What Is Coronary Artery Disease? – Symptoms, Treatment

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What Is Coronary Artery Disease?/Coronary Artery Disease (CAD) is the most common form of heart disease. It is the result of atheromatous changes in the vessels supplying the heart. CAD is used to describe a range of clinical disorders from asymptomatic atherosclerosis and stable angina to acute coronary syndrome (unstable angina, NSTEMI, STEMI). In the US, it is still one of the leading causes of mortality. Initial evaluation of risk factors is the first step in the prevention of coronary artery diseases.

Coronary artery disease (CAD), also known as coronary heart disease (CHD) or ischemic heart disease (IHD), involves the reduction of blood flow to the heart muscle due to build-up of plaque in the arteries of the heart. It is the most common of the cardiovascular diseases.[rx] Types include stable angina, unstable angina, myocardial infarction, and sudden cardiac death.[rx] A common symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck, or jaw.[rx] Occasionally it may feel like heartburn.

Causes and Risk Factors for Coronary Artery Disease

Risk factors for coronary artery disease classify into modifiable and non-modifiable risk factors.

A 2019 article indicated that age, sex, and race captured 63 to80% of prognostic performance, while modifiable risk factors contributed only modestly. Yet, control of modifiable risk factors led to substantial reductions in CAD events. Non-modifiable risk factors are discussed first:

  • Age – CAD prevalence increases after 35 years of age in both men and women.  The lifetime risk of developing CAD in men and women after 40 years of age is 49% and 32%, respectively.
  • Gender – Men are at increased risk compared to women.
  • Ethnicity – African Americans, Hispanics, Latinos, and Southeast Asians, are ethnic groups with an increased risk of CAD morbidity and mortality.
  • Family history – Family history is also a significant risk factor.  Patients with a family history of premature cardiac disease younger than 50 years of age have an increased CAD mortality risk. A separate article indicated that a father or brother diagnosed with CAD before 55 years of age, and a mother or sister diagnosed before 65 years of age are considered risk factors.

Modifiable risk factors have a smaller but still significant role. Yet, only two-thirds of patients receive optimal medication interventions. If this were achieved, there would be a substantial reduction in CAD events. One study observed that those with optimal risk factor profiles had a substantially lower rate of death from cardiovascular events.

Hypertension

  • About 1 out of every three patients have hypertension. Hypertension and smoking were responsible for the largest number of deaths in a 2009 review comparing twelve modifiable risk factors. Yet, only 54% of these patients achieve adequate blood pressure control.
  • Hypertension has long been a major risk factor for heart disease through both oxidative and mechanical stress; it places on the arterial wall.
  • A 1996 article reported that in the Framingham cohort, a systolic of 20mmHg and diastolic of 10 mmHg increase was observed from age 30 years to 65 years.

Hyperlipidemia

  • Hyperlipidemia is considered the second most common risk factor for ischemic heart disease.
  • According to the World Health Organization, raised cholesterol caused an estimated 2.6 million deaths.
  • A recent cross-sectional study utilizing the coronary calcium score indicated a 55%, 41%, and 20% higher prevalence of hypercholesterolemia, combined hyperlipidemia, and low HDL-c, respectively.
  • Elevated triglycerides have also been implicated in coronary artery disease; however, the relationship is more complicated as the association becomes attenuated when adjusted for other risk factors such as central adiposity, insulin resistance, and poor diet. Thus, it is challenging to determine an isolated effect of triglycerides on coronary artery disease.

Diabetes mellitus

  • The Center for Disease Control (CDC) reports that more than one out of every three adult patients in the United States have prediabetes, which puts one at risk of developing type 2 diabetes, heart disease, and stroke.
  • The heart disease rate is 2.5 times higher in men and 2.4 times higher in women in diabetic adult patients compared to those without diabetes.
  • A 2017 meta-analysis indicated that diabetic patients with an A1C > 7.0 had an 85% higher likelihood (hazard ratio 1.85, 95% CI 1.14-2.55) of cardiovascular mortality, compared to those with an A1C < 7.0%.  It also revealed that non-diabetic patients with an A1C > 6.0% had a 50% higher likelihood (hazard ratio, 1.50, 95% CI 1.01-2.21) of cardiovascular mortality compared to those with an A1C of < 5.0%. Researchers also reported a significant study heterogeneity.
  • Cardiovascular disease is the leading cause of morbidity and mortality in patients with diabetes.

