essay on coronary heart disease

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Coronary Heart Disease What Is Coronary Heart Disease?

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Coronary artery disease affects the larger coronary arteries on the surface of the heart. Another type of heart disease, called coronary microvascular disease, affects the tiny arteries within the heart muscle. Coronary microvascular disease is more common in women .

The  cause  of coronary heart disease depends on the type. Coronary artery disease is often caused by cholesterol, a waxy substance that builds up inside the lining of the coronary arteries, forming plaque. This plaque buildup can partially or totally block blood flow in the large arteries of the heart. Coronary microvascular disease occurs when there is damage to the inner walls of the heart’s small blood vessels. For most people, coronary heart disease is preventable with a  heart-healthy lifestyle and medications.

Symptoms  of coronary heart disease may be different from person to person even if they have the same type of coronary heart disease. However, because many people have no symptoms, they do not know they have coronary heart disease until they have chest pain; blood flow to the heart is blocked, causing a  heart attack ; or the heart suddenly stops pumping blood, also known as  cardiac arrest .

If you have coronary heart disease, you may need heart-healthy lifestyle changes, medicines, surgery, or a combination of these approaches to manage your condition and prevent serious problems .

Know the Difference Fact Sheet

Learn basic facts about coronary heart disease.

• Patient Care & Health Information
• Diseases & Conditions
• Coronary artery disease

Coronary artery disease (CAD) is a common type of heart disease. It affects the main blood vessels that supply blood to the heart, called the coronary arteries. In CAD, there is reduced blood flow to the heart muscle. A buildup of fats, cholesterol and other substances in and on the artery walls, a condition called atherosclerosis, usually causes coronary artery disease. The buildup, called plaque, makes the arteries narrow.

Coronary artery disease often develops over many years. Symptoms are from the lack of blood flow to the heart. They may include chest pain and shortness of breath. A complete blockage of blood flow can cause a heart attack.

Treatment for coronary artery disease may include medicines and surgery. Eating a nutritious diet, getting regular exercise and not smoking can help prevent coronary artery disease and the conditions that can cause it.

Coronary artery disease also may be called coronary heart disease.

• What is coronary artery disease? A Mayo Clinic cardiologist explains.

Stephen Kopecky, M.D., talks about the risk factors, symptoms and treatment of coronary artery disease (CAD). Learn how lifestyle changes can lower your risk.

{Music playing}

Stephen Kopecky, M.D., Cardiovascular Disease, Mayo Clinic: I'm Dr. Stephen Kopecky, a cardiologist at Mayo Clinic. In this video, we'll cover the basics of coronary artery disease. What is it? Who gets it? The symptoms, diagnosis and treatment. Whether you're looking for answers for yourself or someone you love, we're here to give you the best information available.

Coronary artery disease, also called CAD, is a condition that affects your heart. It is the most common heart disease in the United States. CAD happens when coronary arteries struggle to supply the heart with enough blood, oxygen and nutrients. Cholesterol deposits, or plaques, are almost always to blame. These buildups narrow your arteries, decreasing blood flow to your heart. This can cause chest pain, shortness of breath or even a heart attack. CAD typically takes a long time to develop. So often, patients don't know that they have it until there's a problem. But there are ways to prevent coronary artery disease, and ways to know if you're at risk and ways to treat it.

Who gets it?

Anyone can develop CAD . It begins when fats, cholesterols and other substances gather along the walls of your arteries. This process is called atherosclerosis. It's typically no cause for concern. However, too much buildup can lead to a blockage, obstructing blood flow. There are a number of risk factors, common red flags, that can contribute to this and ultimately lead to coronary artery disease. First, getting older can mean more damaged and narrowed arteries. Second, men are generally at a greater risk. But the risk for women increases after menopause. Existing health conditions matter, too. High blood pressure can thicken your arteries, narrowing your blood flow. High cholesterol levels can increase the rate of plaque buildup. Diabetes is also associated with higher risk, as is being overweight. Your lifestyle plays a large role as well. Physical inactivity, long periods of unrelieved stress in your life, an unhealthy diet and smoking can all increase your risk. And finally, family history. If a close relative was diagnosed at an early age with heart disease, you're at a greater risk. All these factors together can paint a picture of your risk for developing CAD .

What are the symptoms?

When coronary arteries become narrow, the heart doesn't get enough oxygen-rich blood. Remember, unlike most pumps, the heart has to pump its own energy supply. It's working harder with less. And you may begin to notice these signs and symptoms of pressure or tightness in your chest. This pain is called angina. It may feel like somebody is standing on your chest. When your heart can't pump enough blood to meet your body's needs, you might develop shortness of breath or extreme fatigue during activities. And if an artery becomes totally blocked, it leads to a heart attack. Classic signs and symptoms of a heart attack include crushing, substernal chest pain, pain in your shoulders or arms, shortness of breath, and sweating. However, many heart attacks have minimal or no symptoms and are found later during routine testing.

How is it diagnosed?

Diagnosing CAD starts by talking to your doctor. They'll be able to look at your medical history, do a physical exam and order routine blood work. Depending on that, they may suggest one or more of the following tests: an electrocardiogram or ECG, an echocardiogram or soundwave test of the heart, stress test, cardiac catheterization and angiogram, or a cardiac CT scan.

How is it treated?

Treating coronary artery disease usually means making changes to your lifestyle. This might be eating healthier foods, exercising regularly, losing excess weight, reducing stress or quitting smoking. The good news is these changes can do a lot to improve your outlook. Living a healthier life translates to having healthier arteries. When necessary, treatment could involve drugs like aspirin, cholesterol-modifying medications, beta-blockers, or certain medical procedures like angioplasty or coronary artery bypass surgery.

