heart Attack?
	Interactive Tool: Is Your Weight Increasing Your Health Risks?

Frequently Asked Questions

Cause

Coronary artery disease is caused by the buildup of plaque on the inside of your coronary arteries. In most people, plaque buildup begins early in life and gradually develops over a lifetime.¹

Coronary artery disease typically begins when the inside walls of the coronary arteries are damaged because of another health problem, such as:

• High cholesterol.
• High blood pressure.
• Diabetes.
• Smoking.

Plaque, which is made up of excess cholesterol, calcium, and other substances in your blood, builds up on the damaged inner walls of your coronary arteries. This process usually occurs throughout the body and is called atherosclerosis, or "hardening of the arteries." See pictures of atherosclerosis and how high blood pressure damages arteries.

Over time, plaque buildup narrows the coronary arteries and can lead to ischemia (insufficient blood flow to the heart muscle). Ischemia (say "is-KEE-mee-uh") can weaken the heart muscle, but it usually does not cause heart muscle cells to die.

But heart muscle cells can die if blood flow is severely reduced or completely blocked for a period of time. This can happen if plaque breaks apart and makes a clot that blocks an artery. This can cause myocardial infarction, or heart attack.

Symptoms

Symptoms of coronary artery disease

The most common symptoms of coronary artery disease are:

• Chest pain, also called angina.
• Shortness of breath when exercising or during another vigorous activity.

Other symptoms include:

• A fast heartbeat.
• Weakness, dizziness, and feeling sick to your stomach (nausea).
• Increased sweating.

Symptoms of heart attack

Heart attack symptoms in men and women often differ. Men often have the typical type of chest pain that feels like squeezing or pressure. But the pain is more severe than usual and does not go away with rest. Women, older adults, and people with diabetes may have symptoms different from chest pain. These groups of people may have symptoms like breathlessness, heartburn, nausea, fatigue, jaw pain, or back pain.

In one study, many women reported having warning symptoms 1 month before they had a heart attack. These symptoms included unusual fatigue, trouble sleeping, and shortness of breath. Only 30 out of 100 women reported chest pain, which the majority of men report.² For more information about the differences between coronary artery disease in women and men, see women and coronary artery disease.

Unfortunately, sometimes a heart attack is the first sign of coronary artery disease. According to the large, 50-year Framingham Heart Study, more than 50 out of 100 men and 63 out of 100 women who died suddenly of coronary artery disease (mostly from heart attack) had no previous symptoms of this disease.³

Some people who have coronary artery disease and insufficient blood flow to the heart muscle (ischemia) do not have any symptoms. This is called "silent ischemia." In rare instances, you can even have a "silent heart attack," a heart attack without symptoms.

One Man's Story: Alan, 73 “At some point in my life I was going to have a heart attack. Smoking just sped it up. It happened while I was playing basketball with some guys from work. I started getting pains in my chest. The next thing I knew, I was on the floor.”—Alan Read more about Alan and how he learned to cope after a heart attack.

Angina (chest pain)

Chest pain, also called angina, is the most common symptom of coronary artery disease. The pain may have a distinct pattern. Angina can be described as:

• A feeling of pressure, heaviness, weight, tightness, squeezing, discomfort, burning, or dull aching in the chest. People often put their fist to their chest when describing the pain.
• Hard to pinpoint (you can't point to the exact location of the pain). Pressing on the chest wall does not cause the pain.

The chest pain of angina usually begins at a low level, then increases over several minutes to a peak. Angina that starts with an activity usually will decrease when the activity is stopped. Chest pain that begins suddenly or lasts only a few seconds is less likely to be angina.

Angina usually begins in the chest, but it can also start in or spread to different areas of the body, such as:

• Down the left arm (most common site).
• To the left shoulder.
• To the neck or lower jaw.
• To the mid-back.
• Down the right arm.

Some people may feel tingling or numbness in their arm, hand, or jaw when they have angina.

See a picture of areas that may be affected by angina.

How does angina happen?

Angina is often brought on by activities that make the heart work harder, because the heart needs more oxygen than can be delivered through the narrowed arteries. Some of these activities include:

• Strenuous exercise (especially if you ordinarily do not exercise).
• Use of cocaine or amphetamines.
• Exposure to cold temperatures.
• Sudden, intense emotions such as anger or fear.
• Smoking.
• Eating a heavy meal.

Many people have stable angina, which is predictable. It eases after they rest and take nitroglycerin, a medicine that opens blood vessels to improve blood flow. But if there is a change in the usual pattern of your angina, you may have unstable angina. In unstable angina, chest pain occurs at rest or with less and less exertion, may be more severe and last longer, or doesn't respond to nitroglycerin. Because unstable angina can progress to a heart attack, it requires medical attention right away.

For information about their differences, see stable versus unstable angina. For information about variant, or Prinzmetal's, angina and other kinds of angina, see types of angina. For more information, see the topic Heart Attack and Unstable Angina.

How do you know if chest pain is heart-related?

