Coronary artery disease (CAD), also known as ischemic heart disease
(IHD), refers to a group of diseases which includes stable angina,
unstable angina, myocardial infarction, and sudden cardiac death.
It is within the group of cardiovascular diseases of which it is the
most common type. A common symptom is chest pain or discomfort
which may travel into the shoulder, arm, back, neck, or jaw.
Occasionally it may feel like heartburn. Usually symptoms occur with
exercise or emotional stress, last less than a few minutes, and
improve with rest.
Shortness of breath may also occur and sometimes
no symptoms are present. Occasionally, the first sign is a heart
attack. Other complications include heart failure or an abnormal
Risk factors include high blood pressure, smoking, diabetes, lack of
exercise, obesity, high blood cholesterol, poor diet, depression, and
excessive alcohol. The underlying mechanism involves
reduction of blood flow and oxygen to the heart muscle due to
atherosclerosis of the arteries of the heart. A number of tests may
help with diagnoses including: electrocardiogram, cardiac stress
testing, coronary computed tomographic angiography, and coronary
angiogram, among others.
Ways to reduce CAD risk include eating a healthy diet, regularly
exercising, maintaining a healthy weight, and not smoking.
Medications for diabetes, high cholesterol, or high blood pressure are
sometimes used. There is limited evidence for screening people who
are at low risk and do not have symptoms. Treatment involves the
same measures as prevention. Additional medications such as
antiplatelets (including aspirin), beta blockers, or nitroglycerin may
be recommended. Procedures such as percutaneous coronary
intervention (PCI) or coronary artery bypass surgery (CABG) may be
used in severe disease. In those with stable CAD it is unclear
if PCI or CABG in addition to the other treatments improves life
expectancy or decreases heart attack risk.
In 2015 CAD affected 110 million people and resulted in 8.9 million
deaths. It makes up 15.9% of all deaths making it the most
common cause of death globally. The risk of death from CAD for a
given age has decreased between 1980 and 2010, especially in developed
countries. The number of cases of CAD for a given age has also
decreased between 1990 and 2010. In the
United States in 2010
about 20% of those over 65 had CAD, while it was present in 7% of
those 45 to 64, and 1.3% of those 18 to 45. Rates are higher among
men than women of a given age.
1 Signs and symptoms
2 Risk factors
2.1 Blood fats
4.1 Stable angina
4.2 Acute coronary syndrome
4.3 Risk assessment
5.2 Secondary prevention
6.1.2 Anti-platelet therapy
8 Society and culture
8.2 Support groups
8.3 Industry influence on research
11 External links
Signs and symptoms
Chest pain that occurs regularly with activity, after eating, or at
other predictable times is termed stable angina and is associated with
narrowings of the arteries of the heart.
Angina that changes in intensity, character or frequency is termed
Unstable angina may precede myocardial infarction. In adults
who go to the emergency department with an unclear cause of pain,
about 30% have pain due to coronary artery disease.
Coronary artery disease has a number of well determined risk factors.
These include high blood pressure, smoking, diabetes, lack of
exercise, obesity, high blood cholesterol, poor diet, depression,
family history, and excessive alcohol. About half of cases
are linked to genetics. Smoking and obesity are associated with
about 36% and 20% of cases, respectively. Smoking just one
cigarette per day about doubles the risk of CAD. Lack of exercise
has been linked to 7–12% of cases. Exposure to the herbicide
Agent Orange may increase risk. Both rheumatoid arthritis and
systemic lupus erythematosus are independent risk factors as
Job stress appears to play a minor role accounting for about 3% of
cases. In one study, women who were free of stress from work life
saw an increase in the diameter of their blood vessels, leading to
decreased progression of atherosclerosis. In contrast, women who
had high levels of work-related stress experienced a decrease in the
diameter of their blood vessels and significantly increased disease
progression. Having a type A behavior pattern, a group of
personality characteristics including time urgency, competitiveness,
hostility, and impatience, is linked to an increased risk of
High blood cholesterol (specifically, serum LDL concentrations). HDL
(high density lipoprotein) has a protective effect over development of
coronary artery disease.