Discovering you have coronary artery disease can be overwhelming. But be encouraged. There are things you can do to manage and live with this condition. Reducing cholesterol, lowering blood pressure, quitting tobacco, eating healthier, exercising and managing your stress can make a world of difference. Better heart health starts by educating yourself. So don't be afraid to seek out information and ask your doctors about coronary artery disease. If you'd like to learn even more about this condition, watch our other related videos or visit Mayoclinic.org. We wish you well.

Symptoms of coronary artery disease happen when the heart doesn't get enough oxygen-rich blood. Coronary artery disease symptoms may include:

• Chest pain, called angina. You may feel squeezing, pressure, heaviness, tightness or pain in the chest. It may feel like somebody is standing on your chest. The chest pain usually affects the middle or left side of the chest. Activity or strong emotions can trigger angina. There are different types of angina. The type depends on the cause and whether rest or medicine makes symptoms better. In some people, especially women, the pain may be brief or sharp and felt in the neck, arm or back.
• Shortness of breath. You may feel like you can't catch your breath.
• Fatigue . If the heart can't pump enough blood to meet your body's needs, you may feel unusually tired.

Symptoms of coronary artery disease may not be noticed at first. Sometimes symptoms only happen when the heart is beating hard, such as during exercise. As the coronary arteries continue to narrow, symptoms can get more severe or frequent.

A completely blocked coronary artery will cause a heart attack. Common heart attack symptoms include:

• Chest pain that may feel like pressure, tightness, squeezing or aching.
• Pain or discomfort that spreads to the shoulder, arm, back, neck, jaw, teeth or sometimes the upper belly.
• Cold sweats.
• Shortness of breath.
• Lightheadedness or sudden dizziness.

Chest pain is usually the most common symptom of heart attack. But for some people, such as women, the elderly and those with diabetes, symptoms may seem unrelated to a heart attack. For example, they may have nausea or a very brief pain in the neck or back. Some people having a heart attack don't notice symptoms.

When to see a doctor

If you think you're having a heart attack, immediately call 911 or your local emergency number. If you don't have access to emergency medical services, have someone drive you to the nearest hospital. Drive yourself only as a last option.

Smoking or having high blood pressure, high cholesterol, diabetes, obesity or a strong family history of heart disease makes you more likely to get coronary artery disease. If you're at high risk of coronary artery disease, talk to your healthcare professional. You may need tests to check for narrowed arteries and coronary artery disease.

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Development of atherosclerosis

If there's too much cholesterol in the blood, the cholesterol and other substances may form deposits called plaque. Plaque can cause an artery to become narrowed or blocked. If a plaque ruptures, a blood clot can form. Plaque and blood clots can reduce blood flow through an artery.

Coronary artery disease is caused by the buildup of fats, cholesterol and other substances in and on the walls of the heart arteries. This condition is called atherosclerosis. The buildup is called plaque. Plaque can cause the arteries to narrow, blocking blood flow. The plaque also can burst, causing a blood clot.

Some causes of atherosclerosis and coronary artery disease are:

• Diabetes or insulin resistance.
• High blood pressure.
• Lack of exercise.
• Smoking or tobacco use.

Risk factors

Coronary artery disease is common.

Coronary artery disease risk factors you can't control include:

• Age. Getting older increases the risk of damaged and narrowed arteries.
• Birth sex. Men are generally at greater risk of coronary artery disease. However, the risk for women increases after menopause.
• Family history. A family history of heart disease makes you more likely to get coronary artery disease. This is especially true if a parent, brother, sister or child got heart disease at an early age. The risk is highest if your father or a brother had heart disease before age 55 or if your mother or a sister developed it before age 65.

Coronary artery disease risk factors you can control are:

• Smoking. If you smoke, quit. Smoking is bad for heart health. People who smoke have a much greater risk of heart disease. Breathing in secondhand smoke also increases the risk.
• High blood pressure. Uncontrolled high blood pressure can make arteries hard and stiff. This can lead to atherosclerosis, which causes coronary artery disease.
• Cholesterol. Too much "bad" cholesterol in the blood can increase the risk of atherosclerosis. "Bad" cholesterol is called low-density lipoprotein (LDL) cholesterol. Not enough "good" cholesterol, called high-density lipoprotein (HDL) cholesterol, also leads to atherosclerosis.
• Diabetes. Diabetes increases the risk of coronary artery disease. Type 2 diabetes and coronary artery disease share some risk factors, such as obesity and high blood pressure.
• Obesity. Too much body fat is bad for overall health. Obesity can lead to type 2 diabetes and high blood pressure. Ask your healthcare team what a healthy weight is for you.
• Chronic kidney disease. Having long-term kidney disease increases the risk of coronary artery disease.
• Not getting enough exercise. Physical activity is important for good health. A lack of exercise is linked to coronary artery disease and some of its risk factors.
• A lot of stress . Emotional stress may damage the arteries and worsen other risk factors for coronary artery disease.
• Unhealthy diet. Eating foods with a lot of saturated fat, trans fat, salt and sugar can increase the risk of coronary artery disease.
• Alcohol use. Heavy alcohol use can lead to heart muscle damage. It also can worsen other risk factors of coronary artery disease.
• Amount of sleep. Too little sleep and too much sleep both have been linked to an increased risk of heart disease.

Risk factors often happen together. One risk factor may trigger another. When grouped together, some risk factors make you even more likely to develop coronary artery disease. For example, metabolic syndrome is a group of conditions that includes high blood pressure, high blood sugar, too much body fat around the waist and high triglyceride levels. Metabolic syndrome increases the risk of coronary artery disease.