Chest pain can be a symptom of many other conditions. For example, anxiety, inflammation in or injury to the chest wall, or a blood clot in the lung can cause pain in the chest.

Chest pain and shortness of breath are more likely to be serious and related to your heart if:

• They are like symptoms you have had before because of coronary artery disease.
• You have risk factors for coronary artery disease.

Your chest pain is less likely to be caused by a heart problem if:

• You can point to the exact spot that hurts.
• The pain gets worse when you take a deep breath, or holding your breath for a few seconds reduces the pain significantly.
• The pain gets better or worse when you move or press on a specific part of the chest wall, neck, or shoulder.
• Antacids dramatically relieve the pain.
• The pain lasts only a few seconds.

It's important to treat symptoms early to prevent permanent damage to your heart. If any type of chest pain continues, it needs to be checked by a doctor.

Because many vital organs are found in the chest, even chest pain that is not caused by coronary artery disease may be a sign of a serious problem in the aorta (the large blood vessel that leads out of the heart), lungs, or digestive organs.

What Increases Your Risk

Things that can increase your risk for coronary artery disease are called risk factors. Some risk factors, such as your gender, your age, and your family history, can't be changed. Other risk factors for heart disease are tied to your lifestyle and habits. These often are things you can change. Your chance of getting coronary artery disease rises with the number of risk factors you have.

Risk factors you may be able to change include:

• Smoking. See the Interactive Tool: How Does Smoking Increase Your Risk of Heart Attack?
• High blood pressure.
• High cholesterol.
• Diabetes.
• Obesity. See the Interactive Tool: Is Your Weight Increasing Your Health Risk?
• Lack of exercise.
• Personality factors and high stress level.
• Using birth control pills if you smoke and are older than 35 or if you have a family history of atherosclerosis or blood-clotting disorders.
• Using hormone therapy after menopause. This risk is higher for some women than others.

Smoking, high cholesterol, high blood pressure, and lack of exercise are risk factors you can reduce with lifestyle changes and medicine. Diabetes and obesity can sometimes be prevented when lifestyle changes are made early in life. To learn more, see the Prevention section of this topic.

Risk factors that you can't change include:

• Family history. You're more at risk if one or more of your close relatives have or had early CAD.
• Being male. Men generally develop heart disease 10 years earlier than women do. But women who have diabetes may develop heart disease at a younger age. By age 60, heart disease is one of the leading causes of death in both sexes.
• Age. People over 65 are more likely to have heart disease.

What's your risk?

Your doctor can check your risk for heart disease using screening guidelines from the American Heart Association. The guidelines include all of the things that can place you at higher risk for disease.

See the Interactive Tool: Are You at Risk for a Heart Attack? to calculate your risk of having a heart attack in the next 10 years. The tool is based on a calculator created by the National Cholesterol Education Program. It's for adults age 20 and older who do not have heart disease or diabetes.

Metabolic syndrome can also increase your risk for heart disease.⁴ People with metabolic syndrome have a group of health problems related to their metabolism, including too much fat around the waist, high triglycerides, high blood pressure, high fasting blood sugar, and low HDL cholesterol.

When to Call a Doctor

Call 911 or other emergency services immediately if you have any of the following symptoms:

• Chest pain that has not gone away within 5 minutes after you have taken one nitroglycerin and/or rested. After calling 911, continue to stay on the phone with the emergency operator. He or she will give you further instructions. See how to take nitroglycerin.
• Chest pain or discomfort that is crushing or squeezing, feels like pressure on the chest, and lasts more than 5 minutes, especially if it occurs with any of the following symptoms:
  • Sweating
  • Shortness of breath
  • Nausea or vomiting
  • Pain that spreads from the chest to the neck, jaw, or one or both shoulders or arms
  • Dizziness or lightheadedness
  • A fast or irregular pulse
  • Signs of shock

Women are more likely to have symptoms such as shortness of breath, heartburn, nausea, jaw pain, back pain, or fatigue.

After calling 911 or other emergency services, you should chew 1adult-strength aspirin (325 mg) if you are not allergic to aspirin or unable to take aspirin for some other reason. By calling 911 and taking an ambulance to the hospital, you may be able to start treatment before you arrive at the hospital. If any complications occur along the way, ambulance personnel are trained to evaluate and treat them.

If an ambulance is not readily available, have someone else drive you to the emergency room. Do not drive yourself to the hospital.

If you witness a person becoming unconscious, call 911 or other emergency services and start cardiopulmonary resuscitation (CPR). The emergency operator can coach you on how to perform CPR. For more information, see the CPR section in the topic Dealing With Emergencies.

Contact your doctor immediately if you have new, more frequent, or severe episodes of chest painor discomfort, which may mean that you have an increased risk for a heart attack.

Talk to your doctor if you have:

• Chest pain or discomfort for the first time with features similar to those of coronary artery disease. See the Symptoms section of this topic.
• Episodes of chest pain or discomfort and your work involves responsibility for the lives of other people (for example, if you are a pilot, bus driver, or sole caregiver for small children).

