For Patients - DrCRaghu - Page 2


Thromboembolism refers to a condition where a blood clot formed in the blood vessel unplugs itself and flows in the blood stream to block another blood vessel leading to obstruction of blood flow. Although clotting is a normal bodily function, if a clot occurs where it is not required, it may lead to serious problems.

Types of Thromboembolism:

The type of thromboembolism differs depending on the area in which the clot may appear. It can obstruct the blood flow in the veins, arteries, brain, gastrointestinal tract or kidneys.

Thromboembolism can be further classified as below:

Venous Thromboembolism:

A venous thromboembolism is a thrombus (blood clot) formed in a vein. The blood flow in the veins is slow when compared to arteries which can increase the likelihood of the blood clots forming in these vessels.

It can be categorized into three different types

  • Superficial Vein Thrombosis
    The clot may occur in a superficial vein, close to the surface of the body. Usually, it is not serious until it enters the deep veins.
  • Deep Vein Thrombosis (DVT)
    Deep vein thrombosis occurs within the deep veins, and mostly occurs within the legs.
  • Pulmonary embolism (PE)
    It is a medical emergency in which the thrombus blocks the blood vessel in the lungs.

Renal Vein Thrombosis (RVT)

A renal vein thrombosis is a thrombosis that occurs in the veins that drain blood away from the kidneys. These clots reduce the ability of the kidneys to clean and filter the blood.

Arterial Thrombosis (atherothrombosis)

Arterial thrombosis is much less common than venous thrombosis. It can have similar risks. Usually arterial thrombosis may lead to necrosis of the tissue.

A thromboembolism in the coronary artery can cause a heart attack. If blood supply to the brain is disrupted, the patient may suffer a stroke.


Signs and symptoms of venous thromboembolism include the following


  • Pain in arm or leg, usually in the thigh or calf
  • Swollen leg or arm
  • Reddening or warming of the skin
  • Red streaks on the skin


  • Shortness of breath
  • Chest pain under your rib cage that can get worse when you take a deep breath
  • Rapid heart rate
  • Feeling lightheaded or passing out
  • Accentuated second heart sound

Arterial Thrombosis

  • Muscle pain or spasm in the affected area
  • Numbness and tingling in the arm or leg
  • Pale color of the arm or leg (pallor)
  • Weakness of an arm or leg

If the condition is severe, it may lead to blister formation and shedding of the skin, leading to tissue necrosis.

Symptoms of a clot in an organ vary with the organ involved but may include:

  • Pain in the part of the body that is involved
  • Temporary decrease in organ function


The blood clots can occur due to injury to a vein, consequence of a surgery, use of certain medications and lack of movement of the limbs.

In the case of PE, the blood clot may block the blood vessels of the lungs. The affected portion of the lung may die due to loss of blood supply, the condition is called as pulmonary infraction, making it difficult to provide oxygen to the rest of the body.

Occasionally, the blood vessels can be blocked by substances other than blood like collagen, part of a tumour, air bubbles etc.

Risk factors:

The common risk factors include

  • Inheriting a blood-clotting disorder
  • Prolonged immobility which may be due to bed rest or long trips
  • Injury or surgery
  • Pregnancy
  • Birth control pills or hormone replacement therapy
  • Being overweight or obese
  • Smoking
  • Cancer
  • Heart failure
  • Inflammatory bowel disease
  • Family history of deep vein thrombosis or pulmonary embolism


The diagnosis of thromboembolism includes the following tests which could be considered depending on the type:

D-dimer: The blood sample is tested for the presence of D-dimer which is a marker for the presence of blood clots.

Duplex Ultrasound: This is an imaging test in which the presence of clots is identified using ultrasound waves.

Pulse oximetry: In this test, a sensor attached on the end of the finger of the patient helps to measure the level of oxygen in the blood.

Arterial blood gas: The blood drawn from the artery is checked for oxygen levels present in it.

Chest X-ray: This test may not be useful in finding the presence of clots, but can help to rule out a clot.