Other possible risk factors for coronary artery disease may include:

• Breathing pauses during sleep, called obstructive sleep apnea. This condition causes breathing to stop and start during sleep. It can cause sudden drops in blood oxygen levels. The heart must work harder to pump blood. Blood pressure goes up.
• Increased high-sensitivity C-reactive protein (hs-CRP). This protein appears in higher than usual amounts when there's inflammation somewhere in the body. High hs-CRP levels may be a risk factor for heart disease. It's thought that as coronary arteries narrow, the level of hs-CRP in the blood goes up.
• High triglycerides. This is a type of fat in the blood. High levels may raise the risk of coronary artery disease, especially for women.
• High levels of homocysteine. Homocysteine is a substance that the body uses to make protein and to build and maintain tissue. But high levels of homocysteine may raise the risk of coronary artery disease.
• Preeclampsia. This pregnancy complication causes high blood pressure and increased protein in the urine. It can lead to a higher risk of heart disease later in life.
• Other pregnancy complications. Diabetes or high blood pressure during pregnancy are known risk factors for coronary artery disease.
• Certain autoimmune diseases. People who have conditions such as rheumatoid arthritis and lupus have an increased risk of atherosclerosis.

Complications

Complications of coronary artery disease may include:

• Chest pain, also called angina. This is a symptom of coronary artery disease. But it also can be a complication of worsening CAD. The chest pain happens when arteries narrow and the heart doesn't get enough blood.
• Heart attack. A heart attack can happen if atherosclerosis causes a blood clot. A clot can block blood flow. The lack of blood can damage the heart muscle. The amount of damage depends in part on how quickly you are treated.
• Heart failure. Narrowed arteries in the heart or high blood pressure can slowly make the heart weak or stiff. This can make it harder for the heart to pump blood.
• Irregular heart rhythms, called arrhythmias. If the heart doesn't get enough blood, changes in heart signaling can happen. This can cause irregular heartbeats.

Coronary artery disease care at Mayo Clinic

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• Scientific Report of the 2020 Dietary Guidelines Advisory Committee. Alcoholic beverages. U.S. Department of Health and Human Services and U.S. Department of Agriculture. https://www.dietaryguidelines.gov/2020-advisory-committee-report. Accessed Feb. 1, 2024.
• Heart disease in women. American Heart Association. https://www.heart.org/en/health-topics/heart-attack/warning-signs-of-a-heart-attack/heart-attack-symptoms-in-women. May 8, 2024.
• Angina treatment: Stents, drugs, lifestyle changes — What's best?
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News from Mayo Clinic

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Prevention of Heart Failure in Hypertension - the Role of Coronary Heart Disease Events Treated with Versus without Revascularization: the ALLHAT Study

Affiliations.

• 1 Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH.
• 2 University of Texas School of Public Health, Houston, TX.
• 3 Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH.
• 4 Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH; Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH. Electronic address: [email protected].
• PMID: 39243877
• DOI: 10.1016/j.amjcard.2024.08.033

In modern clinical practice, less than half of new-onset heart failure (HF) patients undergo ischemic evaluation, and only a minority undergo revascularization. We aimed to assess the proportion of the effect of hypertension (antihypertensive treatment) on incident HF to be eliminated by prevention of CHD event treated with or without revascularization, considering possible treatment-mediator interaction. Causal mediation analysis of ALLHAT included 42,418 participants (age 66.9±7.7; 35.6% black, 53.2% men). A new CHD event (myocardial infarction or angina) that occurred after randomization but before the incident HF outcome was the mediator. Incident symptomatic congestive HF (CHF) and hospitalized/fatal HF (HHF) were the primary and secondary outcomes. Logistic regression (for mediator) and Cox proportional hazards regression (for outcome) were adjusted for demographics, cardiovascular disease history, and risk factors. During a median 4.5-year follow-up, 2,785 patients developed CHF, including 2,216 HHF events. Participants who developed CHD events had twice the higher incidence rate of CHF than CHD-free (28.5 vs 13.9 events/ 1,000 person-years). The proportion of reference interaction indicating direct harm due to CHD event for lisinopril (234% for CHF; 355% for HHF) and amlodipine (244% for CHF; 468% for HHF) was greater than for chlorthalidone (143% for CHF; 269% for HHF). In patients with revascularized CHD events, chlorthalidone and amlodipine eliminated 21-24%, and lisinopril - 45% of HHF. Antihypertensive treatment was not able to eliminate harm from CHD events treated without revascularization. In conclusion, the antihypertensive drugs (chlorthalidone, lisinopril, amlodipine) prevent HF not principally by preventing CHD events but via other pathways. HF is moderated but not mediated by CHD events. Revascularization of CHD events is paramount for HF prevention.

Keywords: causal mediation analysis; coronary heart disease; heart failure; hypertension; myocardial revascularization.

Copyright © 2024. Published by Elsevier Inc.

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Conflict of interest statement

Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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Diet and heart disease risk

Actions for this page.

• Diet is an important risk factor in coronary heart disease.
• Food-related risk factors include obesity, high blood pressure, uncontrolled diabetes and a diet high in saturated fats.
• A low-saturated fat, high-fibre, high plant food diet can substantially reduce the risk of developing heart disease.

On this page

Heart disease, characteristics of heart disease, risk factors for heart disease, dietary fats and cholesterol levels, blood pressure and salt (sodium), reduce your heart disease risk with healthy eating, foods important for heart health, how to reduce your risk of heart disease with healthy eating, where to get help.

Heart disease is the number one cause of death in Australia – in 2021, 10% of all deaths were as a result of coronary heart disease and 25% of deaths were a result of cardiovascular disease. Although there is not one single cause, an unhealthy diet can be one of the contributing risk factors for heart disease.

Paying attention to what you eat and consuming a variety of healthy foods from the 5 food groups is one of the most important preventative measures you can take.

Heart disease results from the narrowing of the arteries that supply the heart with blood through a process known as atherosclerosis. Fatty deposits (or plaque) gradually build up on the inside of the artery walls, narrowing the space in which blood can flow to the heart. Atherosclerosis can start when you are young, so by the time you reach middle age, it can be quite advanced.

Plaque build-up can be considered as stable or unstable. If there is too much build-up of stable plaque, it narrows the arteries, causing pain and discomfort due to not enough blood reaching the heart – this is called angina and it needs to be treated.

