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Coronary Artery Disease
The coronary arteries are the blood vessels that supply the heart with oxygen and nutrients. When there is build up of cholesterol (plaque) inside the walls of the coronary arteries, the blood flow to the heart decreases. Usually there are no symptoms when the blockage is small. Chest pain (angina) can develop when the blockage becomes severe. A heart attack develops when plaque in the artery breaks and a clot forms. This completely blocks the flow of blood in the artery. The area of heart muscle supplied by that artery then becomes damaged due to lack of oxygen and nutrients. Blockages of any size can cause a heart attack (myocardial infarction).Coronary artery disease is very common throughout the world. Coronary artery disease is the number one killer of men and women in the US. You may be at risk for developing coronary artery disease if you have any of these risk factors:
- Advanced age
- Family history of early heart disease in a first degree relative (onset of disease before age 55 in men, before age 65 in women)
- High blood pressure
- High cholesterol
- Diabetes Mellitus
- Smoking
- Physical inactivity
- Obesity (especially if fat is concentrated around the waist)
- Poor diet
The figures above show the inside of a blood vessel. The inside of the blood vessel is like a pipe which carries blood to different parts of the body. The figure on the left shows a normal blood vessel that has no blockages. The figure on the right shows an artery with a severe blockage that prevents normal flow of blood.
Symptoms
Coronary artery disease at its early stages may have no symptoms. As blockages become more severe or if a heart attack occurs, the following symptoms may develop:
- Chest discomfort (may be located in the center of the chest, in the arms, in the jaw or in the back).
- Shortness of breath
- Fatigue
- Nausea
- Sweating
- Difficulty with exercise
Diagnosis
There are a variety of tests available to evaluate individuals with known or suspected coronary artery disease. A discussion with your doctor is the best way to determine which test is best for you.
A resting echo can show areas of damage to the heart muscle due to a heart attack. The echo can also show how well the heart muscle is working before and after exercise. The test will be abnormal in the presence of severe blockages. For patients that cannot exercise, the echo can also be used in combination with an IV medication that mimics exercise.
Treatment
A stress echo is designed to detect blockages when they are severe. Therefore, patients with mild coronary artery disease or no coronary artery disease may have normal stress echo results. In these cases, attention should be paid to reducing risk factors. A detailed discussion about the results with your doctor is important. A positive stress echo usually means that severe blockages are present in the coronary arteries. There are several treatments available for this condition, including:
- Medications
- Angioplasty and stents
- Bypass surgery
Hypertension
Hypertension is high blood pressure and is defined when your blood pressure is higher than normal for an extended period of time. When the heart muscle contracts blood is squeezed out of the heart and flows through the blood vessels or arteries which travel to the rest of your body. As blood flows it pushes against the wall of the artery creating pressure. The more pressure the blood places on the artery wall the higher the blood pressure will be.
Blood pressure is measured by placing an inflatable cuff (sphygmomanometer) around your upper arm. The cuff is inflated and then air is slowly released and the person performing the test will listen to your pulse. The report generally will include two numbers a systolic and diastolic pressure measured in millimeters of mercury (e.g. 120/80 mmHg). The first number is the systolic blood pressure. This pressure is generated when the heart is actively contracting and blood is being forced into your arteries. Following a contraction there is a period of relaxation allowing the heart to fill with blood in preparation for the next contraction. During this period of relaxation blood pressure is at its lowest and this is recorded as the diastolic blood pressure, the second number recorded.
A normal blood pressure is <120/80 mmHg. High blood pressure occurs when the average of two or more readings on two or more separate days is >140/90 mmHg. Those with a blood pressure of 120-139/80-89 mmHg are characterized as having “prehypertension” and are at increased risk for developing hypertension.
Symptoms
Hypertension is often referred to as the “silent killer” disease as most patients with hypertension are completely unaware and its presence can result in problems for your heart, brain, kidneys and/or other organs. Symptoms that can be associated with hypertension include headaches, dizzy spells, blurry vision and more frequent nosebleeds.
Causes
In approximately 90-95% of adults with hypertension there is no identifiable cause. This type of hypertension is called essential or primary hypertension. Essential hypertension tends to develop gradually over many years. The other 5-10% of individuals with hypertension is classified as having secondary hypertension. This means that their hypertension is “secondary” or caused by a specific underlying disorder. This disorder generally involves a specific organ or blood vessel.
Some causes of secondary hypertension:
- kidney disease (renal hypertension)
- adrenal gland tumors
- sleep apnea
- thyroid and parathyroid disease
- coarctation of the aorta
- certain medications
Tests
Once you have been diagnosed with high blood pressure you will often undergo a few routine tests which include blood and urine testing along with an electrocardiogram (ECG). Your doctor may suggest that you have an echocardiogram or heart ultrasound examination. The echocardiogram is very useful in the evaluation of the hearts structure and function along with an assessment of the major arteries all of which can be adversely affected by hypertension.
Treatment
The treatment of hypertension and blood pressure goals are dependent on how healthy you are. In general the goal is to lower blood pressure to <140/90 mmHg, if one has diabetes or kidney disease this target is lowered to <130/80 mmHg. There are three basic strategies employed in an attempt to reach these targets:
- Lifestyle modifications: This includes weight reduction in those who are overweight, dietary modification which in general is a diet rich in potassium and calcium along with salt reduction, moderation of alcohol consumption, and physical activity.