Other diagnostic tests may include ELISA, pulmonary angiography, venography, echocardiography, helical computed tomography of pulmonary vessels etc.


Treatment of thromboembolism includes:

Blood thinners: These are anticoagulant drugs which prevent formation of new clots while the body works to break up the previous clots present. They include heparin, low-molecular-weight heparin, apixaban, edoxaban, rivaroxaban, and warfarin.

Clot-busting drugs: These are intravenous injections to dissolve the clots in the case of life-threatening situations. They include drugs belonging to the class of tissue plasminogen activators.

Surgical and other procedures:

  • Removal of clot: Surgery is considered only if the condition is life threatening. The clot is removed using a catheter threaded through the blood vessel.
  • Vein filter: A catheter can also be used to position a filter in the inferior vena cava which helps to stop the clots from being carried into the lungs.


If the patient is at a risk of the condition, the following preventive measures may be considered to reduce the occurrence:

  • Use of blood thinners
  • Use of compression stockings
  • Use of intermittent pneumatic compression devices that automatically squeeze the legs to keep blood flowing

Other preventive measures include

  • Regular exercise
  • Maintaining healthy weight
  • Cessation of smoking

Consideration during travel include

  • Walk every 1 to 2 hours
  • Stretch legs and move around on the seat
  • Drink lots of fluids
  • Avoid smoking and consumption of alcohol before journey


Varicose veins are the twisted, swollen and bulging veins that appear in blue, red and skin color, just beneath the surface of the skin. They occur mostly in the legs and feet, causing aching pain and discomfort in the legs.

Larger varicose veins appear rope-like and make the skin to bulge out. Inner varicose veins usually do not appear, but cause aching pain and swelling in the legs. Spider veins are the type of varicose veins which are most common and occur superficially, surrounded by the patches of flooded capillaries.


Arteries have a thick layer of muscle or tissue to supply oxygenated blood to different parts of the body. Veins carry blood back to the heart and it should work against the gravity, so they rely on surrounding muscles pressure. Valves in the veins open to move the blood towards the heart and then close to prevent the back flow of blood.

Any damage/abnormality in the functioning of the valves will lead to pooling up of blood in the vessels, causing them to stretch and twist, resulting in varicosity. It mostly occurs due to prolonged standing and walking, which builds up pressure in the veins of the lower legs.

Signs and Symptoms:

  • Dark purple or blue color veins
  • Twisted and bulging veins that appear on the surface of the skin
  • Aching pain and heaviness in the legs
  • Burning, throbbing, muscle cramping and swelling in the lower legs
  • Worsened pain after sitting or standing for a long time
  • Itching around affected veins
  • Skin discoloration around a varicose vein
  • Web-like reddish blue varicose veins called spider veins

Risk factors:

The factors that increase the risk of developing varicose veins are:

  • Age: As the age increases, the functioning of the valves in the veins may be damaged, resulting in pooling up of blood in the lower leg veins, leading to varicose veins.
  • Gender: Hormonal changes in women during pregnancy, premenstruation and menopause will relax the vein walls, which increases the risk for varicose veins. Use of hormonal birth control pills also increases the risk.
  • Pregnancy: Blood volume increases during pregnancy to support the developing fetus, but can also produce a side effect of enlarged veins.
  • Family history: If any family member has varicose veins or deep vein thrombosis, it increases the risk.
  • Obesity: Being overweight will increase the pressure in the veins of lower legs.
  • Standing or sitting for long periods of time will reduce the free flow of blood in the blood vessels and results in clot formation.


  • Ulcers: Skin ulcers may form near the ankle, which is an indication of vascular disease.
  • Blood clots: Clots may occur in the veins deep inside the legs, causing swelling and leg pain. The condition is referred as thrombophlebitis.
  • Bleeding: Sometimes, the superficial veins may burst, causing bleeding.