Unstable plaque is inflamed and has a thin cap which is prone to developing a crack, allowing the blood to come in contact with the fatty contents of the plaque. The blood will clot to try to seal the gap but in doing so, the blood clot blocks the artery. This prevents the flow of blood to the heart, cuts off its oxygen supply and damages or kills the heart cells. This is a heart attack .

There are many factors that can increase your risk of heart disease . Although some of these cannot be changed, the good news is that there are plenty of risk factors within your control. For example, by being physically active , ensuring you have good social support and not smoking , your risk of heart disease is reduced.

Some risk factors are connected. For example, cholesterol levels and blood pressure can be affected by diet, as can your body weight and management of diabetes.

Therefore, one of the best things you can do to reduce your risk of heart disease is to have a healthy diet and maintain a healthy weight!

Cholesterol is a fat crucial to many metabolic functions and is an essential part of all the body’s cell membranes. It is made by the body from the food we eat and is produced in the liver.

Blood lipids (fats) that contain cholesterol include low-density lipoprotein (LDL) and high-density lipoprotein (HDL). LDL (‘bad’) cholesterol can lead to plaque forming in the arteries while HDL (‘good’) cholesterol helps to remove cholesterol from the body and makes it harder for plaque to form in the arteries.

Saturated fats

Saturated fats (also known as ‘bad fats’) tend to increase LDL (‘bad’) cholesterol in the blood. Common sources of saturated fats include – animal products (butter, coconut oil, meat fat including lard and dripping, beef, lamb, chicken skin and palm oil), and processed foods like pastries and biscuits.

Full fat or reduced fat dairy?

Although full fat dairy foods (such as milk , cheese and yoghurt) contain saturated fat, it appears this type of fat has a neutral relationship with heart health.

The Heart Foundation recommends unflavoured milk, yoghurt and cheese can be consumed by the general population but for people who need to lower their LDL cholesterol, reduced fat versions should be consumed instead.

It was once thought cholesterol naturally found in eggs was bad for heart health. However, research suggests eggs have a neutral relationship with heart health – they neither increase nor decrease the risk of heart disease for the general population.

For people who need to lower their LDL cholesterol or those with type 2 diabetes , the Heart Foundation recommends a maximum of 7 eggs per week.

Like saturated fats, trans fats tend to increase LDL (bad) cholesterol in the blood but they also tend to reduce HDL (good) cholesterol levels. So, they are more damaging to our health and can increase our risk of cardiovascular diseases (such as heart disease and stroke ).

Trans fatty acids form when monounsaturated or polyunsaturated vegetable oils are ‘hydrogenated’ and hardened to form margarines, oils for deep frying and shortening for baked products.

These harder vegetable fats and shortenings are used by the food industry in processed foods (such as cakes and biscuits and deep-fried takeaway meals).

Some trans fatty acids also occur naturally in some meats, butter and dairy products.

Most monounsaturated and polyunsaturated table margarines sold in Australia have very low levels of trans fatty acids and are a preferred substitute to butter, which contains saturated fat.

Monounsaturated and polyunsaturated fats

Reduce your risk of heart disease, by replacing energy intake from saturated and trans (‘bad fats’) in your diet with unsaturated (‘good fats’).

Substitute butter, coconut and palm oil, lard, dripping and copha with oils made from seeds or plants (such as olive, avocado, sunflower, canola, safflower, peanut, soybean and sesame).

Other sources of unsaturated fats include unsalted nuts, seeds (including chia, tahini and linseed) and avocado.

A diet high in salt is linked to hypertension (high blood pressure) , which can increase your risk of heart disease and stroke. Most of us consume more than 10 times the amount of salt we need to meet our sodium requirements (salt contains sodium and chloride).

Most of the sodium in our diet is not from added salt at the table, but from packaged and processed foods . Even sweet foods and those that don’t taste ‘salty’ can have much more sodium than you’d expect!

A simple way to cut down on the amount of sodium in your diet is to reduce the amount of processed foods, limit fast food and use herbs and spices for flavour.

Eating a variety of foods is beneficial to our health and can help reduce our risk of disease (including heart disease). Try to eat a wide variety of foods from each of the 5 food group s , in the amounts recommended. Not only does this help you maintain a healthy and interesting diet, but it provides essential nutrients to the body.

The Heart Foundation recommends:

• plenty of vegetables, fruits and wholegrains
• a variety of healthy protein sources (especially fish and seafood), legumes (such as beans and lentils), nuts and seeds. Smaller amounts of eggs and lean poultry can also be included in a heart healthy diet. If choosing red meat, make sure it is lean and unprocessed, or minimally processed, and limit to one to 3 times a week
• unflavoured milk, yoghurt and cheese. Those with high blood cholesterol should choose reduced fat varieties
• healthy fat choices – nuts, seeds, avocados, olives and their oils for cooking
• herbs and spices to flavour foods, instead of adding salt.

Also, be mindful on how much you are eating and whether you are filling up on unhealthy foods. Portion sizes have increased over time and many of us are eating more than we need which can lead to obesity and increase our risk of cardiovascular disease.

Ideally, a healthy plate would include servings of – ¼ protein, ¼ carbohydrates and ½ vegetables.

