Diseases Conditions - DrCRaghu - Page 2

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Coronary artery disease (CAD) is the most common type of heart disease, in which the coronary arteries (major artery that supplies blood to the heart muscle) become rigid and narrowed due to buildup of plaque (deposition of cholesterol) in the inner walls of the heart. This restricts the flow of oxygen rich blood to the heart muscle, which may result in angina (chest pain) and shortness of breath. If the plaque ruptures or due to a complete blockage in the artery, it may result in heart attack or sudden cardiac death.

Causes:

The cause of coronary artery disease is the buildup of plaque in the inner walls of coronary artery, which is called as atherosclerosis.

The plaque makes the inner walls of the artery sticky, so that the inflammatory cells, lipoproteins, and calcium travelling through the blood stream may adhere to the plaque. The plaque gradually enlarges, narrowing the blood vessel and further restricting the blood flow to the heart muscle and reducing the supply of oxygen and nutrients to the heart.

Signs and symptoms:

  • Angina (chest pain)
  • Shortness of breath
  • Palpitations (irregular heartbeats or skipped beats)
  • Tachycardia (fast heartbeat)
  • Weakness or dizziness
  • Nausea
  • Sweating
  • Fatigue, mainly after exercise or any activity.


Risk factors:

  • Age: Risk for damaged or narrowed arteries increases with age.
  • Gender: Men are at greater risk of developing CAD. In women, risk increases after menopause stage.
  • Family history: Risk increases if any family member has coronary artery disease.
  • Smoking: People who have the habit of smoking and who are exposed to smoke are at increased risk of CAD.
  • High blood pressure: It results in the narrowing and hardening of the walls of arteries.
  • High blood cholesterol levels: It can increase the risk of atherosclerosis.
  • Diabetes: It is associated with the symptoms of CAD, such as high BP and obesity.
  • Obesity: Overweight increases the risk of CAD.
  • Life style activities: Reduced physical activity, high stress and unhealthy diet also contribute to the development of CAD.

Other possible risk factors, according to research, include:

  • Sleep apnea: It is a condition in which the person may experience intermittent cessation of breathing during sleep, resulting in reduced oxygen levels in the blood. Sleep apnea may cause an increase in the blood pressure and high strain on the heart, leading to CAD.
  • Increased C-reactive protein (CRP) levels in blood: CRP levels are increased mostly if there is any inflammation in the body. It is a risk factor for CAD.
  • High triglycerides (a type of lipid).
  • High homocysteine (amino acid) levels.
  • Preeclampsia (high blood pressure during pregnancy).
  • Alcohol use can lead to heart muscle damage.
  • Autoimmune diseases such as rheumatoid arthritis and lupus.


Complications:

If left untreated, CAD can lead to life threatening complications such as:

  • Angina: Due to narrowed blood vessels, the heart muscles receive inadequate oxygen laden blood, causing chest pain or shortness of breath.
  • Heart attack: The plaque may rupture forming a clot and blocking the blood flow to the heart muscle.
  • Heart failure: Due to reduced oxygen and nutrient rich blood flow, the heart is unable to pump enough blood, thus increasing its workload. Over time, it may lead to heart failure.
  • Arrhythmia: Reduced amount of blood supply may lead to abnormal heart rhythms.


Diagnosis:

The diagnostic work up includes a physical examination, in addition to medical history, family history, risk factors and any signs and symptoms of CAD. Further diagnostic tests may be recommended:

  • Electrocardiogram (ECG): It records the heart’s electrical activity and helps to determine the blood flow in the heart as well as heart muscle stress.
  • Echocardiogram: It uses sound waves to produce clear images of the heart and helps to identify the damaged heart muscles.
  • Stress test: The test involves performing any high intensity activity like treadmill or bicycling under medical supervision, and close monitoring of heart function during the physical activity, to determine if there are any symptoms of CAD.
  • Cardiac catheterization and angiogram: A special dye is inserted into the coronary blood vessels using a thin, flexible tube called catheter, which is inserted through a small incision at the groin or an arm to view the blood flow in the heart.
  • Heart scan: Computerized tomography (CT) technologies are used to identify the calcium deposits in the blood vessel of the heart, which indicates CAD.


Treatment:


Lifestyle changes:

  • Quit smoking.
  • Avoid processed foods and eat high protein and fiber rich diet.
  • Exercise regularly and lose excess weight.
  • Manage stress.
  • Control diabetes.


Medications:

The doctor may prescribe medications, which help in reducing the symptoms of CAD, such as:

  • Dyslipidemic agents such as statins, niacin, fibrates and bile acid sequestrants a to lower the blood cholesterol levels
  • Aspirin, a blood thinner, to prevent blood clots, which might obstruct the coronary arteries
  • Beta blockers decrease the heart rate and blood pressure and reduce the oxygen demand of the heart.
  • Calcium channel blockers to lower blood pressure
  • Ranolazine, an anti-anginal drug, to reduce chest pain
  • Nitroglycerin to dilate the coronary arteries and reduce chest pain
  • Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) to decrease blood pressure


Surgical procedures:

  • Angioplasty and stent placement: It is also called as percutaneous coronary revascularization, and involves inserting a thin, flexible tube (catheter) into the narrowed coronary artery, followed by a wire with deflated balloon to the narrowed area. The balloon is inflated to widen the blood vessel; a stent may also be placed to keep the artery patent.
  • Coronary artery bypass surgery: A graft is created using any blood vessel in the body, to bypass the blocked coronary arteries.