A physical examination is performed, and the patient is enquired about the nature of leg pain diagnose varicose veins. The family medical history of varicose veins and information about their daily lifestyle activities is gathered. Certain tests may be needed to confirm the diagnosis of varicose veins, and include:

  • Ultrasound test: This is a non-invasive test, which uses sound waves to create the images of internal organs of the body. This test helps to identify the blood flow in the veins and also identify the clots and weakened or leaky valves in the veins.
  • Venogram: This test is a type of angiogram, which uses contrast dye to clearly view the blood flow through the veins, mainly if physician suspects the presence of large clots in the veins.


Initially, after the diagnosis of varicose veins, the doctor would recommend some lifestyle modifications that can relieve pain and reduce worsening of the condition, such as:

  • Perform exercises
  • Elevate the legs.
  • Avoid tight fitting clothes that can prevent the free circulation
  • Avoid long periods of standing or sitting

Compression stockings: It will compress the leg veins and muscles and improve the blood flow efficiently, without forming any clots in the veins. The stockings are available in different sizes and lengths and can be bought without prescription in the local pharmacy.

Sclerotherapy: This procedure is mainly used for severe varicose veins, and involves injecting a chemical solution near the varicose veins, which helps in closing and scarring of the veins.

Laser treatment: This technique uses bursts of light reflected onto the vein, which makes the vein slowly fade and disappear. This test is mainly used to treat smaller varicose veins.

Catheterization: This procedure uses a thin, flexible tube (catheter) that is inserted into the enlarged vein, which uses radiofrequency or laser energy, mainly to collapse the larger varicose veins.

High ligation and vein stripping: Veins are tied off before it joins a deep vein and then it is removed through an incision.

Ambulatory phlebectomy: Series of small punctures are made in the skin under general anaesthesia, to remove the smaller varicose veins.

Endoscopic vein surgery: A thin tube attached with a camera is inserted into the vein to view and close the varicose veins and then removing them by making small incisions on the skin, under general anaesthesia.


Varicose veins cannot be prevented completely, but can be reduced by following some measures like:

  • Exercising regularly and losing extra weight
  • Eating a high-fiber and low-salt diet
  • Avoiding high heels and tight hosiery
  • Elevating the legs.
  • Changing the position regularly, when sitting or standing for long periods


Patent ductus arteriosus (PDA) is a congenital heart condition in which there is an opening between the pulmonary artery and the aorta. The ductus arteriosus is a small connection in the fetal heart helps oxygen rich blood to by-pass the immature baby’s lungs and flow into the body. This connection naturally closes shortly after birth. The connections that fail to close, are called patent ductus arteriosus, where the oxygen-rich and oxygen-poor combines together resulting in an increase in the workload of heart and various other complications.

It is the sixth most common type of congenital heart disease, and is frequently diagnosed in infants; although it may remain unknown until childhood or even adulthood.


The symptoms depend on the size of the patent duct and the gestational age of the neonate. A small patent ductus arteriosus can remain unrecognized until adulthood, whereas, a large patent ductus arteriosus may lead to life threatening conditions such as heart failure.

In neonates, a heart murmur on auscultation during regular checkup may indicate PDA.

In infants, a large PDA would show the following symptoms:

  • Inability or difficulty in feeding, leading to poor growth
  • Sweating on crying or eating
  • Persistent fast breathing or breathlessness
  • Cough
  • Lower respiratory tract infections
  • Pneumonia
  • Easy tiring
  • Rapid heart rate

The symptoms in the case of adults with undiagnosed PAD include heart attack, atrial arrhythmia or with the occurrence of shunting of unoxygenated blood from pulmonary to systemic circulation.


In most of the children the cause of PDA is unknown, but genetic factors were thought to play a causative role. Every baby is born with ductus arteriosus which eventually narrows and closes within three to four days after birth. It may take longer time for closure in the case of premature babies. But if the duct doesn’t close, it may lead to an increase in the blood flow to the heart and lungs of the baby, which might enlarge or weaken the heart muscle.