- Medications: When lifestyle modifications are not enough your doctor may prescribe a medication(s) to help achieve a desired target. There are many classes of medications that are used in the treatment of hypertension and type of medication used can depend on what other problems may coexist. It is important to recognize that most patients will require two or more medications to achieve their blood pressure goals.
- Treating the underlying cause: If one is diagnosed with secondary hypertension then treatment is often directed at trying to correct this underlying cause.
Peripheral Arterial Disease (PAD)
PAD is a common disorder that occurs in the circulatory system, also referred to as poor circulation, hardening of the arteries, and atherosclerosis. Atherosclerosis is a build-up of fat, cholesterol, minerals, blood and muscle cells which cause narrowing within the arterial walls known as “plaque”. The arteries function to carry oxygen rich blood away from the heart to all parts of the body including the brain, intestine; kidney’s, arms and legs. Over time plaque build-up hardens within the arterial walls narrowing the channel of the arteries. This narrowing limits the blood flow. In addition, blood clots can form around the plaques. The plaque or clot can rupture or tear away from the vessel wall and travel too smaller arteries where it may totally block the blood flow. Severe atherosclerosis may block an artery causing” ischemia”, which is a restriction in oxygen rich blood supply to a muscle group, tissue, or organ. Two common results of ischemia are heart attacks and stroke.
The “periphery” refers to all the vessels outside of the heart and brain. Atherosclerosis can occur in any artery within the body but is most commonly referred as PAD when it is in the legs or less commonly the arms. As plaque worsens the arteries in the legs slowly become more narrowed reducing blood flow to the muscles and skin of the legs. This reduction of blood causes muscle pain and cramping especially during exercise when the demand for oxygen is greatest. Cramping, muscle fatigue, and pain in the legs caused by PAD during exercise is usually predictable and reproducible, and is relieved with rest.
The figures above show the inside of a blood vessel. The inside of the blood vessel is like a pipe which carries blood to different parts of the body. The figure on the left shows a normal blood vessel that has no blockages. The figure on the right shows an artery with a severe blockage that prevents normal flow of blood.
Causes
Smoking, high cholesterol, high blood pressure, diabetes, a family history of cardiovascular disease and aging are all related risks associated with PAD. The number one risk is smoking. Tobacco is very harmful to the circulatory system. Smoking releases nicotine into the arterial system which causes the vessels to narrow, or restrict, leaving a smaller channel for the blood to travel and also increases the risk of clot formation. Smoking also reduces the amount of oxygen found in the blood.
Symptoms
Initial symptoms may include a heavy feeling in the legs, fatigue, weakness or numbing of the legs and feet. Hair loss, cold legs or feet, changes of skin color, paleness or blueness and in severe cases a loss of the pulse. Ulcers and sores that do not heal can also be associated with PAD. In the earliest development of PAD there may be no related symptoms. The most common, and first noticeable symptom is painful cramping of the leg muscles during walking or exercise which is relieved with rest. This is known as intermittent claudication. The cramping or leg pain is usually predictable and can be easily reproduced. Moderately advanced stages of PAD can cause foot pain at rest or even wake and individual up from a deep sleep. Standing up right or sitting with the legs over the side of the bed often relieves the pain as circulation is restored by the effects of gravity.
Testing
The ankle brachial index or ABI is easily performed in the doctor’s office. The feet and legs should be warm, and the patient should be resting for a period of 10-15 minutes. Blood pressure cuffs are placed on the ankle and arm and the systolic blood pressure pulse is recorded. The doctor or technician may use a small pencil like stethoscope to hear the pulse.
Treadmill testing predicts how severe the blockage is and how much exercise is required to bring on the symptoms, and how long they take to go away with rest. An ABI may be performed before the treadmill test and then again immediately after.
Doppler ultrasound is a test that uses sound waves to show whether a blood vessel is blocked. This test also uses a blood pressure cuff and a probe similar to the pencil stethoscope to measure blood flow in the arteries of the legs, feet or arms. Waveforms recorded with the Doppler ultrasound can help indicate the location and the severity of the disease. Further testing with Duplex ultrasound would include imaging of the arteries at the same time the Doppler waveforms are recorded. Blood test may be performed to check for cholesterol levels and diabetes.
An arteriogram is a test in which a catheter or tube is placed into your artery in the lag and a dye is injected through the tube producing and image or a “roadmap” of the arteries, which can be seen with the help of an X-ray. This test can identify the exact location, and the severity of the plaque or occlusion. The arteriogram can also determine if surgical or a less invasive treatment is necessary.
Treatment
This more than likely will involve lifestyle modifications.
- If you smoke, quit immediately. Studies have shown that smoking increases the risk of developing PAD by 4 times. Smoking also increases your chances of developing coronary heart disease.
- Lower your blood pressure to <130/80. This important lifestyle change will also reduce your risk of heart attacks, stroke and/or kidney disease.
- If you have diabetes keep your blood glucose levels under control.
- Exercise and get regular physical activity. Walking can stimulate new growth of the small arteries in your legs which can decrease the symptoms of PAD.
- Keep your weight under control, if you are presently obese see you physician about starting a weight reduction program.
- Medication may be necessary which may relieve the pain, thin your blood and prevent further plaque from forming, and lower your blood pressure.
- If the blockage is severe surgical intervention may be necessary.