Never wait if you have symptoms of a heart attack

Many people are unsure whether they are having a heart attack, and so they take a "wait and see" approach. Heart attack symptoms often vary. People often discount their symptoms if they do not fit into the expected "extreme chest pain" scenario. Some people are embarrassed or don't want to bother others by calling for help if they think it may not be a heart attack. Even if you're not sure it's a heart attack, you should still have it checked out. Rapid treatment can save your life.

Who to See

To see if you are at risk for heart disease, have symptoms of coronary artery disease, or require long-term care for existing heart disease, see your family doctor or internist. For diagnosis of coronary artery disease, you may see a cardiologist. For ongoing care of stable angina, you will likely see your family doctor or an internist. For surgical intervention, you will be referred to a cardiovascular surgeon.

Exams and Tests

To find out if you have or are at risk for coronary artery disease, your doctor will start by doing a physical exam. He or she will ask questions about your health and your risk factors. Risk factors are the things that increase your risk. You may then have several different kinds of tests to check your risk for getting heart disease. If your doctor thinks you have heart disease, you will need more tests to make sure.

Tests to measure your risk for coronary artery disease

The main tests your doctor uses to check your risk for getting heart disease include:

• Blood pressure. High blood pressure increases your risk for heart disease.
• Cholesterol (a blood test). High cholesterol increases your risk for heart disease.

Your doctor will use your blood pressure, cholesterol, and other risk factors such as your age and if you smoke, to know your risk of heart disease. If you know your blood pressure and cholesterol levels, you can check your risk for a heart attack:

Interactive Tool: Are You at Risk for a Heart Attack?

Other tests may help your doctor find out your risk for heart disease, especially when they are considered along with your other risk factors. But these tests are not helpful for everyone. Such tests may include:

• C-reactive protein (CRP) test. High CRP levels are linked to higher risk for heart disease.
• Coronary artery calcium scan. This test uses a special kind of X-ray to check for buildup of calcium in the heart's arteries. The result is a number, or score. If you have a high score, you may need more tests to check for heart disease or to find out how bad it is. For more information, see:

  Heart disease risk: Should I have a coronary calcium scan?

Depending on your age, health, and family history, you may have some of these tests every year to check your risk. Screening guidelines from the American Heart Association advise regular testing to check blood pressure, blood sugar, and cholesterol levels starting at age 20.

Most doctors agree that you should be checked for heart disease if you are older than 39, have diabetes or more than one risk factor for heart disease, and want to start a vigorous exercise program or plan to have major surgery.

Tests to diagnose coronary artery disease

If your doctor thinks you may have heart disease, you will need some tests to make sure. Most often, the first tests include:

• An electrocardiogram (EKG or ECG).
• A chest X-ray.
• Blood tests.
• An exercise electrocardiogram. This is also called a "stress test."

Other tests may include:⁵

• Cardiac perfusion scan. This test shows if you have enough blood flow to the heart.
• Echocardiogram and stress echocardiogram. This test uses ultrasound to see areas of poor blood flow in the heart. It can also check how well your heart is working after a heart attack. The test can help your doctor find out how much blood your heart is pumping during each heartbeat (ejection fraction).
• Coronary angiogram. This is an X-ray test that creates pictures of the blood flow through your coronary arteries. It allows your doctor to see any blockage or narrowing of the artery. It's done using a soft, thin tube (catheter) that is put in a blood vessel in the arm or groin and gently moved into the heart. Most often, the test is only done if bypass surgery or angioplasty is an option. For more information, see:

  Heart disease: Should I have an angiogram?

Treatment Overview

Treatment for coronary artery disease focuses on taking steps to manage symptoms and reduce the risk of heart attack and stroke. For example:

• If your doctor agrees, take a low-dose aspirin each day to reduce your risk of heart attack or stroke.
• If you can't control your high blood pressure and high cholesterol with healthier habits, you may need to take medicines. They can help you manage these health problems and lower your risk.
• Your doctor may also suggest medicines if you often have chest pain that makes it hard to do everyday activities.
• If medicines don't help your chest pain, your doctor may suggest procedures to improve blood flow to the heart. Angioplasty with or without stent placement is one way to open clogged coronary arteries. Or sometimes coronary artery bypass graft surgery may be needed.
• No matter what kind of treatment you get, healthy habits such as quitting smoking, eating a heart-healthy diet, and getting regular exercise are important. You can start today:

  Interactive Tool: Are You Ready to Quit Smoking?

  Heart disease: Eating a heart-healthy diet

  Heart disease: Exercising for a healthy heart

What to Think About

Keep these questions in mind as you think about your treatment options:

• Will this treatment improve my symptoms?
• Will this treatment help prevent future heart problems?
• Am I likely to live longer with this treatment?
• What are the risks of this treatment?

Some things that can affect your choice of treatment include the severity of your chest pain, your test results, and your feelings about treatment.

Initial treatment

Lifestyle changes are the first step for anyone with coronary artery disease. But sometimes lifestyle changes are not enough. You may also need medicines. If you take medicines, take them on a schedule and take the correct dose. Taking medicines properly can help you prevent a heart attack or stroke.