High blood triglycerides may play a role.
High levels of lipoprotein(a), a compound formed when LDL
cholesterol combines with a protein known as apolipoprotein(a).
Dietary cholesterol does not appear to have a significant effect on
blood cholesterol and thus recommendations about its consumption may
not be needed. Saturated fat is still a concern.
The heritability of coronary artery disease has been estimated between
40% and 60%.
Genome-wide association studies
Genome-wide association studies have identified
around 60 genetic susceptibility loci for coronary artery disease.
Endometriosis in women under the age of 40.
Depression and hostility appear to be risks.
The number of categories of adverse childhood experiences
(psychological, physical, or sexual abuse; violence against mother; or
living with household members who were substance abusers, mentally
ill, suicidal, or incarcerated) showed a graded correlation with the
presence of adult diseases including coronary artery (ischemic heart)
Hemostatic factors: High levels of fibrinogen and coagulation factor
VII are associated with an increased risk of CAD.
In the Asian population, the b fibrinogen gene G-455A polymorphism was
associated with the risk of CHD.
Micrograph of a coronary artery with the most common form of coronary
artery disease (atherosclerosis) and marked luminal narrowing.
Illustration depicting coronary artery disease
Limitation of blood flow to the heart causes ischemia (cell starvation
secondary to a lack of oxygen) of the heart's muscle cells. The
heart's muscle cells may die from lack of oxygen and this is called a
myocardial infarction (commonly referred to as a heart attack). It
leads to damage, death, and eventual scarring of the heart muscle
without regrowth of heart muscle cells. Chronic high-grade narrowing
of the coronary arteries can induce transient ischemia which leads to
the induction of a ventricular arrhythmia, which may terminate into a
dangerous heart rhythm known as ventricular fibrillation, which often
leads to death.
Typically, coronary artery disease occurs when part of the smooth,
elastic lining inside a coronary artery (the arteries that supply
blood to the heart muscle) develops atherosclerosis. With
atherosclerosis, the artery's lining becomes hardened, stiffened, and
accumulates deposits of calcium, fatty lipids, and abnormal
inflammatory cells – to form a plaque. Calcium phosphate
(hydroxyapatite) deposits in the muscular layer of the blood vessels
appear to play a significant role in stiffening the arteries and
inducing the early phase of coronary arteriosclerosis. This can be
seen in a so-called metastatic mechanism of calciphylaxis as it occurs
in chronic kidney disease and hemodialysis (Rainer Liedtke 2008).
Although these people suffer from a kidney dysfunction, almost fifty
percent of them die due to coronary artery disease. Plaques can be
thought of as large "pimples" that protrude into the channel of an
artery, causing a partial obstruction to blood flow. People with
coronary artery disease might have just one or two plaques, or might
have dozens distributed throughout their coronary arteries. A more
severe form is chronic total occlusion (CTO) when a coronary artery is
completely obstructed for more than 3 months.
Cardiac syndrome X
Cardiac syndrome X is chest pain (angina pectoris) and chest
discomfort in people who do not show signs of blockages in the larger
coronary arteries of their hearts when an angiogram (coronary
angiogram) is being performed. The exact cause of cardiac syndrome
X is unknown. One explanation is microvascular dysfunction. For
reasons that are not well understood, women are more likely than men
to have it; however, hormones and other risk factors unique to women
may play a role.
