Coronary Artery Disease Treatment Guide

For information: 866.289.6911 © 2000-2009 Cleveland Clinic. All rights reserved. Rev. 9/09

CoRonARy ARteRy diseAse tReAtment guide

sydell And ARnold milleR FAmily heARt & vAsCulAR institutewww.clevelandclinic.org/heart

Yourheartisastrongmuscularpumpthatisresponsibleformovingabout3,000gallonsofbloodthroughyourbodyeveryday.Likeothermuscles,yourheartrequiresacontinuoussupplyofbloodtofunctionproperly.Yourheartmusclegetstheblooditneedstodoitsjobfromthecoronaryarteries.

What is coronary artery disease?

Coronaryarterydiseaseisthenarrow-ingorblockageofthecoronaryarteries,usuallycausedbyatherosclerosis.Atherosclerosis(sometimescalled“hardening”or“clogging”ofthearteries)isthebuildupofcholesterolandfattydeposits(calledplaques)ontheinnerwallsofthearteries.Theseplaquescanrestrictbloodflowtotheheartmusclebyphysicallycloggingthearteryorbycausingabnormalarterytoneandfunction.

Withoutanadequatebloodsupply,theheartbecomesstarvedofoxygenandthevitalnutrientsitneedstoworkproperly.Thiscancausechestpaincalledangina.Ifbloodsupplytoaportionoftheheartmuscleiscutoffentirely,oriftheenergydemandsoftheheartbecomemuchgreaterthanitsbloodsupply,aheart attack(injurytotheheartmuscle)mayoccur.

What causes the coronary arteries to narrow?

Yourcoronaryarteriesareshapedlikehollowtubesthroughwhichbloodcanflowfreely.Themuscularwallsofthecoronaryarteriesarenormallysmoothandelasticandarelinedwithalayerofcellscalledtheendothelium.Theendotheliumprovidesaphysicalbarrierbetweenthebloodstreamandthecoronaryarterywalls,whileregulatingthefunctionofthearterybyreleasingchemicalsignalsinresponsetovariousstimuli.

left coronary artery

circumflex artery

marginal branch

left descending artery

right coronary artery

posterior descending artery

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What causes the coronary arteries to narrow? (continued)

Coronaryarterydiseasestartswhenyouareveryyoung.Beforeyourteenyears,thebloodvesselwallsbegintoshowstreaksoffat.Asyougetolder,thefatbuildsup,causingslightinjurytoyourbloodvesselwalls.Othersubstancestravelingthroughyourbloodstream,suchasinflammatorycells,cellularwasteproducts,proteinsandcalciumbegintosticktothevesselwalls.Thefatandothersubstancescombinetoformamaterialcalledplaque.

Overtime,theinsideofthearteriesdevelopplaquesofdifferentsizes.Manyoftheplaquedepositsaresoftontheinsidewithahardfibrous“cap”coveringtheoutside.Ifthehardsurfacecracksortears,thesoft,fattyinsideisexposed.Platelets(disc-shapedparticlesinthebloodthataidclotting)cometothearea,andbloodclotsformaroundtheplaque.Theendotheliumcanalsobecomeirritatedandfailtofunctionproperly,causingthemusculararterytosqueezeatinappropriatetimes.Thiscausesthearterytonarrowevenmore.

Sometimes,thebloodclotbreaksapart,andbloodsupplyisrestored.Inothercases,thebloodclot(coronary thrombus)maysuddenlyblockthebloodsupplytotheheartmuscle(coronary occlusion),causingoneofthreeseriousconditions,calledacute coronary syndromes(seebelow).

What are acute coronary syndromes?unstable angina: This may be a new symptom or a change from stable angina. The angina may occur more frequently, occur more easily at rest, feel more severe, or last longer. Although this can often be relieved with oral medications, it is unstable and may progress to a heart attack. Usually more intense medical treatment or a procedure are required to treat unstable angina.

non-st segment elevation myocardial infarction (nstemi): This type of heart attack, or MI, does not cause major changes on an electrocardiogram (ECG). However, chemical markers in the blood indicate that damage has occurred to the heart muscle. In NSTEMI, the blockage may be partial or temporary, so the extent of the damage is relatively minimal.

st segment elevation myocardial infarction (stemi): This type of heart attack, or MI, is caused by a prolonged period of blocked blood supply. It affects a large area of the heart muscle, and causes changes on the ECG as well as in blood levels of key chemical markers.

