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What do we know about coronary artery disease


Heart

Facts about Coronary artery disease (CAD)

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What is coronary artery disease (heart disease)?

What do we know about coronary artery disease

Coronary artery disease (CAD) remains the number one cause of death in the industrially developed countries. Nearly 600,000 individuals will succumb annually to CAD and nearly half will do so suddenly. For approximately one-quarter of the individuals who die suddenly, death is the first manifestation of underlying CAD.

The American Heart Association estimates that more than 25% of the adult population in the United States has some form of heart disease. This is a striking figure, given the fact that over the past 4 decades the mortality from coronary disease has declined by nearly 40%.

Much of the decrement in mortality began to emerge prior to the widespread use of interventional revascularization, such as percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG) surgery.

Risk Factors for Coronary artery disease

Risk factors for coronary disease can be classified as follows:

Major Modifiable Risk Factors

  • Lipid abnormalities
  • Hypertension
  • Cigarette smoking
  • Sedentary lifestyle.

Possible Major Modifiable Abnormalities

Stress in the most general sense, as well as individual personality patterns:

  • Hostility
  • Anger
  • Social isolation.

Non-modifiable Major Risk Factors

  • Age
  • Male gender
  • Family history of heart disease before age 55.

Management of the patient with angina requires aggressive attention to risk factor modification. Physicians emphasize to cigarette smokers, for example, that discontinuation of cigarettes will reduce their risks for cardiac events to that of nonsmokers within 2 years following cessation. Incorporating a regular exercise program and maintaining ideal body weight also result in a significant reduction in risk for coronary disease, as does intermittent aspirin therapy.

Recently, studies have supported the use of vitamin E and perhaps other antioxidants in certain populations.

Possible Major Modifiable Abnormalities

Lipid Abnormalities

A full discussion of hyperlipidemia is beyond the intent of this section. However, recent studies have underscored the importance of lipid-lowering drugs in improved outcome for both primary and secondary prevention.

Assessing total cholesterol, including the high-density lipoproteins (HDLs) and low-density lipoproteins (LDLs), is now an official recommendation of the National Institutes of Health. Elevated HDL cholesterol exerts a cardioprotective effect, particularly among individuals with levels greater than 50 mg/dL. Levels of HDL cholesterol less than 35 mg/dL are an independent risk factor for coronary disease.

Symptoms of coronary artery disease

Similarly, elevations in LDL cholesterol have an independent relationship to development of coronary disease, and recommended “desirable” LDL cholesterol levels are less than 130 mg/dL. An additional advantage among patients who discontinue cigarette smoking is that HDL cholesterol will increase quite significantly in some individuals.

Significant decrease in intake of saturated fat is probably the most important element for control of lipids.

It is currently recommended that fat in the diet not exceed 30% of total calories, and some studies (particularly those by Ornish and co-workers) suggest that extremely low percentages of fat (10%) may, in fact, result in a regression or at least a significant plateauing of plaque deposition in the coronary vessels.

Hypertension

Modification of the important risk factor hypertension not only reduces the level of active angina but also reduces the additive risk among individuals with hyperlipidemia and continued cigarette smoking.

Moreover, patients with significant hypertension and ventricular dysfunction are more likely to experience the anginal equivalent of breathlessness, particularly occurring at night and awakening them from sleep. With the availability of once-daily beta-blockers and calcium channel blockers, both angina and hypertension can be treated with the same agents simultaneously.

What is CAD

Cigarette Smoking

Approximately 20% of deaths in the United States from coronary disease may be directly attributable to cigarette smoking. Women under age 65 have even higher death rates, with smoking accounting for approximately 50% of all myocardial infarctions in women under age 55.

Women who smoke and use oral contraceptives may increase their risk for coronary disease 20- to 40-fold.

Cessation of cigarette smoking is mandatory for the proper management of patients with active angina. Physicians are loathe to aggressively pursue elective invasive interventions among cigarette smokers in view of the increased risk for graft occlusion in patients undergoing CABG surgery who continue to smoke, as well as higher percentages of patients returning with reocclusion of a previously PTCA-dilated vessel.

Sedentary Lifestyle

A consistent program of aerobic exercise has many advantages for the coronary patient including:

  • Improvement in lipid profile
  • Lowering of blood pressure
  • Improved control of diabetes.

Regular exercise is associated with reduction in the frequency of anginal attacks (see Section #17, Exercise, for further discussion of objective and subjective benefits associated with aerobic exercise).

Possible Major Modifiable Abnormalities

Diabetes Mellitus

The wide spectrum of disease in patients with Type I and Type II diabetes does not allow for simple conclusions other than its optimal management. Control of hyperglycemia will help to modify the vascular effects for the diabetic patient. Insulin-dependent diabetics:

  • Are at particularly high risk for all vascular injury
  • Are prone to silent ischemia
  • Are more likely to experience associated carotid and peripheral vascular occlusive disease.

Obesity

Obesity is currently defined as an increase of at least 30% over desired body weight. Modification of diet with associated weight reduction is difficult without a life-long commitment. It is emphasized to patients that absolute portions of food, if reduced, will result in weight loss.

What can cause coronary artery disease

If there is a simultaneous elimination of dietary fat, lipid levels will drop significantly. Patients should:

  • Spend at least 30 minutes eating lunch or dinner
  • Eat slowly
  • Not “fast” during the day only to engorge themselves at dinner.

Losing weight by reducing portions requires that sufficient time be taken during the meal to allow visual and physical cues to create a feeling of satiety. When eating in restaurants, patients should:

  • Drink two or three glasses of water prior to dinner
  • Eliminate bread
  • Divide an entree with another individual or order two appetizers rather than the invariably larger entree.

Modification of the traditional risk factors (eg, cigarette smoking, hypertension, hyperlipidemia) needs to be part of a program to keep patients’ lives in balance. Patients are encouraged to develop levels of priorities so that there is adequate time for relaxation, family, and the development of hobbies.

The mechanism of coronary artery disease

Without attention to the “total picture,” neither pharmacotherapy nor invasive interventions will alter the course of this disease.

Stress/Personality Profile

Individuals who are angry and hostile, particularly if they are socially isolated and depressed, are at significantly higher risk for all cardiac events.

Many patients with coronary disease bring to the process a life filled with “joyless striving,” dealing with internal furies, job dissatisfaction, and significant amounts of anger.

Encouraging these patients to seek counsel support groups or organized rehabilitation programs, or to embark on a regular exercise program are elements in management of equal importance to any pharmacologic or invasive intervention.

Although physicians caring for patients with coronary disease and active angina may not be able to change their patients’ social environments, they can do much to alleviate patients’ anxieties and fears by demonstrating significant interest and lending a sympathetic ear.



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Anastasia Prikhodko
Assistant nurse at the regional hospital of the city of Kalmar. Creator, owner and inspirer of a project NetDoctor.center.