Obesity

  • 69% of adults in the United States are overweight or obese.  35% of adults are obese.
  • Obesity is an independent risk factor for CAD and also increases the risk of developing other CAD risk factors, including hypertension, hyperlipidemia, and diabetes mellitus.
  • One recent study indicated that obese patients were twice as likely to have coronary heart disease (hazard ratio 2.00, 95% CI 1.67-2.40) after adjustment for demographics, smoking, physical activity, and alcohol intake.
  • A 1998 research study and 2016 review article conferred that obesity is associated with more complex, raised, and hi-grade atherosclerotic coronary artery lesions.
  • The “obesity paradox” has also been reported. Despite evidence pointing to obesity as an independent risk factor for cardiovascular morbidity, some authors have described better outcomes in overweight and obese patients.  There is an ongoing debate in light of this conflicting data.

Smoking

  • The Food & Drug Administration (FDA) estimates that cardiovascular disease causes 800,000 deaths and 400,000 premature deaths per year. About one-fifth and one-third of these result from smoking, respectively.
  • A 2015 meta-analysis revealed that smoking resulted in a 51% increased risk (21 studies, RR 1.51, 95% CI 1.41.1-62) of coronary heart disease in diabetic patients.
  • A separate 2015 meta-analysis revealed that smoking resulted in twice the risk of cardiovascular disease for current smokers and a 37% increase in risk with former smokers, among patients > 60 years old.
  • Nonsmokers regularly exposed to second-hand smoke also have a 25 to 30% increased risk of coronary heart disease compared to those not exposed.

Poor diet

  • The association between saturated fat and coronary heart disease has been a journey. Initially, thought to be a significant causative factor in the development of coronary heart disease, more recent reviews have cast more doubt on this association, placing more of an emphasis on the re-emergence of refined sugars as the main risk factor.
  • Research has more clearly shown that trans fat increases the risk of cardiovascular disease, through adverse effects on lipids, endothelial function, insulin resistance, and inflammation. Every 2% of calories consumed from trans fat was associated with a 23% higher CAD risk (RR 1.23, 95% CI 1.11-1.37).
  • A 2016 systemic review revealed that soft drinks and sweetened beverages were associated with a 22% higher risk of myocardial infarction.
  • A 2014 prospective cohort study revealed a 30% and 175% higher chance of cardiovascular disease mortality in the groups who consumed 10 to 24.9% (adjusted hazard ratio 1.30, 95% CI 1.09-1.55) and 25% (adjusted hazard ratio 2.75, 95% CI 1.40-5.42) more calories from added sugar compared with those who consumed less than 10% calories from added sugar. High fructose corn syrup, sucrose, and table sugar have also been reported to play a significant component in coronary artery disease.
  • More recent studies and systematic review articles have focused on red and processed meat consumption.  These articles have revealed a consistently higher risk of coronary heart disease and cardiovascular events ranging from 15 to 29% higher risk with red meat and 23 to 42% higher risk with processed meat consumption.  Most studies included approximately 50 to 100 grams per day of consumption.Only one of these review articles revealed no significant association between red meat and coronary heart disease (4 studies, RR 1.00 per 100 gram serving per day, 95% CI 0.92-1.46, P=0.25). One article indicated no significant association between processed meats and overall mortality, however, added that the combined intake of red and processed meats was associated with a 23% higher risk (HR 1.23, 95% ci 1.11-1.36) of overall mortality.

Sedentary lifestyle

  • Exercise is a protective factor in preventing the development of CAD. A 2004 case-control study performed in 52 countries, representing all continents, and involving 15,152 cases and 14,820 controls revealed a population attributable risk of 12.2% that physical inactivity has on myocardial infarction.
  • Several observational studies have shown that individuals who self-select for exercise have lower morbidity and mortality.  Mechanisms for this include enhanced production of endothelial nitrous oxide, more effective deactivation of reactive oxygen species, and improved vasculogenesis.

In addition to these traditional cardiovascular risk factors, novel risk factors have also been subject to research.  These include:

Non-alcoholic fatty liver disease (NAFLD)

  • NAFLD has links to cardiovascular disease.  It is also the most common chronic liver disease in developed countries.
  • A 2017 meta-analysis revealed a 77% higher risk (RR 1.77, 95% CI 1.26-2.48) of cardiovascular events and over double the risk (RR 2.26, 95% CI 1.04-4.92) for coronary artery disease in NAFLD patients.
  • A more recent prospective study revealed that NAFLD patients had greater than double the risk of cardiovascular events.  Patients with liver fibrosis had a four-fold increase.

Chronic kidney disease (CKD)

  • CKD has been reported as an independent risk factor for coronary artery disease. Pro-inflammatory mediators, oxidative stress, and decreased nitric oxide production leading to endothelial dysfunction have been reported as possible mechanisms. Silent myocardial infarctions occur more commonly, likely due to the higher incidence of diabetic and uremic neuropathy in CKD patients.
  • CKD, with a GFR of 15-59, is noted as a risk enhancing factor in the American Heart Association Guideline for the Primary Prevention of Cardiovascular Disease.