Coronary angiogram of a man
Coronary angiogram of a woman
For symptomatic people, stress echocardiography can be used to make a
diagnosis for obstructive coronary artery disease. The use of
echocardiography, stress cardiac imaging, and/or advanced non-invasive
imaging is not recommended on individuals who are exhibiting no
symptoms and are otherwise at low risk for developing coronary
The diagnosis of "Cardiac Syndrome X" – the rare coronary artery
disease that is more common in women, as mentioned, is a diagnosis of
exclusion. Therefore, usually the same tests are used as in any person
with the suspected of having coronary artery disease:
Baseline electrocardiography (ECG)
Exercise ECG – Stress test
Exercise radioisotope test (nuclear stress test, myocardial
Echocardiography (including stress echocardiography)
Magnetic resonance imaging
Magnetic resonance imaging (MRI)
The diagnosis of coronary disease underlying particular symptoms
depends largely on the nature of the symptoms. The first investigation
is an electrocardiogram (ECG/EKG), both for "stable" angina and acute
coronary syndrome. An X-ray of the chest and blood tests may be
In "stable" angina, chest pain with typical features occurring at
predictable levels of exertion, various forms of cardiac stress tests
may be used to induce both symptoms and detect changes by way of
electrocardiography (using an ECG), echocardiography (using ultrasound
of the heart) or scintigraphy (using uptake of radionuclide by the
heart muscle). If part of the heart seems to receive an insufficient
blood supply, coronary angiography may be used to identify stenosis of
the coronary arteries and suitability for angioplasty or bypass
Stable coronary artery disease (SCAD) is also often called stable
ischemic heart disease (SIHD). A 2015 monograph explains that
"Regardless of the nomenclature, stable angina is the chief
manifestation of SIHD or SCAD." There are U.S. and European
clinical practice guidelines for SIHD/SCAD.
Acute coronary syndrome
Main article: Acute coronary syndrome
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Diagnosis of acute coronary syndrome generally takes place in the
emergency department, where ECGs may be performed sequentially to
identify "evolving changes" (indicating ongoing damage to the heart
muscle). Diagnosis is clear-cut if ECGs show elevation of the "ST
segment", which in the context of severe typical chest pain is
strongly indicative of an acute myocardial infarction (MI); this is
STEMI (ST-elevation MI) and is treated as an emergency with
either urgent coronary angiography and percutaneous coronary
intervention (angioplasty with or without stent insertion) or with
thrombolysis ("clot buster" medication), whichever is available. In
the absence of ST-segment elevation, heart damage is detected by
cardiac markers (blood tests that identify heart muscle damage). If
there is evidence of damage (infarction), the chest pain is attributed
to a "non-
ST elevation MI" (NSTEMI). If there is no evidence of
damage, the term "unstable angina" is used. This process usually
necessitates hospital admission and close observation on a coronary
care unit for possible complications (such as cardiac arrhythmias –
irregularities in the heart rate). Depending on the risk assessment,
stress testing or angiography may be used to identify and treat
coronary artery disease in patients who have had an N
STEMI or unstable
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There are various risk assessment systems for determining the risk of
coronary artery disease, with various emphasis on different variables
above. A notable example is Framingham Score, used in the Framingham
Heart Study. It is mainly based on age, gender, diabetes, total
cholesterol, HDL cholesterol, tobacco smoking and systolic blood
Up to 90% of cardiovascular disease may be preventable if established
risk factors are avoided. Prevention involves adequate
physical exercise, decreasing obesity, treating high blood pressure,
eating a healthy diet, decreasing cholesterol levels, and stopping
smoking. Medications and exercise are roughly equally effective.
High levels of physical activity reduce the risk of coronary artery
disease by about 25%.
Most guidelines recommend combining these preventive strategies. A
2015 Cochrane Review found some evidence that such an approach might
help with blood pressure, body mass index, and waist circumference.
However, there was insufficient evidence to show an effect on
mortality or actual cardiovascular events.
In diabetes mellitus, there is little evidence that very tight blood
sugar control improves cardiac risk although improved sugar control
appears to decrease other problems such as kidney failure and
World Health Organization
World Health Organization (WHO) recommends "low to
moderate alcohol intake" to reduce risk of coronary artery disease
while high intake increases the risk.
Main article: Diet and heart disease
A diet high in fruits and vegetables decreases the risk of
cardiovascular disease and death. Vegetarians have a lower risk of
heart disease, possibly due to their greater consumption of
fruits and vegetables. Evidence also suggests that the
Mediterranean diet and a high fiber diet lower the risk.