Risk factors:

The risk factors of having patent ductus arteriosus include:

  • Gender: PDA is more common in girls than in boys.
  • Prematurity: It is more common in babies who are born before the gestational term than in full term babies.
  • Family history: A family history of heart conditions and other genetic disorders, such as Down’s syndrome may increase the risk of PDA.
  • Rubella infection: If the mother is affected with rubella infection during pregnancy, the virus may cross the placenta and spread through the baby’s circulatory system potentially damaging blood vessels and organs including the heart.
  • High altitude birth risk: Babies born at altitudes higher than 10,000 feet are at an increased risk.
  • Congenital heart problems: Babies with congenital heart problems such as hypoplastic left heart syndrome, transposition of the great vessels, and pulmonary stenosis are at high risk


A heart murmur heard during a regular checkup may lead to further work-up for PDA.

The following tests Are recommended for diagnosis of PDA:

  • Chest X-ray to assess the condition of the heart and lungs, and also to rule out other conditions
  • Echocardiogram to assess the heart, its valves and chambers for any defects and see if the heart is pumping properly
  • Electrocardiogram (ECG) to assess the electrical activity of the heart to diagnose any heart defects or rhythm problems
  • Cardiac catheterization to rule out other congenital heart defects found during an echocardiogram or in a case where the catheter procedure is considered for the treatment


Treatment is generally not considered, as the PDA usually closes on its own in the case of a premature baby. Close monitoring is considered for full term babies, children and adults with small PDA and with no other health complications. During follow-up, if the baby does not have any other complications, it is considered to be closed. On the other hand, if the baby has certain heart problems or defects, the ductus arteriosus might be lifesaving.

In a premature baby, it may take one to two years. But in full term babies, PDA that remains open after several weeks rarely closes on its own.

Medicines such as indomethacin or ibuprofen may be considered. These medicines work well for some newborns. The earlier treatment is given; greater are the chances for it to succeed.

Medical procedures may be considered in the case where medications are not effective. A transcatheter procedure is used to block blood flow through the vessel. An open heart surgery might be considered if the catheter procedure is not suitable to repair PDA.


Patent ductus arteriosus may not be prevented, but certain measures should be observed for a healthy pregnancy.

  • Early prenatal care
  • Healthy diet
  • Regular exercise
  • Avoiding consumption of alcohol, illegal drugs and cigarettes.
  • Getting vaccinated as recommended.
  • Optimal diabetes control.


The heart consists of four chambers, of which upper two chambers are called as atria and lower two chambers are called as ventricles. Right and left chambers are separated by a wall of muscle called a septum. Right two chambers pump the deoxygenated blood to the lungs and left two chambers pump oxygenated blood to the different parts of the body.

Ventricular septal defects (VSD) is a common type of congenital heart defect, which is characterized by an abnormal opening or a hole in interventricular septum, the dividing wall between right and left ventricles. The oxygen-rich blood from the left ventricle will enter into the right ventricle through the opening, thereby getting mixed with deoxygenated blood and then enters into lungs. This will force the heart and lungs to work harder.


The exact cause of VSD is unknown. During fetal heart developmental stage, the heart develops from a large tube which eventually divides into chambers and walls. Any abnormality in this process will lead to the formation of a defect in the septum. If the defect is in the interventricular septum, then it is said to be ventricular septal defect. There may be one or more VSDs.


Based on the location and development of VSD, it is classified into following types:

  • Conoventricular Ventricular Septal Defect: It occurs just below the pulmonary and aortic valves.
  • Perimembranous Ventricular Septal Defect: It occurs in the upper part of the ventricular septum.
  • Inlet Ventricular Septal Defect: It occurs adjacent to the tricuspid and mitral valves. This type of defect might be associated with atrial septal defect.
  • Muscular Ventricular Septal Defect: It is the most common type of VSD, which occurs in the lower muscular part of the interventricular septum.

Signs and symptoms:

Small defects in the septum do not show any symptoms because it closes on its own gradually during childhood. Large defects shows signs and symptoms usually after birth within few days or weeks or months.