Lifestyle changes

When you're first diagnosed with heart disease, your doctor will strongly advise you to make lifestyle changes. These include quitting smoking, eating a heart-healthy diet, and getting regular exercise. These healthy habits can slow or even stop the disease and improve the quality and length of your life.

Quit smoking. It's the best thing you can do to reduce your risk of future problems. And avoid secondhand smoke. People with heart disease who keep smoking have a 43% greater chance of dying from a heart attack than those who quit.⁶

Your doctor may prescribe medicine and counseling to help you quit. Nicotine replacement therapy, the medicines bupropion (Zyban or Wellbutrin) and varenicline (Chantix), and counseling can help you quit for good.⁷ For more information, see the topic Quitting Smoking.

Eat a heart-healthy diet. This can help you keep your disease from getting worse. A chart that compares heart-healthy diets (What is a PDF document?) can help you see what foods are suggested in each plan. A heart-healthy diet means:

• Eat more fruits, vegetables, whole grains, and other high-fiber foods.
• Choose foods that are low in saturated fat, trans fat, and cholesterol.
• Limit salt.
• Stay at a healthy weight by balancing the calories you eat with how much physical activity you get.
• Eat more foods that are high in omega-3 fatty acids, such as fish.

Start an exercise program (if your doctor says it's safe). Try walking, swimming, biking, or jogging for at least 30 minutes on most, if not all, days of the week. You may need to start slow and build up to this amount. Any activity you enjoy will work, as long as it gets your heart rate up. In people with heart disease, exercise reduces the chances of having a fatal heart attack.⁸

One Man's Story: Alan, 73 “I've had to work at keeping my weight under control, and that has really helped my cholesterol. When you have heart disease, you learn to eat better for the rest of your life. And if you don't, you're asking for trouble.”—Alan Read more about Alan and the lessons he's learned about diet and exercise.

Medicines

Aspirin.Your doctor will probably recommend that you take an aspirin every day. Aspirin can reduce the risk of having a heart attack in people with heart disease. Lower doses seem to work as well as higher doses to prevent heart attacks, and they have fewer side effects. Talk with your doctor before you start taking aspirin. For more information, see:

Heart attack: Should I take daily aspirin to prevent a heart attack or stroke?

Cholesterol. If you have average to high cholesterol, your doctor may prescribe a medicine to lower your cholesterol, such as a statin. For more information, see:

High cholesterol: Should I take statins?

Chest pain. If you have chest pain (angina), your doctor may prescribe medicines such as:

• Nitroglycerin and other nitrates, which relax arteries and increase blood flow.
• Beta-blockers, which decrease the heart's workload.
• Calcium channel blockers, which may be used to treat angina if you can't take beta-blockers.
• Ranolazine, if nitroglycerin, beta-blockers, and calcium channel blockers don't help your chest pain. Unlike other medicines used to treat angina, ranolazine doesn't affect heart rate or blood pressure. Most of the time, it is taken with nitrates or beta-blockers.
• An ACE inhibitor. ACE inhibitors save lives and reduce the risk of heart attack in people with heart disease.⁵

Ongoing treatment

After you start treatment for coronary artery disease, your doctor will want to keep track of how you are doing. He or she will want to know if you've made lifestyle changes and if they have helped. For example, your blood pressure, cholesterol, and weight will be checked. These measures will help your doctor find out if lifestyle changes are working.

If you take medicines, your doctor will want to know if you feel any side effects. If you take medicine for chest pain (angina), your doctor will want to know how well it works. Does the medicine ease your pain quickly? Do you get chest pain less often?

You will likely need to keep taking medicines that lower your cholesterol and blood pressure and that reduce your risk of having a heart attack. Your doctor will also want to check how well these medicines work for you. If they're not working, he or she may want you to try a different dose or take a different kind of medicine.

It can be hard to make lifestyle changes on your own. If you need help, talk to your doctor about cardiac rehabilitation. In cardiac rehab, a team of health professionals provides education and support to help you make new, healthy habits.

Treatment if the disease gets worse

Sometimes coronary artery disease gets worse even with treatment. If you start to have abnormal heart rhythms (arrhythmias), your doctor might suggest a pacemaker or medicines to control your heart rate.

If your chest pain keeps getting worse even though you are taking medicines, you may need procedures to improve blood flow to your heart. They are also done when the coronary arteries are severely blocked. These procedures include angioplasty with or without stenting and coronary artery bypass graft (CABG) surgery.

When deciding between bypass surgery and angioplasty, your doctor will think about several things, such as how many arteries are blocked and whether you have diabetes. To learn more, see the Surgery section and the Angioplasty and Other Treatment section of this topic.

Also see:

Heart disease: Should I have angioplasty for stable angina?

Heart disease: Should I have bypass surgery?

Coronary artery disease can lead to heart failure and the need for other medicines. These medicines can help you feel better and prevent your heart failure from getting worse.