Some people have symptoms that indicate they may soon develop an acute coronary syndrome, others may have no symptoms until something happens, and still others have no symptoms of the acute coronary syndrome at all.

All acute coronary syndromes require emergency evaluation and treatment.

Plaque Build-up

progression of plaque build-up

platelets

clot

coronary artery wall

beginning of fatty matter build-up

lining of coronary arteries

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Collateral Circulation

Asthesizeoftheblockageinacoronaryarteryincreases,thenarrowedcoronaryarterymaydevelop“collateral circulation.”Collateralcirculationisthedevelopmentofnewbloodvesselsthatreroutebloodflowaroundtheblockage.However,duringtimesofincreasedexertionorstress,thenewarteriesmaynotbeabletosupplyenoughoxygen-richbloodtotheheartmuscle.

What is ischemia?

Ischemiaisaconditiondescribedas“crampingoftheheartmuscle.”Ischemiaoccurswhenthenarrowedcoronaryarteryreachesapointwhereitcannotsupplyenoughoxygen-richbloodtomeettheheart’sneeds.Theheartmusclebecomes“starved”foroxygen.

Ischemiaoftheheartcanbecomparedtoacrampintheleg.Whensomeoneexercisesforaverylongtime,themusclesinthelegscrampupbecausethey’restarvedforoxygenandnutrients.Yourheart,alsoamuscle,needsoxygenandnutrientstokeepworking.Iftheheartmuscle’sbloodsupplyisinadequatetomeetitsneeds,ischemiaoccurs,andyoumayfeelchestpainorothersymptoms.

Ischemiaismostlikelytooccurwhentheheartdemandsextraoxygen.Thisismostcommonduringexertion(activity),eating,excitementorstress,orexposuretocold.

Whenischemiaisrelievedinlessthan10minuteswithrestormedications,youmaybetoldyouhave“stablecoronaryarterydisease”or“stableangina.”Coronaryarterydiseasecanprogresstoapointwhereischemiaoccursevenatrest.

Ischemia,andevenaheartattack,canoccurwithoutanywarningsignsandiscalled“silent”ischemia.Silentischemiacanoccuramongallpeoplewithheartdisease,thoughitismorecommonamongpeoplewithdiabetes.

What are the symptoms of coronary artery disease?

Themostcommonsymptomofcoronaryarterydiseaseisangina(alsocalledanginapectoris).Anginaisoftenreferredtoaschestpain.Itisalsodescribedaschestdiscomfort,heaviness,tightness,pressure,aching,burning,numbness,fullness,orsqueezing.Itcanbemistakenforindigestionorheartburn.Anginaisusuallyfeltinthechest,butmayalsobefeltintheleftshoulder,arms,neck,backorjaw.

Othersymptomsthatmayoccurwithcoronaryarterydiseaseinclude:

Shortnessofbreath

Palpitations(irregularheartbeats,skippedbeatsora“flip-flop”feelinginyourchest)

Afasterheartbeat

Dizziness

Nausea

Extremeweakness

Sweating If you experience any of these symptoms, it is important to call your doctor, especially if these are new symptoms or if they have become more frequent or severe.

symptoms in Women:

Womenoftenhavedifferentsymptomsofcoronaryarterydiseasethanmen.Forexample,symptomsofaheartattackinwomeninclude:

Painordiscomfortinthechest,leftarmorback

Unusuallyrapidheartbeat

Shortnessofbreath

Nauseaorfatigue

If any of these symptoms occur, it is important to get medical help right away - call 9-1-1 or have someone take you to the nearest emergency room.

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For information: 866.289.6911© 2000-2009 Cleveland Clinic. All rights reserved. Rev. 9/09

sydell And ARnold milleR FAmily heARt & vAsCulAR institutewww.clevelandclinic.org/heart

What you should do if you have symptoms:

Ifyouorsomeoneyouarewithhaschest,leftarmorbackpainthatlastsmorethan5minutes,withoneormoreofthesymptomslistedpreviously,call 911 to get emergency help. DO NOT WAIT. Quicktreatmentofaheartattackisveryimportanttoreducetheamountofdamagetoyourheart.

Aspirin: Aftercalling911,emergencypersonnelmaytellyoutochewonefull(325mg)aspirinslowly,ifyoudonothaveahistoryofaspirinallergyorbleeding.Aspirinisespeciallyeffectiveiftakenwithin30minutesafterthestartofsymptoms.Do NOT take an aspirin for symptoms of a stroke.

Ifyoursymptomsstopcompletelyin5minutes,stillcallyourdoctortoreportyoursymptoms.