The first sign of VSD is heart murmur, which is a whooshing sound that can be heard using a stethoscope. The other symptoms include:

  • Fatigue (tiredness)
  • Arrhythmias (abnormal heart rhythm)
  • Fast breathing or breathlessness
  • Poor feeding
  • Poor weight gain
  • Pale skin
  • Enlarged liver

Risk factors:

Ventricular septal defects mostly occur due to defective genes and chromosomes, that may be hereditary. Environmental factors during pregnancy may also play a role in development of VSD in the fetus.


Large or medium septal defects if left untreated, may lead to life threatening complications such as:

  • Heart failure, as heart need to work harder to pump enough blood to the body.
  • Pulmonary hypertension (increased blood flow to the lungs results in increased blood pressure in the lung arteries).
  • Endocarditis (infection in the endocardium of heart).
  • Other heart problems such as abnormal heart rhythms and valve problems.


If heart murmurs are detected during the physical examination, the patient may be advised further testing to conform the diagnosis.

  • Echocardiogram: This test is the primary tool for the diagnosis of VSD, as it can be used to determine the size, location and severity of the ventricular septal defect. Sound waves are used to produce the detailed images of the heart.
  • Electrocardiogram (ECG): This test records the electrical activity of the heart and helps to identify the abnormal heart rhythms and defects in the septum.
  • Chest X-ray: X-rays are used to view the images of heart and lungs. In VSD, this test helps to determine the enlarged heart and extra fluid in the lungs.
  • Cardiac catheterization: The test involves inserting a thin, flexible tube into the blood vessel at the groin or an arm, which is guided to the heart, to identify any congenital heart defects and to determine the function of the heart chambers and its valves.
  • Pulse oximetry: Oxygen levels in the blood can be measured using a small clip which is placed on the fingertip.


Usually treatment is not needed for small VSDs, as they close on their own gradually after birth. Babies with larger VSD need surgery to prevent any further complications. The treatment for ventricular septal defects include:

  • Medications such as diuretics like furosemide are used to reduce the amount of fluid in the blood that is pumped to the lungs and in the circulation. Beta blockers like metoprolol, propranolol and digoxin are used to maintain the regular heartbeat.
  • Surgical procedures include surgical repair, catheter procedure and hybrid procedure.
    Surgical repair involves open heart surgery, in which the doctor uses a patch or stitches to close the hole, performed under general anaesthesia.
    In catheter procedure, a catheter is inserted into a blood vessel and then passed to the heart. The defect is closed using a specially sized mesh device.
    Hybrid procedure uses both surgical repair and catheterization procedures to close the hole, with the help of a heart-lung machine and a catheter placed through an incision.


Ventricular septal defects cannot be prevented, but following certain measures during pregnancy may be helpful to prevent the risk of VSD. The measures include:

  • Prenatal care before pregnancy: Consult a physician before planning for pregnancy and inform him about the family history of any congenital defects and the medications using currently, so that he may give suggestions or recommend some lifestyle modifications to avoid the risk of heart defects.
  • Healthy diet: Having a balanced diet including vitamins and folic acid during pregnancy will help in giving birth to a healthy child without any heart defects.
  • Regular exercise under the supervision of a gynecologist is necessary during pregnancy.
  • Avoid alcohol, tobacco and harmful drug use during pregnancy to prevent the risk of VSD.
  • Get vaccinated: Check whether you are vaccinated for vaccine-preventable infections before getting pregnant.
  • Control diabetes: Monitor your sugar levels regularly to prevent the risk of heart defects.


Heart consists of four chambers, of which upper two chambers are called as atria and lower two chambers are called as ventricles. Atrial septal defect (ASD) is a type of congenital heart defect, in which there is an abnormal opening or a hole in interatrial septum (dividing wall between two atria). This opening allows the passage of pulmonary venous blood from left atrium to right atrium, causing mixing of oxygenated and deoxygenated blood in right atrium and increasing the flow of blood to lungs. The increased blood flow may increase the workload of the lungs, and eventually cause lung damage.