The consumption of trans fat (commonly found in hydrogenated products
such as margarine) has been shown to cause a precursor to
atherosclerosis and increase the risk of coronary artery
Evidence does not support a beneficial role for omega-3 fatty acid
supplementation in preventing cardiovascular disease (including
myocardial infarction and sudden cardiac death). There is
tentative evidence that intake of menaquinone (Vitamin K2), but not
phylloquinone (Vitamin K1), may reduce the risk of CAD mortality.
Secondary prevention is preventing further sequelae of already
established disease. Lifestyle changes that have been shown to be
effective to this goal include:
Avoiding the consumption of trans fats (in partially hydrogenated
Decrease psychosocial stress
Exercise; aerobic exercise, like walking, jogging, or swimming, can
reduce the risk of mortality from coronary artery disease. Aerobic
exercise can help decrease blood pressure and the amount of blood
cholesterol (LDL) over time. It also increases HDL cholesterol which
is considered as "good cholesterol". Separate to the question
of the benefits of exercise; it is unclear whether doctors should
spend time counseling patients to exercise. The U.S. Preventive
Services Task Force found "insufficient evidence" to recommend that
doctors counsel patients on exercise but "it did not review the
evidence for the effectiveness of physical activity to reduce chronic
disease, morbidity and mortality", it only examined the effectiveness
of the counseling itself. The American
Heart Association, based on
a non-systematic review, recommends that doctors counsel patients on
There are a number of treatment options for coronary artery
Medical treatment – drugs (e.g., cholesterol lowering medications,
beta-blockers, nitroglycerin, calcium channel blockers, etc.);
Coronary interventions as angioplasty and coronary stent;
Coronary artery bypass grafting (CABG)
Statins, which reduce cholesterol, reduce the risk of coronary artery
Calcium channel blockers and/or beta-blockers
Antiplatelet drugs such as aspirin
It is recommended that blood pressure typically be reduced to less
than 140/90 mmHg. The diastolic blood pressure however should not
be lower than 60 mmHg.[vague] Beta blockers are recommended first line
for this use.
In those with no previous history of heart disease, aspirin decreases
the risk of a myocardial infarction but does not change the overall
risk of death. It is thus only recommended in adults who are at
increased risk for coronary artery disease where increased risk is
defined as "men older than 90 years of age, postmenopausal women, and
younger persons with risk factors for coronary artery disease (for
example, hypertension, diabetes, or smoking) are at increased risk for
heart disease and may wish to consider aspirin therapy". More
specifically, high-risk persons are "those with a 5-year risk ≥
Clopidogrel plus aspirin reduces cardiovascular events more than
aspirin alone in those with a STEMI. In others at high risk but not
having an acute event the evidence is weak. Specifically, its use
does not change the risk of death in this group. In those who have
had a stent more than 12 months of clopidogrel plus aspirin does not
affect the risk of death.
Revascularization for acute coronary syndrome has a mortality
benefit. Percutaneous revascularization for stable ischaemic heart
disease does not appear to have benefits over medical therapy
alone. In those with disease in more than one artery coronary
artery bypass grafts appear better than percutaneous coronary
interventions. Newer "anaortic" or no-touch off-pump coronary
artery revascularization techniques have shown reduced postoperative
stroke rates comparable to percutaneous coronary intervention.
Deaths due to ischaemic heart disease per million persons in 2012
Disability-adjusted life year
Disability-adjusted life year for ischaemic heart disease per
100,000 inhabitants in 2004.
As of 2010, CAD was the leading cause of death globally resulting in
over 7 million deaths. This increased from 5.2 million deaths
from CAD worldwide in 1990. It may affect individuals at any age
but becomes dramatically more common at progressively older ages, with
approximately a tripling with each decade of life. Males are
affected more often than females.
