Coronary artery disease

Possible symptoms of CAD include chest pain. Some people describe the pain as dull, pressing, constricting, or burning. Others may feel more like they have a large knot in their chest or throat, or as if they have a heavy weight on their chest. These kinds of symptoms, called angina (or angina pectoris), can make you feel anxious or scared.

The pain often spreads into the arms, neck, back, upper belly, or jaw. This may be accompanied by shortness of breath, nausea, dizziness and general weakness, sweating, or cold sweats.

Chest tightness is a less common CAD symptom in women, older people, and people with diabetes or heart failure. They are then more likely to have symptoms such as shortness of breath, upper abdominal pain, and palpitations. Heart attacks can even go unnoticed (silent heart attack) in people with diabetes-related nerve damage.

For people who are experiencing CAD symptoms for the first time, it's difficult to tell whether the symptoms are caused by stable CAD following exertion, or by a heart attack. So it's important to know the possible signs of a heart attack and know what to do in an emergency.

CAD is caused by arteriosclerosis (hardening of the arteries). Arteries are blood vessels that transport blood to the tissues and organs of the body. Arteriosclerosis starts with small inflammations and damage on and in the wall of the arteries. Immune system cells, fats and other substances collect there. These deposits are called plaques. They can get bigger over time and then block the flow of blood in the artery.

In CAD, at least one coronary artery is affected by arteriosclerosis. The coronary arteries are marked red in the following illustration. The blue vessels are the coronary veins, which take the blood away once the oxygen in it has been used up.

Arteriosclerosis can have various effects:

• In chronic CAD, one of the coronary arteries is so narrow that not enough oxygen gets to the heart during physical activity. Then the heart can no longer beat strongly enough to go up the stairs, for instance. That can cause certain symptoms that get better again after resting. These typically occur if the artery is at least 70% narrower than usual. Chronic CAD is also referred to as stable CAD because the symptoms often don't get worse over a long period of time, especially if kept under control with good treatment.
• In acute CAD, one of the arteries is completely or almost completely blocked. That causes a heart attack because too little blood reaches the heart to keep the muscle cells alive. That can happen if a deposit in the wall of the blood vessel suddenly breaks open, and a blood clot forms there and blocks the vessel. If the blockage isn't treated quickly, the part of the heart muscle that doesn't get enough blood dies.

The risk of coronary artery disease increases with age. Other risk factors for CAD include smoking, being very overweight, high cholesterol, high blood pressure, and diabetes.

The risk is particularly high if a person has a number of risk factors at the same time.

CAD is a common chronic disease. Older people are more likely to have it: Around 2% of 40 to 49-year-olds have CAD, compared to 22% of 70 to 79-year-olds. It is somewhat more common in men than in women.

Deposits in the coronary arteries usually develop over many years.

In chronic (stable) CAD, the symptoms are triggered by physical or emotional strain. The point at which the symptoms start is sometimes called the physical activity threshold. The symptoms go away quickly if you rest or take the right medicine.

The severity of the symptoms depends on various things, including how much blood is still reaching the heart muscle. There are four levels of severity:

Chronic CAD can take different courses. According to current knowledge, good long-term treatment can even make angina symptoms disappear again.

Chronic CAD is often stable for a long time. But it can sometimes also progress and cause a heart attack. So it's important for people with CAD to know the signs of a heart attack. These include:

• Symptoms that suddenly get worse without physical or emotional strain (at rest)
• Symptoms that appear sooner, last longer or are more severe than usual
• Symptoms that don't get better even after taking emergency medication such as nitrates

It is not always easy to tell the difference between temporary symptoms and a heart attack. If in doubt, you should never wait. Call the emergency services straight away (112 in Germany and many other countries, 911 in the U.S.).

CAD can also lead to other health problems. The main ones are (further) heart attacks, an irregular heartbeat like atrial fibrillation, and heart failure (cardiac insufficiency).

Some people who have CAD may develop depression too, especially after a heart attack.

Symptoms in the chest area can be caused by many different things, including problems affecting the muscles or bones in the rib cage. Diseases of the lungs, food pipe or the airways can also cause chest pains, as can emotional strain and mental illnesses. Other cardiovascular diseases such as heart muscle inflammations (myocarditis) and irregular heartbeats can also cause similar symptoms.

To get an idea of whether it's CAD, the doctor will first ask your age, whether you have any other diseases, what exactly the symptoms feel like and when they occur. They will also ask about cardiovascular disease in your family and about risk factors such as smoking. They will do a physical examination of your chest, too.

If the doctor suspects you have CAD, the most important examination is an electrocardiogram (ECG). This is done either while you're resting or while you're exercising. It is also possible to do an ultrasound scan of the heart (echocardiography) or use another imaging technique to examine the heart. Whether further heart tests are needed, and what kind, will depend on your age, any other medical conditions you have, and your symptoms.

To assess the risk of complications and make a treatment plan, your doctor will suggest having several other tests. The diagnosis typically involves:

• Measuring blood pressure: Blood pressure is measured because if someone who has CAD also has high blood pressure, the CAD is more likely to lead to complications.
• Physical examinations: Examinations such as listening to the heart or feeling the liver can help to find out whether you might have other conditions such as heart failure or heart valve problems.
• Test for metabolic disorders: A blood sample is usually taken as well, to look for any metabolic disorders such as type 2 diabetes or to measure your cholesterol level. Type 2 diabetes can greatly increase the risk of developing complications.