Palliative care

If your coronary artery disease gets worse, you may want to think about palliative care. Palliative care is a kind of care for people who have diseases that do not go away and often get worse over time. It is different from care to cure your illness, which is called curative treatment.

Palliative care focuses on improving your quality of life—not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.

Palliative care may help you manage symptoms or side effects from treatment. It can also help you and your family to:

• Cope with your feelings about living with a long-term disease.
• Make future plans around your medical care.
• Understand your disease and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Palliative Care.

Prevention

You can slow or even prevent coronary artery disease by taking steps toward a healthier lifestyle. Many people already have. More people are adopting healthy habits such as eating right, exercising more, and not smoking. Doing these things can also help reduce risk factors such as high cholesterol and high blood pressure. In one study by the American Heart Association, the number of deaths from heart disease dropped because so many people made these kinds of changes.³

Lifestyle changes

• Quit smoking. It may be the best thing you can do to prevent heart disease. Smokers who quit cut their risk of heart disease by half after 1 year. You can cut your risk even more by staying away from cigarettes for good. After 15 years of not smoking, your risk of death from heart disease is the same as if you had never smoked at all.³ And avoid secondhand smoke. For more information, see:

  Interactive Tool: How Does Smoking Increase Your Risk of Heart Attack?

  Interactive Tool: Are You Ready to Quit Smoking?

• Exercise. There are lots of ways that exercise boosts your health. It can lower cholesterol and blood pressure. It can also help you reach a healthy weight. Try to exercise for at least 30 minutes on most, if not all, days of the week. Talk to your doctor before starting an exercise program. To learn more, see:

  Heart disease: Exercising for a healthy heart.

• Eat a heart-healthy diet. The way you eat can help you control your cholesterol and blood pressure. It can be hard to know what's best to eat for a healthy heart. See these guidelines for heart-healthy eating for general tips and special diets to help lower cholesterol and blood pressure. Remember that some foods you may hear about are just fads that don't prevent heart disease at all. To help you start and stay with a healthy eating plan, see:

  Heart disease: Eating a heart-healthy diet.

  A chart that compares heart-healthy diets (What is a PDF document?).

These three big changes—quitting smoking, getting exercise, and eating right—will give you the best chance at preventing heart disease. But there are a few other things you can do to keep yourself healthy.

• Relax, and reduce stress. Stress can hurt your heart. Keep stress low by talking about your problems and feelings, rather than keeping your feelings hidden. Try exercise, deep breathing, meditation, or yoga.
• Manage depression and anger. Getting treatment for depression and learning how to manage anger can help you stay healthy.

Control your cholesterol and blood pressure

To reduce your risk of heart disease, it's important to control your cholesterol and manage your blood pressure. Quitting smoking, changing the way you eat, and getting more exercise can help. But if these things don't work, you may need to take medicines as well. For more information, see:

Heart disease: Should I take statins?

High blood pressure: Should I take medicine?

Aspirin to prevent heart attack and stroke

If you're already at risk for heart disease, taking daily aspirin may reduce your chances of having a stroke or a heart attack. That's because a daily aspirin lowers your risk of getting blood clots. Blood clots can lead to a heart attack in people with heart disease. Clots can also cause heart attacks in people who have other problems that can lead to heart disease, such as diabetes, high blood pressure, and high cholesterol.

Taking aspirin has some risks. Talk with your doctor before starting aspirin treatment. For more information, see:

Heart attack: Should I take daily aspirin to prevent a heart attack or stroke?

What Happens

You can have coronary artery disease and not know it. Sometimes the disease is found during an electrocardiogram or stress test. Often a heart attack is the first sign of heart disease.³

When you do know that you have heart disease, you may wonder how it spreads over time and what you can do to slow its progress. It’s important to take care of yourself. Making healthy lifestyle changes can reduce your chances of heart attack and stroke. Take your medicines as your doctor prescribes. To learn more, see the Treatment and Prevention sections of this topic.

If your heart disease gets worse, your arteries will narrow, and less blood will flow to your heart. You may start to have chest pain (angina) when you exercise or feel stressed. This is called stable angina. Most people are able to control stable angina by resting or taking nitroglycerin.

In some cases, sudden and serious problems can happen. New blockages that form in the arteries of the heart tend to be unstable. They can break apart and cause blood clots to form. These clots block blood flow to your heart, causing a heart attack or unstable angina.

If your heart disease is severe, or if your chest pain and other symptoms can't be controlled with medicines, you may need to think about other treatment, such as:

• Angioplasty.
• Stenting.
• Atherectomy.
• Coronary artery bypass surgery.

These treatments, along with making changes like eating right and not smoking, can help you live a longer, healthier life. If your disease becomes much worse, it can lead to serious medical problems. Many important end-of-life decisions can be made while you are active and able to communicate your wishes. For more information, see the End-of-Life Decisions section of this topic.

Complications of heart disease

Over time, you may have other health problems caused by coronary artery disease. Low blood flow can make it harder for your heart to pump. This can lead to heart failure or atrial fibrillation. Atrial fibrillation increases the risk of stroke. For more information, see the topics Atrial Fibrillation, Heart Failure, and Stroke.