Callyourdoctorifthisisthefirsttimeyouhaveexperiencedthesesymptomssoyoucanbeevaluated.

Learntorecognizeyoursymptomsandthesituationsthatcausethem.

Callyourdoctorifyouhavenewsymptomsoriftheybecomemorefrequentorsevere.

What’s the difference between angina and a heart attack?

Angina is a warning symptom of heart disease – but it is not a heart attack. The symptoms of a heart attack (also called myocardial infarction or “MI”) are similar to angina.

Angina heart Attack

Is brought on by a brief period of poor blood supply to the heart muscle

Occurs when the blood supply to the heart muscle is blocked for an extended period of time (often due to a clot forming in a partially blocked coronary artery)

Does not cause permanent damage to the heart Results in permanent damage to the heart muscle

Symptoms last just a few minutes and are usually relieved by rest and/or medications. Symptoms include chest pain or discomfort, shortness of breath, palpitations, faster heart rate, dizziness, nausea, extreme weakness and sweating.

Symptoms usually last more than a few minutes and include chest pain or discomfort that lasts for more than a few minutes or goes away and comes back; pain or discomfort in other areas of the upper body; difficulty breathing or shortness of breath; sweating or “cold” sweat; fullness, indigestion or choking feeling; nausea or vomiting; light-headedness; extreme weakness; anxiety; rapid or irregular heartbeats

Symptoms are relieved by rest and/or medications within a few minutes

Symptoms are not relieved by rest or oral medications

Does not require emergency medical attention; how-ever, it is important to call your doctor if this is the first time you’ve experienced angina, if you have new symptoms or if they become more frequent or severe

Requires emergency medical attention if symptoms last longer than 5 minutes

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disease.Thesetestshelpyourdoctorevaluatetheextentofyourcoronaryheartdisease,itseffectonthefunctionofyourheart,andthebestformoftreatmentforyou.

Researchintonewtestingprocedures,suchascoronarycomputedtomographyangiogram(CTA),maychangethewaycoronaryarterydiseaseisdiagnosedinthefuture.

What are the risk factors for coronary artery disease?

Non-modifiable risk factors (thosethatcannotbechanged)include:

Male gender.Theriskofheartattackisgreaterinmenthaninwomen,andmenhaveheartattacksearlierinlifethanwomen.However,atage70andbeyond,menandwomenareequallyatrisk.

Advanced age.Coronaryarterydiseaseismorelikelytooccurasyougetolder,especiallyafterage65.

Family history of heart disease.Ifyourparentshaveheartdisease(especiallyiftheywerediagnosedwithheartdiseasebeforeage50),youhaveanincreasedriskofdevelopingit.Askyourdoctorwhenit’sappropriateforyoutostartscreeningsforheartdiseasesoitcanbedetectedandtreatedearly.

Race.AfricanAmericanshavemoreseverehighbloodpressurethanCaucasiansandthereforehaveahigherriskofheartdisease.HeartdiseaseriskisalsohigheramongMexicanAmericans,AmericanIndians,nativeHawaiiansandsomeAsianAmericans.Thisispartlyduetohigherratesofobesityanddiabetesinthesepopulations.

Modifiable risk factors(thoseyoucantreatorcontrol)include:

�Cigarette�smokingandexposuretotobaccosmoke

High blood cholesterol and high triglycerides--especiallyhighLDLor“bad”cholesterolover100mg/dLandlowHDLor“good”cholesterolunder40mg/dL.SomepatientswhohaveexistingheartorbloodvesseldiseaseandotherpatientswhohaveaveryhighriskshouldaimforaLDLlevellessthan70mg/dL.Yourdoctorcanprovidespecificguidelines.

if you have Been Prescribed nitroglycerin

Ifyouhavebeenprescribednitroglycerinandexperienceangina,stopwhatyouaredoingandrest.Takeonenitroglycerintabletandletitdissolveunderyourtongue,orifusingthesprayform,sprayitunderyourtongue.Wait5minutes.Ifyoustillhaveanginaafter5minutes,call911togetemergencyhelp.