The systemic lupus erythematosus (SLE)

  • The most common cause of mortality in SLE is cardiovascular disease. There is also a higher prevalence of the atherosclerotic cardiovascular disease in these patients. The mechanism is likely a pro-inflammatory effect on coronary microcirculation.
  • Pericarditis is a common manifestation of SLE. One case report stated that pericarditis is the most common cardiac manifestation of SLE.

Rheumatoid arthritis (RA)

  • Estimates are that RA patients have a 1.5 to 2.0 fold increased risk of coronary artery disease.   Traditional risk factors such as body mass and lipoprotein levels also showed more unpredictable patterns in their predictive accuracy.  The mechanism behind this associated risk is likely through a pro-inflammatory effect.
  • Rheumatoid arthritis is also listed among the risk enhancing factors in the American Heart Association Guideline for the Primary Prevention of Cardiovascular Disease.

Inflammatory bowel disease (IBD)

  • A 2017 meta-analysis noted that IBD is associated with a higher risk of coronary artery disease. However, the results were interpreted with caution due to the heterogeneity of the studies. The mechanism of the risk was uncertain, but again, it was thought to be due to a chronic inflammatory state.

Human immunodeficiency virus (HIV)

  • HIV is understood to come with a higher risk of cardiovascular disease and its associated sequelae.
  • A 2018 expert analysis from the American College of Cardiology noted that HIV patients showed a 1.5 to 2-fold increased risk of coronary artery disease. The mechanism, again, was based on a pro-inflammatory state.

Thyroid disease

  • The thyroid gland intricately links to cardiovascular function. Proposed mechanisms include the effect of thyroid hormone on dyslipidemia, cardiac function, atherosclerosis, vascular compliance, and cardiac arrhythmias; this is an area still under study. Guidelines also vary on their screening recommendations for thyroid disease, hypothyroidism, and subclinical hypothyroidism.

Testosterone

  • In 2014, the FDA released a required labeling change for low testosterone products for the use of low testosterone due to aging, due to a possible increased risk of heart attack and stroke.  Subsequent studies and reviews have not been consistent in this correlation.  Some reviews have even indicated a potential beneficial cardiovascular effect when treating low testosterone with testosterone supplementation. Further study is needed to provide more clarity on this specific topic.
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Vitamin D

  • Vitamin D has been increasingly studied and debated over the past decade. Vitamin D deficiency has a link with an increased risk of coronary artery disease. Further studies, however, have not confirmed a beneficial effect on Vitamin D supplementation. Further studies are needed to clarify whether Vitamin D supplementation is truly beneficial for coronary artery disease prevention.

Socioeconomic status

  • Socioeconomic status is a significant risk factor for cardiovascular disease. Upstream determinants include financial strain, lack of affordable and nutritious food, exposure to domestic violence, and inadequate housing; this is an important consideration to consider given existing cardiovascular disease risk equations do not capture this.

Women and coronary artery disease (CAD)

  • Although men are at higher risk than women of coronary artery disease, it is still the leading cause of death among women.  Among women, only 54% were aware of this in 2009. Cardiovascular disease caused approximately 1 in 3 female deaths. Women were found to have non-obstructive CAD in 57% of cases, in contrast to men who more commonly had obstructive CAD. Proposed mechanisms for this include coronary microvascular dysfunction (CMD), altered endothelial tone, structural changes, and altered response to vasodilator stimuli. Estrogen is thought to have a protective role in coronary vasoreactivity and is also theorized to promote plaque stabilization via an anti-inflammatory effect on atherosclerosis.
  • Lack of awareness and understanding of coronary artery disease in women has also led to a disparity in health outcomes. There has been more focus on obstructive CAD and men compared to women. One 2012 article reported a decrease in CAD mortality across all age groups in men and an increase in CAD mortality among young women (< 55 years old).