In the long term, it's a good idea to have regular check-ups with your family doctor to keep an eye on how the CAD develops, adjust treatment, and discuss your personal goals and any problems. Check-ups every 3 to 6 months are recommended.

In Germany, people who have statutory health insurance are entitled to one general health check-up between the age of 18 and 35, and then one every three years after that. The aim of this check-up is to detect early signs of cardiovascular disease, diabetes and kidney problems. It involves things like having your blood pressure taken, as well as blood and urine tests.

The treatment for CAD will depend on things like whether it's acute or chronic. Long-term treatment is important in both cases, to prevent complications and symptoms.

In the event of a heart attack, medication is given quickly to stop the blood clotting. The blocked blood vessel is then usually widened in hospital using a cardiac (heart) catheter to get the blood flowing again as soon as possible. Known as angioplasty, this procedure is done by feeding a thin, flexible tube (catheter) into the affected blood vessel and pushing it all the way to the blocked area – usually through an artery in the groin or, less often, in the wrist. A balloon at the tip of the catheter can then be inflated to widen the blood vessel. A tiny wire mesh tube called a stent is then placed in the blood vessel to prevent it from becoming narrow again. Some heart attacks are only treated with medication.

Medication can reduce the symptoms and restrictions in everyday life caused by stable CAD. Beta blockers, calcium channel blockers and nitrates are used for this purpose. If that doesn't help enough, doctors often try to widen the narrowed coronary artery with a procedure using a cardiac catheter.

Bypass surgery might also be an option, depending on which and how many blood vessels are affected. This involves taking a blood vessel from elsewhere in the body and using it to redirect blood around the blocked coronary artery (bypassing it). Whether bypass surgery is a suitable treatment option will depend on things like your age and any other medical conditions you may have.

There are things you can do on your own to help prevent complications like a (further) heart attack or heart failure: for example, eating a healthy diet and getting enough exercise. If you smoke, you could try to give it up. There are also a number of medications that can prevent complications and increase life expectancy. These mainly include:

• Low doses of acetylsalicylic acid (the drug in medicines like "Aspirin") to prevent blood clots
• Statins to protect the blood vessels

Depending on your personal situation and other medical conditions you have, further medications may be considered. People with CAD are also advised to have a yearly flu jab. This is because the flu can be particularly severe in people with CAD. Studies have shown that a flu jab after a heart attack can prevent deaths.

There are many different ways for people who have CAD to improve their physical fitness and quality of life, and also prevent complications. They include the following:

• Cardiac rehabilitation (follow-up rehabilitation treatment)
• Exercising with other heart patients

Cardiac rehabilitation programs often include a combination of exercise, learning how to deal with the disease and risk factors, as well as psychological and social advice and support. Personal issues regarding work, family, relationships and psychological stress might be discussed too. Loved ones can also participate in the rehabilitation program. The program is led by a team of specialists from various fields, including medicine, physical therapy, nutritional sciences and psychotherapy.

Cardiac rehabilitation is particularly recommended for people who

• have had a heart attack,
• have had an operation ( bypass or stent),
• have heart failure because of CAD,
• have a high risk of further heart diseases,
• have depression after a heart attack, or
• need a lot of support in daily life.

Your doctor can help you submit an application for cardiac rehabilitation to the insurance provider in question. In Germany, this will typically be a statutory health insurer or pension fund.

After doing a rehabilitation program, you can take part in an outpatient exercise group for heart patients. These groups meet at least once a week. The training is supervised by doctors and led by health care professionals. As well as doing specially tailored group exercise sessions, the participants are also informed about things like diet and losing weight. A list of these groups is available from the regional organizations of the "German Society for Prevention and Rehabilitation of Cardiovascular Disease (DGPR)." The participation in one of these groups can also be prescribed by doctors as "Rehabilitationssport" (sports for rehabilitation purposes).

Some people who have CAD may feel guilty because they think they should have done more for their health. But personal lifestyle is only one factor. Further key factors include your age, genes, and other things that can hardly be influenced.

People who have heart problems are often given a lot of well-meant advice, and may sometimes feel like they need to change their entire way of living. But that is almost impossible. It is more helpful to set one goal after the other, like taking more exercise.

It can be distressing to live in constant fear of having a heart attack. But good treatment with medication can reduce the risk as much as possible. It is important to be aware of the signs of a heart attack and to seek immediate medical help if necessary.

Many people who have CAD wonder whether they might have a heart attack if they have sex. Like any kind of strenuous physical activity, sex somewhat increases the risk of a heart attack for a short time, but the overall risk is still low. Regularly doing low-intensity endurance exercise could reduce the risk of having a heart attack after physical exertion.

A heart attack is usually a life-changing experience. It is not uncommon for people to feel down or even develop depression requiring treatment after having one. But heart attacks often have fewer serious long-term effects than people first think. It is important not to feel discouraged, but instead learn how to live with CAD. There are effective treatments for depression. Cardiac rehabilitation programs sometimes offer psychological support too.

Anyone with CAD who has statutory health insurance in Germany can participate in a structured disease management program (DMP). These programs aim to improve quality of life and ensure high-quality care. The best way to sign up for a DMP is by contacting your health insurer.