It is estimated that 60% of the world's cardiovascular disease burden
will occur in the South Asian subcontinent despite only accounting for
20% of the world's population. This may be secondary to a combination
of genetic predisposition and environmental factors. Organizations
such as the Indian
Heart Association are working with the World Heart
Federation to raise awareness about this issue.
Coronary artery disease is the leading cause of death for both men and
women and accounts for approximately 600,000 deaths in the United
States every year. According to present trends in the United
States, half of healthy 40-year-old men will develop CAD in the
future, and one in three healthy 40-year-old women. It is the
most common reason for death of men and women over 20 years of age in
the United States.
Society and culture
Other terms sometimes used for this condition are "hardening of the
arteries" and "narrowing of the arteries". In Latin it is known
as morbus ischaemicus cordis (MIC).
The Infarct Combat Project (ICP) is an international nonprofit
organization founded in 1998 which tries to decrease ischemic heart
diseases through education and research.
Industry influence on research
In 2016 research into the archives of the[not in citation given]Sugar
Association, the trade association for the sugar industry in the US,
had sponsored an influential literature review published in 1965 in
New England Journal of Medicine
New England Journal of Medicine that downplayed early findings
about the role of a diet heavy in sugar in the development of CAD and
emphasized the role of fat; that review influenced decades of research
funding and guidance on healthy eating.
Atheroma and Atherosclerosis
Research efforts are focused on new angiogenic treatment modalities
and various (adult) stem-cell therapies. A region on chromosome 17 was
confined to families with multiple cases of myocardial
infarction. Other genome-wide studies have identified a firm risk
variant on chromosome 9 (9p21.3). However, these and other loci
are found in intergenic segments and need further research in
understanding how the phenotype is affected.
A more controversial link is that between Chlamydophila pneumoniae
infection and atherosclerosis. While this intracellular organism
has been demonstrated in atherosclerotic plaques, evidence is
inconclusive as to whether it can be considered a causative
factor. Treatment with antibiotics in patients with proven
atherosclerosis has not demonstrated a decreased risk of heart attacks
or other coronary vascular diseases.
Since the 1990s the search for new treatment options for coronary
artery disease patients, particularly for so called "no-option"
coronary patients, focused on usage of angiogenesis and (adult)
stem cell therapies. Numerous clinical trials were performed, either
applying protein (angiogenic growth factor) therapies, such as FGF-1
or VEGF, or cell therapies using different kinds of adult stem cell
populations. Research is still going on – with first promising
results particularly for FGF-1 and utilization of
endothelial progenitor cells.
Myeloperoxidase has been proposed as a biomarker.
Dietary changes can decrease coronary artery disease. For example,
data supports benefit from a plant-based diet and aggressive lipid
lowering to improve heart disease.[needs update]
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V · T · D
ICD-9-CM: 410-414, 429.2
Coronary artery disease
Risk Assessment of having a heart attack or dying of coronary artery
disease, from the American
Cardiovascular disease (heart) (I00–I52, 390–429)
Coronary artery disease (CAD)
Coronary artery aneurysm
Spontaneous coronary artery dissection (SCAD)
Acute coronary syndrome
Aneurysm of heart / Ventricular aneurysm
Chronic / Constrictive
Arrhythmogenic right ventricular dysplasia
Subacute bacterial endocarditis
Nonbacterial thrombotic endocarditis
Sick sinus syndrome
Heart block: Sinoatrial
Bundle branch block
Left anterior fascicle
Left posterior fascicle
(paroxysmal and sinus)
AV nodal reentrant
Accelerated idioventricular rhythm
Torsades de pointes
Flutter / fibrillation
Ectopic pacemaker / Ectopic beat
Multifocal atrial tachycardia
Long QT syndrome
Jervell and Lange-Nielsen
Sudden cardiac death
Pulseless electrical activity
Other / ungrouped
hexaxial reference system
Right axis deviation
Left axis deviation
Short QT syndrome
T wave alternans
Right / Cor pulmonale
Diastolic heart failure