Although there is no one ‘magic’ food to lower our risk of developing heart disease, there is some evidence that some foods are important for heart health. These include:

• oily fish – such as mackerel, sardines, tuna and salmon which contain omega-3 fatty acids. This type of fat has been shown to decrease triglycerides (a type of fat) and increase HDL-cholesterol levels, improve blood vessel elasticity and thin the blood, making it less likely to clot and block blood flow
• some vegetables oils – such as corn, soy and safflower (which contain omega-6 fatty acids), and those containing omega-3 fatty acids (such as canola and olive oil). All of these can help to lower LDL cholesterol when used instead of saturated fats such as butter
• fruit and vegetables – fibre , potassium and other micronutrients (such as antioxidants ) in fruit and vegetables offer protection against heart disease. They are also an important source of folate – which helps lower the blood levels of the amino acid homocysteine, which appears to be linked to an increased risk of heart disease
• wholegrains – a diet high in fibre from wholegrain cereals is linked to reduced LDL cholesterol and lowered heart disease risk. Foods with high levels of soluble fibre (for example, oats, legumes and barley) are great for lowering total cholesterol levels
• unrefined carbohydrate sources with a low glycaemic load – such as wholegrain breads and cereals, legumes, certain types of rice and pasta, and most fruits and vegetables also help to lower blood triglycerides and glucose (sugar) levels, help manage diabetes and reduce heart disease risk
• legumes, nuts and seeds – are good sources of plant proteins, fibre, healthy fats and micronutrients to help lower your cardiovascular risk
• tea – some research suggests antioxidants in tea can help prevent the build-up of fatty deposits in the arteries. They may also act as an anti-blood clotting agent and improve blood vessel dilation to allow increased blood flow
• foods containing vitamin E – some studies indicate that vitamin E acts as an antioxidant, helping to protect against LDL cholesterol. Sources of vitamin E include – avocados, dark green vegetables, vegetable oils and wholegrain products. Eat foods containing vitamin E rather than supplements , which have not been shown to have the same protective effects
• garlic – a compound in fresh garlic (called allicin) has been found to lower total and LDL cholesterol in the blood, thereby reducing the risk of heart disease
• foods enriched with plant sterols – a daily intake of 2 to 3 g of phytosterols/stanols lowers LDL cholesterol levels by approximately 10% in healthy people, and those with high cholesterol or diabetes. This equates to 2 to 3 serves of phytosterol-enriched foods like margarine spreads, yoghurts, milk and breakfast cereals.

Try these steps to reduce your risk of developing heart disease:

• Limit fried fast food and processed foods.
• Replace energy from saturated fats (such as butter, coconut oil and cream) with healthy unsaturated fats from seeds and plants (such as extra virgin olive oil, avocado, sunflower, canola, safflower, peanut, soybean and sesame) and foods such as nuts, seeds, avocado, olives and soy.
• Increase the amount and variety of plant foods – eat more vegetables, fruits and wholegrain cereals.
• Reduce intake of refined sources of carbohydrates with higher glycaemic indices (including foods with added sugars).
• Limit unprocessed red meats (such as beef, veal, mutton, lamb, pork, kangaroo, rabbit, and other game meats) to a maximum of 350 g (cooked weight) per week and avoid processed meat (such as sausages, ham, salami and prosciutto).
• Trim all visible fat from meat and remove skin from poultry.
• Eat legumes regularly – like baked beans (reduced salt), soybeans, lentils and tofu.
• Snack on a handful of raw, unsalted nuts on most days of the week (especially walnuts and almonds).
• Eat oily fish at least once per week.
• Reduce your salt intake – avoid packaged and processed foods, limit fast foods and salty foods. Replace salt at the table and in cooking, with herbs and spices for flavour.
• Check the sodium content of foods and choose the lowest sodium products.
• If you have elevated cholesterol levels, switch to low-fat or non-fat dairy products and have no more than 7 eggs per week.
• If you drink alcohol, have no more than 2 standard drinks on any one day. A high alcohol intake increases blood pressure and can increase triglycerides in the blood.
• Your GP (doctor)
• Heart Foundation External Link Tel. 13 11 12 or [email protected]
• Dietitians Australia External Link Tel. 1800 812 942
• Diabetes Victoria External Link Tel. 1300 437 386
• Community health centre
• Australian guide to healthy eating External Link
• Your heart External Link , Heart Foundation.
• Heart, stroke and vascular disease: Australian facts External Link , 2023, Australian Institute of Health and Welfare (AIHW).
• Nutrition position statements External Link , Heart Foundation.
• Barkas F, Nomikos T, Liberopoulos E, et al. 2020, ‘Diet and cardiovascular disease risk among individuals with familial hypercholesterolemia: systematic review and meta-analysis’ External Link , Nutrients, vol. 12, no. 8, p.2436.
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• Galli F, Azzi A, Birringer M, et al. 2017, ‘ Vitamin E: Emerging aspects and new directions External Link ’, Free Radical Biology and Medicine, vol. 102, pp. 16-36.
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• Review Article
• Published: 03 April 2012

Stress and cardiovascular disease

• Andrew Steptoe 1 &
• Mika Kivimäki 1  

Nature Reviews Cardiology volume  9 ,  pages 360–370 ( 2012 ) Cite this article

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• Coronary artery disease and stable angina
• Myocardial infarction
• Public health
• Stress and resilience

The physiological reaction to psychological stress, involving the hypothalamic–pituitary–adrenocortical and sympatho–adrenomedullary axes, is well characterized, but its link to cardiovascular disease risk is not well understood. Epidemiological data show that chronic stress predicts the occurrence of coronary heart disease (CHD). Employees who experience work-related stress and individuals who are socially isolated or lonely have an increased risk of a first CHD event. In addition, short-term emotional stress can act as a trigger of cardiac events among individuals with advanced atherosclerosis. A stress-specific coronary syndrome, known as transient left ventricular apical ballooning cardiomyopathy or stress (Takotsubo) cardiomyopathy, also exists. Among patients with CHD, acute psychological stress has been shown to induce transient myocardial ischemia and long-term stress can increase the risk of recurrent CHD events and mortality. Applications of the 'stress concept' (the understanding of stress as a risk factor and the use of stress management) in the clinical settings have been relatively limited, although the importance of stress management is highlighted in European guidelines for cardiovascular disease prevention.