Narrow coronary arteries don't just cause problems for your heart. They can also affect blood vessels in other parts of your body. See a picture of the cardiovascular system.

Most often, problems occur in arteries that bring blood to your heart, brain, and arms and legs (peripheral arterial disease). For more information, see the topic Peripheral Arterial Disease of the Legs.

Living With Heart Disease

A diagnosis of coronary artery disease can be hard to accept and understand. If you don't have symptoms, it may be especially hard to recognize that heart disease is serious and can lead to other health problems.

It's important to talk with your doctor to learn about the disease and what you can do to help manage it and prevent it from getting worse.

Healthy habits

Making healthy lifestyle changes can delay and maybe even reverse heart disease. Quitting smoking, eating a low-fat and low-cholesterol diet, and getting regular exercise are the most important steps you can take to keep your disease from getting worse.⁹ For more information, see:

Interactive Tool: Are You Ready to Quit Smoking?

Heart disease: Eating a heart-healthy diet.

Heart disease: Exercising for a healthy heart.

For more information on how to make healthy lifestyle changes, see the Prevention section of this topic.

Controlling chest pain

Most people are able to control chest pain (angina) by taking medicines as prescribed and nitroglycerin when needed. To learn more, see the topic Quick Tips: Taking Charge of Your Angina.

Dealing with depression

It's common to feel sad or depressed when you find out you have heart disease. Depression is also common for up to 6 months after a heart attack. Asking for and getting support from family and friends may help you avoid depression. But if you keep having "the blues," you may need treatment.

You might feel too embarrassed to ask for help, or maybe you think that you'll get over depression on your own. But most people need treatment to get better. Talk with your doctor about counseling and medicine for depression. For more information, see the topic Depression.

Support can help

Whether you are recovering from a heart attack or changing your lifestyle so you can avoid one, emotional support from friends and family is important. Think about joining a heart disease support group. Ask your doctor about the types of support that are available where you live. Meeting other people with the same problems can help you know you're not alone.

A cardiac rehabilitation program can also provide support. The rehab team can help you make new, healthy habits, such as eating right and getting more exercise. For more information, see the topic Cardiac Rehabilitation.

One Man's Story: Alan, 73 "It’s so easy for cardiac patients to put weight on. And it’s so hard to get it off. You need to walk every day or the weight comes right back. I couldn't do any of it without my support groups. The camaraderie of being together and working out together makes such a big difference. We take care of each other."—Alan Read more about Alan and how he learned to cope after a heart attack.

Medications

Many people have trouble correctly taking their medicines for coronary artery disease. Often, they need to take several medicines at different times of the day. And some people struggle to afford the medicines. But medicines are often a key part of treatment, and people who do not take them as prescribed have an increased risk of complications and death.⁵ Find out more about how to take medicines properly.

Medicines to treat symptoms and prevent complications

If you have symptoms of coronary artery disease, your doctor may prescribe some of the following medicines to control symptoms and, in some cases, slow the progression of the disease:

• Aspirin and other antiplatelet medications help prevent blood clots in your coronary arteries. This can decrease your risk of heart attack and stroke. For more information, see:

  Heart attack: Should I take daily aspirin to prevent a heart attack or stroke?

• Beta-blockers slow your heart rate and lower your blood pressure to reduce the amount of work your heart has to do. They also reduce angina.
• Statins lower your cholesterol and may reduce your risk of a future heart attack. Your doctor may use the National Cholesterol Education Program's (NCEP) guidelines to help decide if you need treatment with medicine to lower cholesterol.
• Nitrates (nitroglycerin and long-acting nitrates) relieve chest pain and other symptoms of angina.
• Calcium channel blockers slow your heart rate and lower your blood pressure to reduce your heart's workload. They also help widen (dilate) your coronary arteries and reduce angina.
• Ranolazine (Ranexa) relieves chest pain when nitroglycerin, beta-blockers, and calcium channel blockers don't work. Unlike other medicines used to treat angina, ranolazine doesn't affect heart rate or blood pressure. Most of the time, it is taken with nitrates or beta-blockers.
• Angiotensin-converting enzyme (ACE) inhibitors lower your blood pressure and reduce the strain on your heart. They may also reduce your risk for a future heart attack or heart failure.
• Angiotensin II receptor blockers (ARBs) lower your blood pressure and reduce the strain on your heart. If you cannot tolerate certain side effects of an ACE inhibitor, your doctor may prescribe an ARB instead.

Anticoagulants may also be used after an angioplasty, atherectomy, or bypass surgery. The anticoagulant warfarin may be used if you have heart disease as well as atrial fibrillation or other complications.

What to Think About

Medicines for angina

Stable angina can often be controlled with medicine. For more help with controlling angina, see the topic Quick Tips: Taking Charge of Your Angina.

If angina symptoms become worse, your doctor may need to adjust your medicines. But if angina symptoms still get worse and medicines don't help, you may need angioplasty or bypass surgery. For angina that gets worse quickly or occurs at rest (unstable angina), you may need hospitalization and urgent angioplasty, stenting, or bypass surgery. For more information, see the topic Heart Attack and Unstable Angina.