Symptoms of Coronary Artery Disease

  • Chest pain (angina) – You may feel pressure or tightness in your chest as if someone were standing on your chest. This pain, called angina, usually occurs on the middle or left side of the chest. Angina is generally triggered by physical or emotional stress. The pain usually goes away within minutes after stopping the stressful activity. In some people, especially women, the pain may be brief or sharp and felt in the neck, arm or back.
  • Shortness of breath – If your heart can’t pump enough blood to meet your body’s needs, you may develop shortness of breath or extreme fatigue with activity.
  • Heart attack – A completely blocked coronary artery will cause a heart attack. The classic signs and symptoms of a heart attack include crushing pressure in your chest and pain in your shoulder or arm, sometimes with shortness of breath and sweating.
  • Chest discomfort (angina)
  • Weakness, light-headedness, nausea (feeling sick to your stomach), or a cold sweat
  • Pain or discomfort in the arms or shoulder
  • Faster heartbeat
  • Nausea
  • Palpitations (irregular heartbeats, skipped beats, or a “flip-flop” feeling in your chest)

Diagnosis of Coronary Artery Disease

Your cardiologist (heart doctor) can tell if you have coronary artery disease by

  • talking to you about your symptoms, medical history, and risk factors
  • performing a physical exam
  • performing diagnostic tests

Diagnostic tests help your doctor evaluate the extent of your coronary heart disease, its effect on the function of your heart, and the best form of treatment for you. They may include:

  • Electrocardiograph tests – such as an electrocardiogram (ECG or EKG) or exercise stress tests, use the electrocardiogram to evaluate the electrical activity generated by the heart at rest and with activity.
  • Laboratory Tests –  include a number of blood tests used to diagnose and monitor treatment for heart disease.
  • Invasive testing – such as cardiac catheterization, involves inserting catheters into the blood vessels of the heart in order to get a closer look at the coronary arteries.
  • Echocardiogram – An echocardiogram uses sound waves to produce images of your heart. During an echocardiogram, your doctor can determine whether all parts of the heart wall are contributing normally to your heart’s pumping activity.
  • Exercise stress test – If your signs and symptoms occur most often during exercise, your doctor may ask you to walk on a treadmill or ride a stationary bike during an ECG. Sometimes, an echocardiogram is also done while you do these exercises. This is called a stress echo. In some cases, medication to stimulate your heart may be used instead of exercise.
  • Nuclear stress test – This test is similar to an exercise stress test but adds images to the ECG recordings. It measures blood flow to your heart muscle at rest and during stress. A tracer is injected into your bloodstream, and special cameras can detect areas in your heart that receive less blood flow.
  • Cardiac catheterization and angiogram – During cardiac catheterization, a doctor gently inserts a catheter into an artery or vein in your groin, neck or arm and up to your heart. X-rays are used to guide the catheter to the correct position. Sometimes, dye is injected through the catheter. The dye helps blood vessels show up better on the images and outlines any blockages.
  • Cardiac CT scan – CT scan of the heart can help your doctor see calcium deposits in your arteries that can narrow the arteries. If a substantial amount of calcium is discovered, coronary artery disease may be likely.
  • CT coronary angiogram – in which you receive a contrast dye that is given by IV during a CT scan, can produce detailed images of your heart arteries.

Other diagnostic tests may include

  • Nuclear Imaging – produces images by detecting radiation from different parts of the body after the administration of a radioactive tracer material.
  • Ultrasound Tests – such as echocardiogram use ultrasound, or high-frequency sound wave, to create graphic images of the heart’s structures, pumping action, and direction of blood flow.
  • Radiographic Tests  – use x-ray machines or very high tech machines (CT, MRI) to create pictures of the internal structures of the chest.
  • Tests used to predict increased risk for coronary artery disease include – C-reactive protein (CRP), complete lipid profile, and calcium score screening heart scan.

New CAD screening tests of Coronary Artery Disease

Coronary artery calcium (CAC) score

  • CAC is an established non-invasive screening test for coronary artery disease.  It involves a non-contrast CT of the heart, and totals identified coronary artery calcium, a component of atherosclerosis.
  • A large prospective cohort study found that CAC improved the detection of at-risk patients for having a coronary event to better match statin therapy with appropriate patients.
  • The 2019 AHA/ACC primary prevention guideline recommends CAC for those who are at intermediate-risk (10-year >/=7.5% to <20%) or selected borderline risk (10-year ASCVD risk 5-<7.5%) patients.  CAC score can help patients who desire more information before starting pharmacotherapy.  If the CAC score is zero, then the patient does not require a statin as long as the patient does not smoke, have diabetes mellitus, or have a family history of premature clinical ASCVD.  If CAC is 1 to 99,  a statin is favored in patients aged 55-years old and greater.  If the CAC is 100 or in the 75th percentile or higher, then statin treatment is favored.
  • The 2017 SCCT (Society of Cardiovascular Computed Tomography) guideline recommends shared-decision making and CAC consideration for those who are 5 to 20% 10-year ASCVD risk or < 5% 10-year ASCVD risk who have another strong indication such as those with a family history of premature CAD.