The exact cause of ASD remains unclear. However, it is believed that during fetal developmental stages, a hole is present in the interatrial septum, which gradually closes before birth or during infancy. If the hole persists, it is called an atrial septal defect.


Based on the location and development of ASD, it is classified into four types:

  • Ostium secundum ASD (75%): It occurs in the middle part of the interatrial septum.
  • Ostium primum ASD (20%): It occurs in the lower part of the interatrial septum, adjacent to atrioventricular (AV) valves.
  • Sinus venosis ASD (4%): It occurs in the upper part of the interatrial septum, near the veins that drain into the right and left atrium.
  • Coronary sinus ASD (<1%): It occurs in the interatrial septum between the coronary sinus and the left atrium.

Signs and symptoms:

Usually after birth, babies who have ASD may not show any associated signs and symptoms. But, symptoms may appear during adulthood around the age of 30 years. Most of them don’t have any symptoms even after many years.

Some of the common symptoms associated with ASD are:

  • Heart murmur, a swishing sound that can be heard through a stethoscope
  • Heart palpitations
  • Arrhythmias (abnormal heart rhythms)
  • Fatigue (feeling tired mainly after exercise)
  • Shortness of breath
  • Swelling of legs, feet or abdomen
  • Stroke
  • Lung infections such as pneumonia

Risk factors:

Genetics and environmental factors usually play a role in congenital heart defects. Some conditions during pregnancy may confer high risk for heart defects, these conditions include:

  • Right-sided heart failure
  • Arrhythmias
  • Increased risk of a stroke
  • Shortened life span
  • Pulmonary hypertension (increased blood flow to the lungs results in increased blood pressure in the lung arteries)
  • Eisenmenger syndrome (pulmonary hypertension causing permanent lung damage)


Most ASDs are diagnosed incidentally during regular heath check-ups. If a heart murmur is heard during auscultation, you may be advised to undergo further tests to confirm the diagnosis of ASD:

  • Echocardiogram: It is a specific diagnostic test for ASD, and provides a detailed image of the heart and blood flow through its chambers. The echocardiogram may show the blood flow through the interatrial septum and the hole size in the septum.
  • Chest X-ray: It helps to identify enlarged heart and lung changes.
  • Electrocardiogram (ECG): It involves recording the electrical activity of the heart, to help identify arrhythmias.
  • Cardiac catheterization: A thin, flexible tube called catheter is inserted into the blood vessel at the groin or arm and is guided to the heart. This test is helpful to determine the function of heart and its valves, and to measure the blood pressure in the lungs.
  • Magnetic resonance imaging (MRI): It uses magnetic and radio waves to create three dimensional images of the heart and other organs. This test is recommended if the ASD is not clearly diagnosed with echocardiogram.
  • Computerized tomography (CT) scan: It uses a series of X-rays to create detailed images of heart; mainly used if echocardiogram doesn’t help to diagnose ASD clearly.


Treatment of ASD depends on the age at diagnosis and the size, location and severity of the defect. Small ASDs might not need any treatment because it closes on its own. The doctor may recommend surgery if the atrial septal defect is large, even with fewer symptoms to prevent problems later in life. Treatment of ASD includes medications and surgery.

  • Medications usually do not help in closing the hole, but reduces the signs and symptoms associated with ASD and risks of complications after surgery. Drugs such as beta blockers (to maintain regular heartbeat) and anticoagulants (to prevent the formation of blood clots) are used.
  • Surgery includes cardiac catheterization and open-heart surgery.
    In cardiac catheterization, the doctor closes the hole in the septum with a mesh patch or a plug in the defect place using a catheter. The heart tissue then grows around the mesh slowly, sealing the hole permanently. This procedure is mainly performed to repair only the secundum type of atrial septal defects. Defects not amenable to closure with device may need open-heart surgery.
    In open-heart surgery, the defect may be closed with stitches or a special patch. This procedure is done under general anesthesia, mainly for repairing primum, sinus venosus and coronary sinus atrial septal defects.