Psychological stress contributes to cardiovascular disease at several stages, including the long-term development of coronary heart disease and acute triggering of cardiac events

Disturbances of inflammatory, hemostatic, and autonomic processes are likely to be the mechanisms by which short-term psychological stress triggers acute myocardial infarction

Chronic stress at work and in private life is associated with a 40–50% increase in the occurrence of coronary heart disease in prospective observational studies

Indicators of elevated long-term stress, such as social isolation and work-related stress, are associated with poor prognosis among patients with established coronary heart disease

Stress-management interventions improve the quality of life of patients with advanced coronary heart disease, but effects on disease prognosis have been inconsistent

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M. Kivimäki is supported by the Medical Research Council, UK.

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Steptoe, A., Kivimäki, M. Stress and cardiovascular disease. Nat Rev Cardiol 9 , 360–370 (2012). https://doi.org/10.1038/nrcardio.2012.45

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• Continuing Education Activity

The cardiovascular system consists of the heart and its blood vessels. A wide array of problems can arise within the cardiovascular system, a few of which include endocarditis, rheumatic heart disease, and conduction system abnormalities. Cardiovascular disease, also known as heart disease, refers to the following 4 entities: coronary artery disease (CAD) which is also referred to as coronary heart disease (CHD), cerebrovascular disease, peripheral artery disease (PAD), and aortic atherosclerosis. CAD results from decreased myocardial perfusion that causes angina due to ischemia and can result in myocardial infarction (MI), and/or heart failure. It accounts for one-third to one-half of all cases of cardiovascular disease. Cerebrovascular disease is the entity associated with strokes, also termed cerebrovascular accidents, and transient ischemic attacks (TIAs). Peripheral arterial disease (PAD) is arterial disease predominantly involving the limbs that may result in claudication. Aortic atherosclerosis is the entity associated with thoracic and abdominal aneurysms. This activity reviews the evaluation and treatment of cardiovascular disease and the role of the medical team in evaluating and treating these conditions.

• Review the cause of coronary artery disease.
• Describe the pathophysiology of atherosclerosis.
• Summarize the treatment options for heart disease.
• Outline the evaluation and treatment of cardiovascular disease and the role of the medical team in evaluating and treating this condition.
• Introduction

The cardiovascular system consists of the heart and blood vessels. [1]  There is a wide array of problems that may arise within the cardiovascular system, for example, endocarditis, rheumatic heart disease, abnormalities in the conduction system, among others, cardiovascular disease (CVD) or heart disease refer to the following 4 entities that are the focus of this article [2] :

• Coronary artery disease (CAD): Sometimes referred to as Coronary Heart Disease (CHD), results from decreased myocardial perfusion that causes angina, myocardial infarction (MI), and/or heart failure. It accounts for one-third to one-half of the cases of CVD.
• Cerebrovascular disease (CVD): Including stroke and transient ischemic attack (TIA)
• Peripheral artery disease (PAD): Particularly arterial disease involving the limbs that may result in claudication
• Aortic atherosclerosis:  Including thoracic and abdominal aneurysms

Although CVD may directly arise from different etiologies such as emboli in a patient with atrial fibrillation resulting in ischemic stroke, rheumatic fever causing valvular heart disease, among others, addressing risks factors associated to the development of atherosclerosis is most important because it is a common denominator in the pathophysiology of CVD.

The industrialization of the economy with a resultant shift from physically demanding to sedentary jobs, along with the current consumerism and technology-driven culture that is related to longer work hours, longer commutes, and less leisure time for recreational activities, may explain the significant and steady increase in the rates of CVD during the last few decades. Specifically, physical inactivity, intake of a high-calorie diet, saturated fats, and sugars are associated with the development of atherosclerosis and other metabolic disturbances like metabolic syndrome, diabetes mellitus, and hypertension that are highly prevalent in people with CVD. [3] [2] [4] [5]

According to the INTERHEART study that included subjects from 52 countries, including high, middle, and low-income countries, 9 modifiable risks factors accounted for 90% of the risk of having a first MI: smoking, dyslipidemia, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits and vegetables, regular alcohol consumption, and physical inactivity. It is important to mention that in this study 36% of the population-attributable risk of MI was accounted to smoking. [6]

Other large cohort studies like the Framingham Heart Study [7] and the Third National Health and Nutrition Examination Survey (NHANES III) [5] have also found a strong association and predictive value of dyslipidemia, high blood pressure, smoking, and glucose intolerance. Sixty percent to 90% of CHD events occurred in subjects with at least one risk factor.

These findings have been translated into health promotion programs by the American Heart Association with emphasis on seven recommendations to decrease the risk of CVD: avoiding smoking, being physically active, eating healthy, and keeping normal blood pressure, body weight, glucose, and cholesterol levels. [8] [9]

On the other hand, non-modifiable factors as family history, age, and gender have different implications. [4] [7] Family history, particularly premature atherosclerotic disease defined as CVD or death from CVD in a first-degree relative before 55 years (in males) or 65 years (in females) is considered an independent risk factor. [10] There is also suggestive evidence that the presence of CVD risk factors may differently influence gender. [4] [7]  For instance, diabetes and smoking more than 20 cigarettes per day had increased CVD risk in women compared to men. [11] Prevalence of CVD increases significantly with each decade of life. [12]  

The presence of HIV (human immunodeficiency virus), [13]  history of mediastinal or chest wall radiation, [14]  microalbuminuria, [15] , increased inflammatory markers [16] [17]  have also been associated with an increased rate and incidence of CVD. 