Carotid intimal medial thickness (CIMT)

  • CIMT is another proposed tool for non-invasive risk stratification for CAD. This assessment is accomplished predominantly by ultrasound, but may also use MRI. There has been conflicting data from several large studies regarding this modality, most likely due to non-standard image acquisition and analysis as well as study design differences.
  • A 2012 meta-analysis combining CIMT and Framingham Risk Score (FRS) did not substantially improve risk prediction.
  • The AHA/ACC changed its stance from class IIa recommendation for its use in intermediate-risk patients in 2010 to recommend against its use in a 2013 update.
  • More recently, a 2017 observational multi-ethnic study of atherosclerosis (MESA) found that the combination of CIMT and positive CAC improved prediction of cardiovascular risk.

Flow-mediated dilation (FMD) and endothelin function

  • FMD is another proposed test that can potentially predict cardiovascular risk by measuring the health of blood vessel endothelial function. Physiologic and pharmacologic stress, such as hypertension, smoking, or certain medications, can alter this.
  • There are different methods to measure FMD. Protocols involving vasoactive agents via coronary catheterization is a more direct measurement of the coronary artery endothelial function, more specifically referred to as coronary flow reserve (CFR).
  • Brachial artery flow-mediated dilation and reactive hyperemia-peripheral arterial tonometry (RH-PAT) are more peripheral measurements. A 2015 meta-analysis conferred that these two methods demonstrated similar prognostic value on cardiovascular outcomes. Additional research is necessary to determine whether this screening strategy can improve cardiovascular outcomes.

Novel biomarkers

  • A 2017 article reviewed novel potential biomarkers for CAD, such as fibrinogen, hs-CRP, Lipoprotein-associated PA2, Lipoprotein A, hs-troponin, NT-proBNP, and Cystatin C.  None met all necessary criteria to be considered an ideal biomarker.

Treatment of Coronary Artery Disease

Self-management

Because angina can be triggered by physical exertion, anxiety or emotional stress, cold weather, or eating a heavy meal, the following behavioral changes may help to alleviate angina symptoms:

  • rest as soon as you feel symptoms coming on
  • pace yourself and take regular breaks
  • reduce and manage stress
  • keep warm
  • avoid eating large meals.
  • stop smoking and avoid second-hand smoke and avoid second-hand smoke
  • control high blood pressure or high blood cholesterol levels
  • exercise moderately and regularly, especially healthy heart exercise (always consult a health professional before commencing a new exercise regime)
  • maintain a healthy weight
  • eat a healthy heart diet
  • manage diabetes
  • avoid drinking alcohol or do so in moderation.
  • Lifestyle changes
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Medication

Various drugs can be used to treat coronary artery disease, including:

  • Cholesterol-modifying medications – These medications reduce (or modify) the primary material that deposits on the coronary arteries. As a result, cholesterol levels — especially low-density lipoprotein (LDL, or the “bad”) cholesterol — decrease. Your doctor can choose from a range of medications, including statins, niacin, fibrates, and bile acid sequestrants.
  • Aspirin – Your doctor may recommend taking a daily aspirin or another blood thinner. This can reduce the tendency of your blood to clot, which may help prevent obstruction of your coronary arteries. If you’ve had a heart attack, aspirin can help prevent future attacks. But aspirin can be dangerous if you have a bleeding disorder or you’re already taking another blood thinner, so ask your doctor before taking it.
  • Beta-blockers – These drugs slow your heart rate and decrease your blood pressure, which decreases your heart’s demand for oxygen. If you’ve had a heart attack, beta-blockers reduce the risk of future attacks.
  • Calcium channel blockers – These drugs may be used with beta-blockers if beta-blockers alone aren’t effective or instead of beta-blockers if you’re not able to take them. These drugs can help improve symptoms of chest pain.
  • Ranolazine – This medication may help people with chest pain (angina). It may be prescribed with a beta-blocker or instead of a beta-blocker if you can’t take it.
  • Nitroglycerin –  Nitroglycerin tablets, sprays and patches can control chest pain by temporarily dilating your coronary arteries and reducing your heart’s demand for blood.
  • Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) – These similar drugs decrease blood pressure and may help prevent the progression of coronary artery disease.
  • Anti-platelet therapy – Clopidogrel plus aspirin (dual antiplatelet therapy) 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.[rx] Specifically, its use does not change the risk of death in this group.[rx] In those who have had a stent, more than 12 months of clopidogrel plus aspirin does not affect the risk of death.[rx]
  • Angiogenesis – For this treatment, you’ll get stem cells and other genetic material through your vein or directly into your damaged heart tissue. It helps new blood vessels grow and go around the clogged ones
  • EECP (enhanced external counterpulsation) – People who have chronic angina but haven’t gotten any help from nitrate medications or don’t qualify for some procedures may find relief with this. It’s an outpatient procedure — one where you won’t need to be admitted to the hospital — that uses cuffs on the legs that inflate and deflate to boost blood supply to your coronary arteries.