For patients diagnosed with chronic stable angina: If�you�experience�angina,�take�one�nitroglycerin�tablet�and�let�it�dissolve�under�your�tongue,�repeating�every�5�minutes�for�up�to�3�tablets�spanning�15�minutes.�If�you�still�have�angina�after�taking�3�doses�of�nitroglycerin,�call�911�to�get�emergency�help.�

Reference: ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. Journal of the American College of Cardiology, 2007. 50(7):1-157.

use of aspirin with unstable chest pain: Aftercalling911,emergencypersonnelmaytellyoutochewonefullaspirin(325mg)slowly,ifyoudonothaveahistoryofaspirinallergyorbleeding.Aspirinisespeciallyeffectiveiftakenwithin30minutesafterthestartofsymptoms.Do NOT take an aspirin for symptoms of stroke. Continuetotakeyournitroglycerinasprescribed.

how is coronary artery disease diagnosed?

Yourdoctordiagnosescoronaryarterydiseasebytalkingtoyouaboutyoursymptoms,reviewingyourmedicalhistoryandriskfactors,andperformingaphysicalexam.

Diagnostictests,includingbloodtests,anelectrocardiogram(ECGorEKG),exercisestresstestsorcardiaccatheterizationmayberequiredtoappropriatelydiagnoseandtreatcoronaryartery

do not wait to get help

At the first signs of a heart attack, call for emergency treatment (911). Do not wait for your symptoms to “go away.” Early recognition and treatment of heart attack symptoms can reduce the risk of heart damage and allow treatment to be started immediately. Even if you’re not sure your symptoms are those of a heart attack, you

should still be evaluated.

For information: 866.289.6911© 2000-2009 the Cleveland Clinic Foundation. All rights reserved. Rev. 9/09

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Modifiable risk factors (continued)

High blood pressure(140/90mm/Hgorhigher)Uncontrolled diabetes Physical inactivity Being overweight (bodymassindexorBMIfrom25-29kg/m2)orbeingobese(BMIhigherthan30kg/m2)

NOTE:Howyourweightisdistributedisimportant.Yourwaistmeasurementisonewaytodeterminefatdistribution.Yourwaistcircumferenceisthemeasurementofyourwaist,justaboveyournavel.Theriskofcardiovasculardiseaseincreaseswithawaistmeasurementofover35inchesinwomenandover40inchesinmen.Uncontrolledstress or anger Diethighin saturated fat and cholesterol Drinkingtoomuchalcohol

Themoreriskfactorsyouhave,thegreateryourriskofdevelopingcoronaryarterydisease.

how is coronary artery disease treated?

Treatmentforcoronaryarterydiseaseinvolvesreducingyourriskfactors,takingmedicationsasprescribed,possiblyundergoinginvasiveand/orsurgicalproceduresandseeingyourdoctorforregularvisits.Treatingcoronaryarterydiseaseisimportanttoreduceyourriskofaheartattackorstroke.

ReduCe youR Risk FACtoRs

Reducingyourriskfactorsinvolvesmakinglifestylechanges.Yourdoctorwillworkwithyoutohelpyoumakethesechanges.

Ifyousmoke,youshouldquit.

Makechangesinyourdiettoreduceyourcholesterol,controlyourbloodpressure,andmanagebloodsugarifyouhavediabetes.Low-fat,low-sodiumandlow-cholesterolfoodsarerecommended.Limitingalcoholtonomorethanonedrinkadayisalsoimportant.Aregistereddietitiancanhelpyoumaketherightdietarychanges.ClevelandClinicoffersnutritionprogramsandclassestohelpyoureachyourgoals.

Increaseyourexercise/activityleveltohelpachieveandmaintainahealthyweightandreducestress.But,checkwithyourdoctorbeforestartinganexerciseprogram.Askyourdoctoraboutparticipatinginacardiacrehabilitationprogram.

tAke mediCAtions As PResCRiBed

Iflifestylechangesaren’tenoughtocontrolyourheartdisease,medicationsmaybeprescribedtotreatcertainriskfactors,suchashighcholesterolorhighbloodpressure.Themedicationsprescribedwilldependonyourpersonalneeds,presenceofotherhealthconditionsandyourspecificheartcondition.

hAve PRoCeduRes to tReAt CoRonARy ARteRy diseAse, As ReCommended

interventional procedures

Commoninterventionalprocedurestotreatcoronaryarterydiseaseincludeballoonangioplasty(PTCA)andstentordrug-elutingstentplacement.Theseproceduresareconsiderednon-surgicalbecausetheyaredonebyacardiologistthroughatubeorcatheterinsertedintoabloodvessel,ratherthanbyasurgeonthroughanincision.Severaltypesofballoonsand/orcathetersareavailabletotreattheplaquewithinthevesselwall.Thephysicianchoosesthetypeofprocedurebasedonindividualpatientneeds.