Pointing out specific diet factors like meat consumption, fiber, and coffee and their relation to CVD remains controversial due to significant bias and residual confounding encountered in epidemiological studies. [18] [19]

• Epidemiology

Cardiovascular diseases (CVD) remain among the 2 leading causes of death in the United States since 1975 with 633,842 deaths or 1 in every 4 deaths, heart disease occupied the leading cause of death in 2015 followed by 595,930 deaths related to cancer. [2]  CVD is also the number 1 cause of death globally with an estimated 17.7 million deaths in 2015, according to the World Health Organization (WHO). The burden of CVD further extends as it is considered the most costly disease even ahead of Alzheimer disease and diabetes with calculated indirect costs of $237 billion dollars per year and a projected increased to $368 billion by 2035. [20]

Although the age-adjusted rate and acute mortality from MI have been declining over time, reflecting the progress in diagnosis and treatment during the last couple of decades, the risk of heart disease remains high with a calculated 50% risk by age 45 in the general population. [7] [21]  The incidence significantly increases with age with some variations between genders as the incidence is higher in men at younger ages. [2]  The difference in incidence narrows progressively in the post-menopausal state. [2]

• Pathophysiology

Atherosclerosis is the pathogenic process in the arteries and the aorta that can potentially cause disease as a consequence of decreased or absent blood flow from stenosis of the blood vessels. [22]

It involves multiple factors dyslipidemia, immunologic phenomena, inflammation, and endothelial dysfunction. These factors are believed to trigger the formation of fatty streak, which is the hallmark in the development of the atherosclerotic plaque [23] ; a progressive process that may occur as early as in the childhood. [24]  This process comprises intimal thickening with subsequent accumulation of lipid-laden macrophages (foam cells) and extracellular matrix, followed by aggregation and proliferation of smooth muscle cells constituting the formation of the atheroma plaque. [25]  As this lesions continue to expand, apoptosis of the deep layers can occur, precipitating further macrophage recruitment that can become calcified and transition to atherosclerotic plaques. [26]

Other mechanisms like arterial remodeling and intra-plaque hemorrhage play an important role in the delay and accelerated the progression of atherosclerotic CVD but are beyond the purpose of this article. [27]

• History and Physical

The clinical presentation of cardiovascular diseases can range from asymptomatic (e.g., silent ischemia, angiographic evidence of coronary artery disease without symptoms, among others) to classic presentations as when patients present with typical anginal chest pain consistent of myocardial infarction and/or those suffering from acute CVA presenting with focal neurological deficits of sudden onset. [28] [29] [28]

Historically, coronary artery disease typically presents with angina that is a pain of substernal location, described as a crushing or pressure in nature, that may radiate to the medial aspect of the left upper extremity, to the neck or the jaw and that can be associated with nausea, vomiting, palpitations, diaphoresis, syncope or even sudden death. [30]  Physicians and other health care providers should be aware of possible variations in symptom presentation for these patients and maintain a high index of suspicion despite an atypical presentation, for example, dizziness and nausea as the only presenting symptoms in patients having an acute MI [31] ), particularly in people with a known history of CAD/MI and for those with the presence of CVD risk factors. [32] [33] [34] [33] [32]  Additional chest pain features suggestive of ischemic etiology are the exacerbation with exercise and or activity and resolution with rest or nitroglycerin. [35]

Neurologic deficits are the hallmark of cerebrovascular disease including TIA and stroke where the key differentiating factor is the resolution of symptoms within 24 hours for patients with TIA. [36]  Although the specific symptoms depend on the affected area of the brain, the sudden onset of extremity weakness, dysarthria, and facial droop are among the most commonly reported symptoms that raise concern for a diagnosis of a stroke. [37] [38]  Ataxia, nystagmus and other subtle symptoms as dizziness, headache, syncope, nausea or vomiting are among the most reported symptoms with people with posterior circulation strokes challenging to correlate and that require highly suspicion in patients with risks factors. [39]

Patients with PAD may present with claudication of the limbs, described as a cramp-like muscle pain precipitated by increased blood flow demand during exercise that typically subsides with rest. [40] Severe PAD might present with color changes of the skin and changes in temperature. [41]  

Most patients with thoracic aortic aneurysm will be asymptomatic, but symptoms can develop as it progresses from subtle symptoms from compression to surrounding tissues causing cough, shortness of breath or dysphonia, to the acute presentation of sudden crushing chest or back pain due to acute rupture. [42]  The same is true for abdominal aortic aneurysms (AAA) that cause no symptoms in early stages to the acute presentation of sudden onset of abdominal pain or syncope from acute rupture. [43]

A thorough physical examination is paramount for the diagnosis of CVD. Starting with a general inspection to look for signs of distress as in patients with angina or with decompensated heart failure, or chronic skin changes from PAD. Carotid examination with the patient on supine position and the back at 30 degrees for the palpation and auscultation of carotid pulses, bruits and to evaluate for jugular venous pulsations on the neck is essential. Precordial examination starting with inspection, followed by palpation looking for chest wall tenderness, thrills, and identification of the point of maximal impulse should then be performed before auscultating the precordium. Heart sounds auscultation starts in the aortic area with the identification of the S1 and S2 sounds followed by characterization of murmurs if present. Paying attention to changes with inspirations and maneuvers to correctly characterize heart murmurs is encouraged. Palpating peripheral pulses with bilateral examination and comparison when applicable is an integral part of the CVD examination. [44]

Thorough clinical history and physical exam directed but not limited to the cardiovascular system are the hallmarks for the diagnosis of CVD. Specifically, a history compatible with obesity, angina, decreased exercise tolerance, orthopnea, paroxysmal nocturnal dyspnea, syncope or presyncope, and claudication should prompt the clinician to obtain a more detailed history and physical exam and, if pertinent, obtain ancillary diagnostic test according to the clinical scenario (e.g., electrocardiogram and cardiac enzymes for patients presenting with chest pain). 