Surgery

  • 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.[rx] In those with the disease in more than one artery, coronary artery bypass grafts appear better than percutaneous coronary interventions.
  • Newer “an aortic” or no-touch off-pump coronary artery revascularization techniques have shown reduced postoperative stroke rates comparable to percutaneous coronary intervention.[rx] Hybrid coronary revascularization has also been shown to be a safe and feasible procedure that may offer some advantages over conventional CABG though it is more expensive.[rx]

Home Remedies For Coronary Artery Disease

Many people use home remedies, which have been in use for many centuries. Some of these remedies are ideal for the treatment of angina as well as common heart problems. Angina is a very serious problem and you need to visit your doctor for treatment but you can follow these home remedies to support the treatment.

  • Lemon – many people find that lemon juice is an effective treatment of angina. This is because lemon juice eliminates and stops cholesterol accumulation in the blood vessels.
  • Garlic – this is a beneficial well-being food, which helps in the effective treatment of a variety of health problems including angina. This food also minimizes the effect of an angina attack on a patient.
  • Grapefruit – This natural tonic improves the functions of the heart. Many people include grapefruits in their diet to help in curing angina.
  • Basil leaves – many home remedies have basil leaves as a major ingredient. Basil leaves can also be used to make a remedy for angina pectoris. These leaves are chewable and may be taken in the morning. This may help an angina sufferer to minimize the effects of the disorder.
  • Lemon with Honey – Take a glass of warm water and squeeze a half-cut slice of lemon and add one teaspoon of honey. Mix it together and drink it before the first thing in the morning.
  • Onion – Onion juice is also very effective for angina suffering person. Take onion juice in the morning. It reduces bad cholesterol in the blood and helps to deliver proper blood supply to the heart.
  • Parsley tea – Taking parsley tea or beetroot juice two times in a day is very effective in the treatment of angina.
  • Diet Change –  Increase fruits and vegetables in your daily diet as they are very essential to avoid any type of cardiovascular disease.

Homeopathic Medicines Of Coronary Artery Disease

The following homeopathic remedies more often administered for the treatment of angina pectoris:

  • Aconite – unexpected episodes of angina with a sharp pain behind the sternum radiating to the left arm and shoulder, pulse big, rapid, bouncing, and hard, severe agitation with congested sensation behind the sternum.
  • Bryonia Alba – you can compare this pain to pins and needles with a scratching component inside the thoracic cage, intensified by any movements, and improved by relaxation while lying on the left side.
  • Digitalis – feeling that the heart stops, and the heart rate diminishes. Digitalis patients report improvement at rest and deterioration of symptoms on movement.
  • Lachesis – shooting chest pain, that radiates up to the throat. These patients never wear any turtleneck sweaters. Men hate ties. I will not administer Lachesis if a patient does not complain about bruises that suddenly appear on different parts of a body without any reason.
  • Crataegus – chest pain radiating to the left clavicle. Pulse is weak and fast, arrhythmia, Fingernails, and Toenails are bluish.
  • Glonoinum – intense palpitation, which radiates in all directions and throbbing in head, torso, arms, and legs.
  • Amyl nitrate – heart rate is fast accompanied by a sensation of a band around the head; breathing is difficult with the sensation of the spasm in the heart area.
  • Naja – severe chest pain, radiating to the nape of the neck, heart rate is slow, arrhythmia, trembling and palpitation
  • Spigelia – sharp chest pain with the feeling of compression behind the sternum radiates down the left arm to about the level of the pinky finger. Acts well in smokers and drunkards
  • Arsenic Album – is an outstanding homeopathic medicine for angina pectoris with intense, excruciating chest pain. This pain aggravates in bed especially if an individual is lying face up. The pick of this pain usually takes place after 12 AM and especially between 1:00 AM and 3:00 AM.
  • Cimicifuga – I would prescribe this homeopathic remedy to women only if the patient reports a sudden cease of heartbeat accompanied by intense chest pain. Traditionally Cimicifuga is a medicine for women who have some disorders in their reproductive system. The Materia Medica description of this medicine clearly states “Cherchez la femme” – French expression for “look for the woman.” In my understanding of the homeopathic philosophy, this remedy will perfectly fit any form of angina pectoris in a woman with GYN issues.
    Veratrum album – is especially effective when the heartbeat ceases in tobacco chewers. This symptom is usually co-existed by the hasty breath.
  • Lilium Tigrinum – severe chest pain radiates to the RIGHT arm (this is not a typo, RIGHT ARM is a special property for Lilium). Patients report a pounding feeling all over the body with the signs of choking. Considering a constitutional approach in homeopathic medicine, I prescribe Lilium Tigrinum only to sexually-oriented women. Yes, this is a very important constitutional property for Lilium – these women love sex and always want it.
  • Argentum Nitricum – a very useful homeopathic drug for patients who report episodes of angina after a meal. Other constitutional properties for Argentum nitricum are very fast speech and sudden cravings for sweets.
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Clinical Significance of Coronary Heart Disease