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treatment Procedures (continued)

Coronary artery bypass graft (CABg) surgery

Oneormoreblockedcoronaryarteriesarebypassedbyabloodvesselgrafttorestorenormalbloodflowtotheheart.Thesegraftsusuallycomefromthepatient’sownarteriesandveinslocatedinthechest,armorleg.Thegraftgoesaroundthecloggedartery(orarteries)tocreatenewpathwaysforoxygen-richbloodtoflowtotheheart.

Whenthesetraditionaltreatmentsarenotoptionsforyou,doctorsmaysuggestotherlesstraditionaltherapies,suchasTMRorEECP.

transmyocardial laser revascularization (tmR)

TMRisatreatmentaimedatimprovingbloodflowtoareasoftheheartthatwerenottreatedbyangioplastyorsurgery.Aspecialcarbondioxide(CO2)laserisusedtocreatesmallchannelsintheheartmuscle,improvingbloodflowintheheart.TMRismostfrequentlyperformedasanadjuncttocoronaryarterybypassgraftsurgery(CABG).Itisrarelyperformedasastand-aloneprocedure.

enhanced external counterpulsation (eeCP)

Forpatientswhohavepersistentanginasymptomsandhaveexhaustedthestandardtreatmentswithoutsuccessfulresults,EECPmaystimulatetheopeningsorformationofcollaterals(smallbranchesofbloodvessels)tocreateanaturalbypassaroundnarrowedorblockedarteries.EECPisanon-invasivetreatmentforpeoplewhohavechronic,stableangina;whoarenotreceivingadequaterelieffromanginabytakingnitratemedications;andwhodonotqualifyforaproceduresuchasbypasssurgery,angioplastyorstenting.

Follow-up Care

Yourcardiologist(heartdoctor)willwanttoseeyouonaregularbasisforaphysicalexamandpossiblytoperformdiagnostictests.Yourdoctorwillusetheinformationgainedfromthesevisitstomonitortheprogressofyourtreatment.Checkwithyourheartdoctortofindoutwhentoscheduleyournextappointment.

Who is affected by coronary artery disease?

Heart disease is the leading cause of death in the United States in men and women. Coronary artery disease affects 16.8 million Americans. The American Heart Association (AHA) estimates that about every 34 seconds, an American will have a heart attack. In addition, the lifetime risk of having cardiovascular disease after age 40 is 2 in 3 men and more than 1 in 2 women.

Reference: Heart Disease and Stroke Statistics 2009 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 2009 January 27.

important note: These procedures increase blood supply to your heart, but they do not cure

coronary heart disease. You will still need to decrease your risk factors by making lifestyle changes, taking

medications as prescribed and following your doctor’s recommendations to reduce the risk of future disease

development.

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Center for Advanced ischemic heart disease

The Center for Advanced Ischemic Heart Disease brings a multi-disciplinary approach to the diagnosis and treatment of patients who have severe ischemic coronary heart disease and for whom the therapeutic options locally are limited. The center consists of specialists from interventional cardiology, cardiothoracic surgery, cardiac imaging, electrophysiology, prevention and nutrition, pain management, stem cell therapy, pharmacy and nursing. We provide:

A thorough evaluation of patients using state-of-the-art diagnostic testing Multi-disciplinary approach to comprehensive care for patients with advanced ischemic diseasesOngoing research and education to provide patients with high-quality and innovative therapies

For more information

For more information about coronary artery disease and treatments, please visit our website at www.clevelandclinic.org/heart, participate in a chat with a nurse online, or e-mail us using the Contact Us form.

To make an appointment or to talk with a nurse about coronary artery disease and available treatment options, please contact the Heart & Vascular Resource Center Nurse toll-free at 866.289.6911. We would be happy to answer your questions.

About the sydell and Arnold miller Family heart & vascular institute

The Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic is one of the largest cardiovascular specialty groups in the world, providing patients with expert medical management and a full range of therapies. our cardiac care program has been ranked number one since 1995 by U.S. News & World Report. Our areas of expertise combine research, education and clinical practice to provide innovative and scientifically-based treatments for cardiovascular disease. The commitment of our physicians and scientists to the prevention and cure of cardiovascular disease has led to innovative care, better outcomes and improved quality of life for patients with cardiovascular disease.

This information is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.

For information: 866.289.6911© 2000-2009 Cleveland Clinic. All rights reserved. Rev. 9/09

sydell And ARnold milleR FAmily heARt & vAsCulAR institutewww.clevelandclinic.org/heart

NOTES

Rev. 9/09