Do not use erection-enhancing medicines such as sildenafil (Viagra), vardenafil (Levitra), or tadalafil (Cialis) if you take nitroglycerin or other nitrates for angina. Combined, these two drugs can cause a serious drop in blood pressure.

If you are taking an erection-enhancing medicine and seek treatment for angina, tell the doctor about your use of this medicine so you don't get nitroglycerin or another type of nitrate. There are other medicines that may work instead to ease your chest pain.

Aspirin

Aspirin, ibuprofen, and naproxen are all nonsteroidal anti-inflammatory drugs (NSAIDs) and can relieve pain and inflammation. But only aspirin will reduce your risk for heart attack or stroke. Don't substitute ibuprofen or naproxen for low-dose aspirin therapy. If you need to take an NSAID for a long time, talk with your doctor to see if it is safe for you.

For more information, see:

Heart attack: Should I take daily aspirin to prevent a heart attack or stroke?

Surgery

The goals of surgery for coronary artery disease are to:

• Improve blood flow to the heart.
• Relieve chest pain (angina).
• Improve your chances of living a longer life.

Many people with heart disease can be treated by lifestyle changes and medicine or angioplasty. But sometimes coronary artery bypass graft surgery (CABG or "cabbage") is needed. It uses healthy blood vessels to create detours around narrowed or blocked arteries. Most of the time, bypass surgery is an open-chest procedure.

To learn more about angioplasty, see the Angioplasty and Other Treatment section of this topic.

Surgery Choices

Coronary artery bypass graft surgery improves blood flow to the heart. During this surgery, a doctor connects (grafts) a healthy artery or vein from another part of your body to the blocked coronary artery. The grafted artery goes around (bypasses) the blocked part of the artery. The bypass provides a new pathway for blood to your heart.

See a slideshow of how bypass surgery is done.

Sometimes transmyocardial laser revascularization (TMR) is used along with bypass surgery. This surgery uses a laser beam to improve blood flow to the heart. It is not common but may be done to reach areas of the heart where bypass grafting does not work as well.

What to Think About

Most of the time, people with severe heart disease benefit more from bypass surgery than from angioplasty.¹⁰ Your treatment will depend in part on:

• How many arteries are blocked.
• How badly the arteries are blocked, and where.
• Other heart problems you may have.
• Your feelings about treatment.

It’s important to understand the benefits and risks of angioplasty versus bypass surgery. You can also read about other factors that affect treatment choices.

Surgery isn't right for everyone. Making lifestyle changes and taking medicine or having angioplasty can work just as well for some people. And these carry fewer risks than surgery.

No matter what treatment you receive, you'll still need to make changes in the way you eat and how much you exercise. These changes, along with not smoking, will give you the best chance of living a longer, healthier life.

To learn more, see:

Heart disease: Should I have bypass surgery?

Heart disease: Should I have angioplasty for stable angina?

If you're thinking about surgery, ask your doctor how many heart surgeries your surgeon and the hospital perform each year. Find out how that number compares with heart surgeries done at other hospitals. People who have bypass surgery at hospitals that do many heart surgeries tend to have better results.

Cardiac rehabilitation

After your surgery, your doctor may suggest that you attend a cardiac rehabilitation program. In cardiac rehab, a team of health professionals provides education and support to help you recover.

The rehab team can help you make new, healthy habits, such as eating right and getting more exercise. Making these changes is just as important as getting treatment in keeping your heart healthy and your arteries open.

For more information, see the topic Cardiac Rehabilitation.

Angioplasty and Other Treatment

The goal of angioplasty is to open blood vessels and increase blood flow to the heart. It is done when arteries are narrowed or blocked from coronary artery disease. Angioplasty can be done with or without a small, wire-mesh tube called a stent.

Angioplasty is not surgery. It is done using a thin, soft tube called a catheter that's inserted in your artery. It doesn't use large cuts (incisions) or require anesthesia to make you sleep.

Most of the time, stents are placed during angioplasty. The stent keeps the artery open. When stents are used, there is a smaller chance that the artery will become narrow again.¹¹ See a picture of angioplasty with stenting.

When angioplasty is done using drug-eluting stents, arteries have a greater chance of staying open longer.¹² When these stents are in place, they slowly release a medicine that prevents the growth of new tissue. This helps keep the artery open.

Drug-eluting stents cost more than standard ones. And experts don't know how safe drug-eluting stents will be over time. They also don't know how well they work over the long term.

Other Treatment Choices

Atherectomy is another treatment for coronary artery disease, but it is only done in certain cases. During atherectomy, a doctor uses a small blade, inserted through a catheter, to shave away plaque buildup from the heart artery wall. Shaving the plaque away helps blood flow to the heart.

Atherectomy may be needed because of the type of plaque in an artery, the location of the plaque, and how much plaque there is. It can clear an artery that has hard plaque that might not open up with angioplasty alone. See a picture of how atherectomy is done.