Hypertension

  • The United States Preventive Services Task Force (USPSTF) gives a grade A recommendation for universal screening for hypertension in patients greater than 18 years of age and a grade I (current evidence insufficient) recommendation for screening for children and adolescents.
  • A systolic and diastolic blood pressure reduction of greater than 10mmHg and 5mmHg, respectively, led to a significant absolute risk reduction in CAD-related events (NNT 91).
  • A systolic blood pressure reduction to a goal of 130mmHg reduced the incidence of CAD (NNT 27).
  • A 2002 meta-analysis revealed that systolic blood pressure reduction of 20mmHg and diastolic blood pressure reduction of 10mmHg decreases the risk of death from coronary heart disease by about 50% between ages 40 to 49 and by about 1/3 between ages 80 to 89.

Hyperlipidemia

  • The USPSTF recommends evaluation for statin use for the primary prevention of cardiovascular disease between 40 to 75 years of age. The USPSTF gives a grade I (current evidence insufficient) recommendation for routine screening for lipid disorders in children and adolescents.
  • In 2011, the National Heart, Lung, and Blood Institute (NHLBI) recommended universal screening between 9 to 11 years of age and again at 17 to 21 years of age.  The American Academy of Pediatrics subsequently endorsed this.  Despite the publication of these guidelines, pediatric lipid screening practice patterns have not followed suit.
  • An early 1994 review showed that a 10% reduction in serum cholesterol leads to a 50%, 40%, 30%, and 20% drop in CAD risk at age 20, 50, 60, and 70, respectively.
  • The Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) study demonstrated that statins reduce the risk of major cardiovascular events. Treatment with a moderate-intensity statin resulted in a CAD absolute risk reduction of 2.7% (NNT 37). Treatment with a high-intensity statin resulted in a 4.1% absolute risk reduction (NNT 24).

Diabetes

  • The USPSTF recommends screening for abnormal glucose in patients aged 40 to 70 years old who are overweight or obese.  Early screening for diabetes can also be a consideration for patients in higher-risk groups. This risk pool includes patients with a family history of diabetes, history of gestational diabetes or polycystic ovarian syndrome, or members of specified racial/ethnic groups (African Americans, American Indians, Alaskan Natives, Asian Americans, Hispanics or Latinos, Native Hawaiians or Pacific Islanders).
  • The American Diabetes Association states that three years is a reasonable screening interval.
  • A 2019 meta-analysis of 12 cardiovascular outcomes trials indicated that a 0.5% reduction in A1C conferred a 20% hazard risk reduction (95% CI 4-33%) for major cardiovascular events.  This analysis included patients on peptidase-4 inhibitors, GLP-1 agonists, and SGLT-2 inhibitors.

Diet

  • The DASH, Mediterranean, and vegetarian diets have the most evidence for cardiovascular disease prevention.
  • The DASH diet can reduce systolic blood pressure up to 11.5 mmHg in adults with hypertension. A 2013 meta-analysis and systematic review revealed a 21% coronary artery disease risk reduction (RR 0.79, 95% CI 0.71-0.88) with the DASH diet.
  • A 2017 meta-analysis and systematic review revealed an 8% risk reduction (15 studies, RR 0.92, 95% CI 0.90-0.95) of coronary artery disease for every 200 grams per day of fruits and vegetables. This effect was observable at up to 800 grams per day.
  • A 2016 meta-analysis and systematic review revealed a 29% risk reduction (29 studies, RR 0.71, 95% CI 0.63-0.80) of coronary artery disease for every 28 grams per day of nut consumption.
  • A 2017 narrative review revealed a decreased risk of about 20 to 25% with the Mediterranean diet on cardiovascular disease. It was also showed positive effects on endothelin function, arterial stiffness, and cardiac function.
  • The American Heart Association recommends the replacement of saturated fat with polyunsaturated and monounsaturated fats. A 5% exchange in saturated fat consumption with polyunsaturated fat is associated with a 10% lower CAD risk (RR 0.90, 95% CI 0.83-0.97). As noted above, a 2018 review, however, challenged the strength of the traditional link between saturated fat and higher CAD risk, compared to other nutrients. In a separate review, the lack of a significant association between saturated fat and cardiovascular disease was due to studies replacing saturated fat with highly refined carbohydrates.  If saturated fats were replaced by polyunsaturated fat, then coronary heart disease is indeed reduced.
  • While it is challenging to carry out research relating to diet practices and coronary artery disease, much research has taken place in the past. The AHA/ACC guidelines recommend a diet consisting mostly of vegetables, fruits, legumes, nuts, whole grains, and fish. Dietary intake of processed meats, refined carbohydrates, and sweetened beverages should be reduced, while avoiding trans fats altogether. Saturated fats should be replaced with polyunsaturated and monounsaturated fats.
  • The USPSTF recommends offering or referring adults who are obese/overweight and have one additional cardiovascular risk factor intensive behavioral counseling to promote a healthful diet and physical activity (Grade B).  The USPSTF also recommends individualizing the decision to offer or refer patients without obesity or other cardiovascular risk factors for behavioral counseling.