Prevention:

To maintain healthy arteries and to prevent coronary artery disease, some measures need to be taken such as lifestyle modifications which includes avoiding smoking and alcohol use, exercising regularly to maintain healthy weight, controlling sugar and cholesterol levels in blood and also eating a healthy diet.

 


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Coronary arteries are the vessels which supply blood (oxygen and nutrients) to the heart; this supply may be disrupted due to buildup of cholesterol and fatty deposits, called plaques, on the inner walls of the arteries (atherosclerosis) causing narrowing of the vessel lumen.

A bifurcation lesion is the stenosis or abnormal narrowing of greater than 50% that occurs in a coronary artery at the origin of the side branch or adjacent to the origin of the side branch. It is a difficult to treat lesion.

Signs and symptoms:

Most of the complex lesions have similar sign and symptoms which are as follows:

  • Acute angina pectoris syndrome (set of sign and symptoms due to decreased blood supply to coronary arteries which leads to malfunction or complete damage of the heart muscle)
  • Chest pain, usually left-sided, radiating to the neck, jaw, or left shoulder of the arm
  • Shortness of breath
  • Palpitations
  • Weakness
  • Lightheadedness
  • Nausea or vomiting
  • Sweating
  • Anxiety
  • Indigestion

Causes and risk factors:

The causes and risk factors involved are like those evident in most of the coronary artery disease, which are as follows:

  • Family history of heart disease
  • Kawasaki disease commonly found in children under 5 years of age
  • Obesity
  • Diabetes
  • Hypertension
  • Age
  • Smoking
  • Hyperlipidemia (elevated levels of lipids in the plasma)

Diagnosis:

Laboratory studies:
There is no specific lab test to diagnose a bifurcation lesion but if the lesion has resulted in acute coronary syndrome there could be an elevation in the white blood cell count. Cardiac specific biomarkers (troponin T and troponin I) will be elevated 4 to 8 hours after the injury which reach its peak in about 12 to 24 hours.

Electrocardiography (ECG):
It is performed to investigate the electrical activity of the heart and to detect any abnormality in its functioning. There are variable findings in the ECG depending on the clinical scenario.

Stress testing:
Exercise ECG is the procedure of choice for the patients who are stable and when their diagnosis is unclear. In individuals who can’t exercise, pharmacologic stress test (with adenosine or dobutamine) may be suggested.

Coronary angiography:
It is the most standard method used for diagnosing coronary lesions wherein a special dye and x-rays shows the blood flow in the arteries of heart and in this case it enables to determine the extent of stenosis (abnormal narrowing) of the coronary arteries. Thus, enabling the evaluation of the further treatment with medical therapy or stent procedure.

Cardiac catheterization:
In this procedure, a catheter is guided through an artery in the arm or leg and eventually into the coronary arteries, simultaneously a high-speed x-ray records the course of the injected dye which flows through the arteries enabling the detection of any blockages.

Prevention:
These lesions usually develop gradually over a period and thus it is possible to prevent it. Prevention can be accomplished by controlling or avoiding the risk factors involved in coronary artery lesions disease and is possible by adopting proper lifestyle modifications and diet which are as follows:

  • Maintain healthy weight by following proper diet and exercise.
  • Avoid smoking.
  • Manage stress.
  • Keep a check on blood pressure and sugar levels.
  • Go for regular health checkups if diagnosed with previous heart problems or having a family history of heart diseases.

Treatment:

Complex coronary lesions cause a higher mortality rate than non-complex lesions. Hence it is essential to treat it immediately and appropriately. However, the medical interventions carry their own risk of associated complications, and it must be managed by proper patient care and education.
Based on the coronary angiography or cardiac catheterization, the following treatment options can be recommended:

Percutaneous coronary intervention: It involves cardiac catheterization, insertion of a stent (usually a metallic tube) which helps to clear the blockage in the artery. Sometimes, two stents may be placed simultaneously. DES (drug eluting stents) are highly recommended than BMS (bare metal stents) as it prevents restenosis.

Medications: The prescribed medications are given in the event of detecting a stenosis which don’t require the use of stents and can be resolved by the drugs alone to clear up the blockage in the coronary artery.

When to seek immediate medical attention?

The first possible presentation of complex coronary lesions is acute coronary syndrome (unstable angina) which can be detected by the following characteristic features:

  • Chest pain occurs at rest or sleep or with minimal exercise
  • Sudden onset of chest pain that lasts longer than usual
  • When medicines and rest don’t provide relieve from the chest pain



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Designed & Developed by R R Deepak Kambhampati.



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