Atrial septal defects cannot be prevented, but following certain measures during pregnancy might be beneficial to prevent the risk of ASD, such as:

  • Immunity test for rubella: If the person is not immune to rubella, it is necessary to get vaccinated.
  • Monitoring current health conditions and medications use: Pre-existing health conditions and usage of any medications should be carefully monitored during pregnancy to prevent the risk of ASD.
  • Reviewing family medical history: If a person has a family history of congenital defects, it is advised to visit a genetic counsellor before becoming pregnant to know the risks of atrial septal defects.




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.


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.


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.


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.


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.


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.


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.



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)


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.

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.


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

Your heart needs to work 24/7 to keep your body systems working. Like any other body tissue, the heart too needs oxygen and nutrients to function efficiently. For this, we have a network of arteries that supply blood to the heart muscles which are called the coronary arteries. There are two chief coronary arteries:

the left and right coronary arteries, that branch out from the aorta near the point where the aorta and the left ventricle meet.

The right coronary artery supplies blood to the right atrium, the right ventricle, a small bottom area of the left ventricle and the back portion of the septum.

The left coronary artery supplies blood to the left atrium and ventricles and the front portion of the septum.

These coronary arteries give out various branches that supply blood to different parts of the heart.

Coronary artery disease:

When there is high level of unhealthy fats in the blood, they gradually start depositing in the insides of the coronary artery vessel wall and form a fatty plaque(atherosclerosis). This gradually narrows the lumen of the coronary arteries which obstructs blood supply to the heart. This condition is called as coronary artery disease. disruption of blood supply to the heart gives rise to a cluster of symptoms, the most important being chest pain or angina.

  • Warning signs of heart disease
  • Risk factors for heart disease
  • Possible complications of heart disease

Your lifestyle, age, family history and your other health condition can dictate your risk to develop a heart disease. However, the three key risk factors are- smoking, high blood pressure and high cholesterol. Learn about the risk factors and see if you are at risk:

  1. High blood pressure: It is an important factor for many diseases. Blood pressure, if not controlled, can lead to heart disease, stroke, kidney failure and other organ system disorders. Decreasing blood pressure by lifestyle changes and medication can greatly reduce your risk for heart disease.
  2. High cholesterol: Did you know that our hardworking liver can generate all the cholesterol that our bodies need? But we all do take in extra bad cholesterol from diet. These bad cholesterol tend to get deposited in our blood vessels and cause heart disease.
  3. Smoking: Cigarette smoking damages your heart and blood vessels. Nicotine present in cigarette smoke also reduces the amount of oxygen that your blood can carry. Not only that, if you smoke, the people around you are also at a higher risk of getting heart disease.
  4. Obesity: Obesity is linked with high level of bad cholesterol level and low levels of good cholesterol levels. Obesity is not only a risk factor for heart disease, but also increases risk of diabetes and high blood pressure.
  5. Diabetes: People with diabetes or high blood sugars are at greater risk of having heart disease than those who don’t have diabetes.
  6. Unhealthy diet: Oily, junk foods which are high in bad cholesterol, saturated fats and trans fats an can increase your risk of heart disease. Foods that are very salty(have high sodium levels) can also increase your risk of high blood pressure and heart disease.
  7. Physical inactivity: Physical inactivity increase your risk of having high blood pressure and diabetes and eventually heart disease.
  8. Alcohol: Excess and frequent alcohol intake can increase the risk of high blood pressure and hypercholesterolemia. Ideally, women shouldn’t have more than 1 drink a day and men shouldn’t have more than 2 drinks a day.
  9. Family history: Genetic factors seem to play a role in conditions like high blood pressure and heart diseases. However, it is also likely that the members of the family sharing common external environments and culture may be exposed to the same set of risk factors for heart diseases.
  10. Age: The risk of heart disease increases as the a person ages.





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Copyright © 2019, Dr C Raghu. All rights reserved.
Designed & Developed by R R Deepak Kambhampati.

Copyright © 2019, Dr C Raghu. All rights reserved.
Designed & Developed by R R Deepak Kambhampati.

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