Smoking

  • The USPSTF recommends screening for tobacco use in all adults with each clinical encounter and to provide behavioral and pharmacologic smoking cessation interventions. The USPSTF also recommends educating children and adolescents about the risks of smoking to prevent the initiation of tobacco use.
  • The American Heart Association recommends a combined behavioral and pharmacologic approach to maximize quit rates.
  • The risk of coronary artery disease drops to a level of lifetime nonsmokers within four years of quitting, according to the FDA, and within ten years, according to the CDC.
  • Behavioral interventions include motivational interviewing (Ask, Advise, Assess, Assist, Arrange for follow-up).
  • Pharmacologic interventions such as nicotine replacement therapy, varenicline (Chantix), and bupropion (Wellbutrin) reduce cravings and withdrawal symptoms.
  • A 2014 Cochrane review revealed that nicotine replacement therapies, such as nicotine gum and the nicotine patch increased the chances of smoking cessation by 49% (55 trials, RR 1.49, 95% CI 1.40-1.60) and 64% (43 trials, RR 1.64, 95% CI 1.52-1.78), respectively. The nicotine oral tablets/lozenges (6 trials, RR 1.95, 95% CI 1.61-2.36), inhaler (4 trials, RR 1.90, 95% CI 1.36-2.67), and nasal sprays (4 trials, RR 2.02, 95% CI 1.49-2.73) approximately doubled the chances of success.  The combination of bupropion and nicotine replacement therapy increased the likelihood of success by 24% compared to bupropion alone (4 trials, RR 1.24, 95% CI 1.06-1.45).
  • Varenicline doubled the chances of smoking cessation. There have been rare reports of neuropsychiatric adverse effects with varenicline.  The FDA removed this black box warning in 2016 after noting that the risk was lower than expected.
  • A 2014 Cochrane review showed that bupropion increases the chances of smoking cessation by 62% (44 trials, N=13,728, RR 1.62, 95% CI 1.48-2.78).
  • A 2016 Cochrane review indicated that the combined use of behavioral support and pharmacotherapy had a higher chance of success.

Obesity

  • A patient’s body mass index (BMI) should be measured at each clinical encounter. The USPSTF recommends that practitioners offer obese adults a referral to a multicomponent behavioral interventionist.
  • There is a large amount of evidence showing that in obese or overweight patients, even just a modest 5% body weight loss can lead to clinically significant health benefits.

Exercise

  • The USPSTF recommends patients who are overweight, obese, or have CAD risk factors to intensive behavioral counseling for interventions to promote physical activity for the prevention of CAD.
  • According to the National Health Interview Survey, only 20.9% of adults met the 2008 federal physical activity guidelines for aerobic and strengthening activity.
  • Approximately 150 minutes per week of moderate-intensity aerobic activity reduces the risk of cardiovascular disease. Moderate-intensity aerobic exercise is defined as 50 to 70 percent of the patient’s maximum heart rate (220 beats per minute minus the patient’s age).  Any amount of physical activity has shown to have benefits in reducing CAD risk. The most active patients have an approximately 35 to 40 percent risk reduction for coronary artery disease.
  • The AHA/ACC guidelines also recommend resistance strength training to be incorporated into regular physical activity, as this can help improve physical function and ability to exercise.

Aspirin in primary prevention

  • Aspirin has long played a role in atherosclerotic cardiovascular disease prevention.  Although still established for secondary prevention, its use in primary prevention has more recently come into question due to a less favorable risk-benefit ratio .  Recent evidence suggested a more tailored approach to the use of aspirin .
  • The USPSTF recommends aspirin for patients age 50 to 59 years of age, with a 10-year atherosclerotic cardiovascular disease risk, and do not have bleeding risk factors. Aspirin may be considered for those 60 to 69 years of age but may have less overall benefit and higher bleeding risk.

References

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