Another treatment for people with long-term chest pain is enhanced external counterpulsation (EECP). Most of the time, this is done only if you are unable to have angioplasty or surgery.

What to Think About

It’s important to understand the benefits and risks of angioplasty versus bypass surgery. You can also read about other factors that affect treatment choices.

Your treatment will depend in part on:

• How many arteries are blocked.
• How badly the arteries are blocked, and where.
• Other heart problems you may have.
• Your feelings about treatment.

No matter what treatment you receive, you'll still need to make changes in the way you eat and how much you exercise. These changes, along with not smoking, will give you the best chance of living a longer, healthier life.

To learn more, see:

Heart disease: Should I have angioplasty for stable angina?

Heart disease: Should I have bypass surgery?

Cardiac rehabilitation

After angioplasty, your doctor may suggest that you attend a cardiac rehabilitation program. In cardiac rehab, a team of health professionals provides education and support to help you recover.

The rehab team can help you make new, healthy habits, such as eating right and getting more exercise. Making these changes is just as important as getting treatment in keeping your heart healthy and your arteries open.

For more information, see the topic Cardiac Rehabilitation.

End-of-Life Decisions

Although treatment for coronary artery disease is increasingly successful at prolonging life and reducing complications and hospitalization, the disease can lead to a heart attack, a stroke, and other fatal conditions. It's a good idea to think about end-of-life decisions before these events happen, while you are still active and able to talk about your wishes.

When you are diagnosed with coronary artery disease, your doctor will discuss treatment options with you. If your heart disease is advanced and your life will most likely be shortened by the illness, your doctor may talk to you about whether you want to be revived (resuscitated) when your illness progresses and your breathing stops. You may want to learn more about aggressive life-sustaining medical treatment and whether it is right for you. For more information, see:

End-of-life care: Should I stop treatment that prolongs my life?

Many other decisions about end-of-life issues, such as writing a living will and estate planning, can be made in advance, leaving valuable time for spending with loved ones and on other important matters. For more information, see the topics Care at the End of Life and Writing an Advance Directive.

References

Citations

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2. McSweeney JC, et al. (2003). Women's early warning symptoms of acute myocardial infarction. Circulation, 108(21): 2619–2623.
3. American Heart Association (2006). Heart disease and stroke statistics—2006 update. Circulation, 113(6): e85–e151.
4. Grundy SM (2001). United States cholesterol guidelines 2001: Expanded scope of intensive low-density lipoprotein-lowering therapy. American Journal of Cardiology, 88(7B): 23J–27J.
5. Snow V, et al. (2004). Primary care management of chronic stable angina and asymptomatic suspected or known coronary artery disease: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 141(7): 562–567. Also available online: http://www.annals.org/cgi/reprint/141/7/562.pdf.
6. Goldenberg I, et al. (2003). Current smoking, smoking cessation, and the risk of sudden cardiac death in patients with coronary artery disease. Archives of Internal Medicine, 163(19): 2301–2305.
7. Silagy C, et al. (2006). Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews (1). Oxford: Update Software.
8. Jolliffe JA, et al. (2006). Exercise-based rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews (1). Oxford: Update Software.
9. Foster C, et al. (2004). Cardiovascular disorders: Primary prevention. Clinical Evidence (12): 159–192.
10. Smith SC Jr, et al. (2006). ACC/AHA/SCAI 2005 guidelines update for percutaneous coronary intervention: Summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Circulation, 113(1): 156–175.
11. Gami A (2006). Secondary prevention of ischaemic cardiac events, search date July 2004. Online version of Clinical Evidence (15): 1–31.
12. Morice M (2002). A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. New England Journal of Medicine, 346(23): 1773–1780.

Other Works Consulted

• BARI 2D Study Group (2009). A randomized trial of therapies for Type 2 diabetes and coronary artery disease. New England Journal of Medicine, 360(24): 2503–2515.
• Buckley DI, et al. (2009). C-reactive protein as a risk factor for coronary heart disease: A systematic review and meta-analysis for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 151(7): 483–495.
• Hirsch J, et al. (2008). Executive summary: American College of Chest Physicians evidence-based clinical practice guidelines (8th ed.). Chest, 133(6): 71–109.
• Pearson TA, et al. (2003). Markers of inflammation and cardiovascular disease: American Heart Association and the Centers for Disease Control and Prevention scientific statement. Circulation, 107(3): 499–511.
• U.S. Preventive Services Task Force (2008). Screening for type 2 diabetes mellitus in adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 148(11): 846–854.
• U.S. Preventive Services Task Force (2009). Using nontraditional risk factors in coronary heart disease risk assessment. Rockville, MD: Agency for Healthcare Research and Quality. Available online: http://www.ahrq.gov/clinic/uspstf09/coronaryhdrs.htm.
• U.S. Preventive Services Task Force (2009). Aspirin for the Prevention of Cardiovascular Disease. Rockville, MD: Agency for Healthcare Research and Quality. Available online: http://www.ahrq.gov/clinic/uspstf/uspsasmi.htm.

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