Besides a diagnosis prompted by clinical suspicion, most of the efforts should be oriented for primary prevention by targeting people with the presence of risk factors and treat modifiable risk factors by all available means. All patient starting at age 20 should be engaged in the discussion of CVD risk factors and lipid measurement. [9]  Several calculators that use LDL-cholesterol and HDL-cholesterol levels and the presence of other risk factors calculate a 10-year or 30-year CVD score to determine if additional therapies like the use of statins and aspirin are indicated for primary prevention, generally indicated if such risk is more than ten percent. [10]  Like other risk assessment tools, the use of this calculators have some limitations, and it is recommended to exert precaution when assessing patients with diabetes and familial hypercholesterolemia as their risk can be underestimated. Another limitation to their use is that people older than 79 were usually excluded from the cohorts where these calculators were formulated, and individualized approach for these populations is recommended by discussing risk and benefits of adjunctive therapies and particular consideration of life expectancy. Some experts recommend a reassessment of CVD risk every 4 to 6 years. [9]

Preventative measures like following healthy food habits, avoiding overweight and following an active lifestyle are pertinent in all patients, particularly for people with non-modifiable risk factors such as family history of premature CHD or post-menopause. [9] [8]

The use of inflammatory markers and other risk assessment methods as coronary artery calcification score (CAC) are under research and have limited applications that their use should not replace the identification of people with known risk factors, nonetheless these resources remain as promising tools in the future of primary prevention by detecting people with subclinical atherosclerosis at risk for CVD. [45]

• Treatment / Management

Management of CVD is very extensive depending on the clinical situation (catheter-directed thrombolysis for acute ischemic stroke, angioplasty for peripheral vascular disease, coronary stenting for CHD); however, patients with known CVD should be strongly educated on the need for secondary prevention by risk factor and lifestyle modification. [9] [46]

• Differential Diagnosis
• Acute pericarditis
• Angina pectoris
• Artherosclerosis
• Coronary artery vasospasm
• Dilated cardiomyopathy
• Giant cell arteritis
• Hypertension
• Hypertensive heart disease
• Kawasaki disease
• Myocarditis

The prognosis and burden of CVD have been discussed in other sections.

• Complications

The most feared complication from CVD is death and, as explained above, despite multiple discoveries in the last decades CVD remains in the top leading causes of death all over the world owing to the alarming prevalence of CVD in the population. [2]  Other complications as the need for longer hospitalizations, physical disability and increased costs of care are significant and are the focus for health-care policymakers as it is believed they will continue to increase in the coming decades. [20]

For people with heart failure with reduced ejection fraction (HFreEF) of less than 35%, as the risk of life-threatening arrhythmias is exceedingly high in these patients, current guidelines recommend the implantation of an implantable-cardioverter defibrillator (ICD) for those with symptoms equivalent to a New York Heart Association (NYHA) Class II-IV despite maximal tolerated medical therapy. [47]

Strokes can leave people with severe disabling sequelae like dysarthria or aphasia, dysphagia, focal or generalized muscle weakness or paresis that can be temporal or cause permanent physical disability that may lead to a complete bedbound state due to hemiplegia with added complications secondary to immobility as is the higher risk of developing urinary tract infections and/or risk for thromboembolic events. [48] [49]

There is an increased risk of all-cause death for people with PAD compared to those without evidence of peripheral disease. [50]  Chronic wounds, physical limitation, and limb ischemia are among other complications from PAD. [51]

• Consultations

An interprofessional approach that involves primary care doctors, nurses, dietitians, cardiologists, neurologists, and other specialists is likely to improve outcomes. This has been shown to be beneficial in patients with heart failure, [52]  coronary disease, [53]  and current investigations to assess the impact on other forms of CVD are under planning and promise encouraging results.

• Deterrence and Patient Education

Efforts should be directed toward primary prevention by leading a healthy lifestyle, and an appropriate diet starting as early as possible with the goal of delay or avoid the initiation of atherosclerosis as it relates to the future risk of CVD. The AHA developed the concept of "ideal cardiovascular health" defined by the presence of [8] :

• Ideal health behaviors: Nonsmoking, body mass index less than 25 kg/m2, physical activity at goal levels, and the pursuit of a diet consistent with current guideline recommendations
• Ideal health factors: Untreated total cholesterol less than 200 mg/dL, untreated blood pressure less than 120/80 mm Hg, and fasting blood glucose less than 100 mg/dL) with the goal to improve the health of all Americans with an expected decrease in deaths from CVD by 20%

Specific attention should be made to people at higher risk for CVD as are people with diabetes, hypertension, hyperlipidemia, smokers, and obese patients. Risk factors modification by controlling their medical conditions, avoiding smoking, taking appropriate measures to lose weight and maintaining an active lifestyle is of extreme importance. [8] [9] [10] The recommendations on the use of statins and low-dose aspirin for primary and secondary prevention has been discussed in other sections.

• Pearls and Other Issues

Cardiovascular disease generally refers to 4 general entities: CAD, CVD, PVD, and aortic atherosclerosis. 

CVD is the main cause of death globally.

Measures aimed to prevent the progression of atherosclerosis are the hallmark for primary prevention of CVD.

Risk factor and lifestyle modification are paramount in the prevention of CVD.

• Enhancing Healthcare Team Outcomes

An interprofessional and patient-oriented approach can help to improve outcomes for people with cardiovascular disease as shown in patients with heart failure (HF) who had better outcomes when the interprofessional involvement of nurses, dietitians, pharmacists, and other health professionals was used (Class 1A). [52]

Similarly, positive results were obtained in people in an intervention group who were followed by an interprofessional team comprised of pharmacists, nurses and a team of different physicians. This group had a reduction in all-cause mortality associated with CAD by 76% compared to the control group. [53]  Healthcare workers should educate the public on lifestyle changes and reduce the modifiable risk factors for heart disease to a minimum.

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Atherosclerosis as a result of coronary heart disease. Contributed by National Heart, Lung and Blood Institute (NIH)

Coronary Artery Disease Pathophysiology. Coronary artery disease is usually caused by an atherosclerotic plaque that blocks the lumen of a coronary artery, typically the left anterior descending artery. Contributed by S Bhimji, MD

Disclosure: Edgardo Olvera Lopez declares no relevant financial relationships with ineligible companies.

Disclosure: Brian Ballard declares no relevant financial relationships with ineligible companies.

Disclosure: Arif Jan declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Olvera Lopez E, Ballard BD, Jan A. Cardiovascular Disease. [Updated 2023 Aug 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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