Coronary heart disease

Coronary heart disease is also called ischaemic heart disease or coronary artery disease. It occurs when fats and other substances circulating in your blood stick together in clumps in the walls of your arteries — this is called atheroma. 

Over time, your arteries become narrow as atheromas build up. This restricts the supply of oxygen-rich blood that your heart needs to beat properly — you might get painful angina attacks.

Sometimes, pieces of the atheroma break off and form a blood clot (thrombosis) which causes a life-threatening condition, such as a stroke or heart attack (myocardial infarction). A heart attack occurs when one or several of the arteries supplying your heart are completely blocked — this can happen even when you are resting.

Some of the symptoms of a heart attack are similar to angina and indigestion. However, unlike angina symptoms, heart attack symptoms are not relieved by taking angina medication (eg a nitrate tablet or spray). In some cases, a heart attack does not cause any symptoms — this is called a silent heart attack and is most common in people with diabetes and older people. 

A common symptom of a heart attack is sudden pain in your chest — this is a medical emergency. It is therefore vital that the cause of your chest pain is diagnosed and treated as soon as possible. If you notice any of the following symptoms, call 999 immediately:

• Chest pain that spreads to your arms, back, neck or jaw
• Chest pain that lasts more than 15 minutes
• Nausea and/or vomiting
• Shortness of breath
• Sweating
• Your chest feels heavy or tight

Another complication of coronary heart disease is heart failure. This occurs when your heart is no longer strong enough to pump blood efficiently around your body. This causes fluid build-up in your lungs, which makes it hard to breathe. Heart failure can occur suddenly (acute heart failure) or gradually (chronic heart failure). 

Your heart is made of cardiac muscle. It pumps blood to your lungs and the rest of your body, delivering vital oxygen and nutrients. Your heart also needs a blood supply, which is delivered by your coronary arteries. 

When excess fat builds up along the walls of your coronary arteries, over time, you can develop coronary heart disease. This build-up of fat forms hardened plaques called atheromas in a process called atherosclerosis. The atheromas narrow your coronary arteries, which prevents sufficient blood flow to your heart and can damage your heart tissue. If an atheroma ruptures, a clot can break off and completely block your coronary artery, which causes a heart attack. 

Coronary heart disease is the leading cause of death in the UK.

You may not notice any symptoms of coronary heart disease. However, you may notice angina symptoms, such as: 

• A pressure, squeezing, burning, tightening or aching sensation on your chest during physical exertion or when feeling stressed — this can vary from mild to severe; mild pain may feel like indigestion; severe pain may feel like a heaviness or tightness in the centre of your chest, which may spread 
• Breathlessness during physical exertion or when feeling stressed
• Cramping
• Indigestion, heartburn and/or nausea
• Pain throughout your body
• Sweating, weakness and/or feeling faint

Not everyone experiences the same symptoms of coronary heart disease. So if you think you are at risk, it is important to see your GP or doctor for a risk assessment. This will assess your possibility of developing angina, a heart attack, heart valve disease or a stroke.

Your GP will carry out a risk assessment and will ask you about:

• Any family history of heart disease
• Your diet and lifestyle
• Your medical history

They may carry out these tests:

• Blood pressure test
• Cholesterol test — you may be asked not to eat for 12 hours before your test to prevent food in your body affecting the results
• Exercise stress tests to check if your heart is getting enough oxygen when you put extra strain on it ie when exercising, usually on a treadmill

If your doctor suspects coronary heart disease they will refer you for other tests. This may include blood tests to check for signs of heart problems as well as: 

• An echocardiogram — a scan to look at the structures of your heart
• Cardiac CT scan or MRI scan to provide a detailed view of your heart and coronary arteries — this can check for signs of coronary heart disease, such as increased calcium levels in your arteries due to calcium in atheromas
• Chest X-ray to look for lung conditions
• Coronary angiogram — a special fluid is inserted into the heart using a long catheter passed through an artery, which then shows the heart’s function on a series of X-rays
• Electrocardiogram (ECG) to measure your heart’s rhythm and electrical activity — an ECG is not a definitive test for coronary heart disease as you can have the disease and still have a normal ECG
• Radionuclide tests — a small amount of radioactive material will be injected into a vein to help check blood flow to your heart; the radioactive material is harmless and can be tracked by a special camera either while you are at rest or exercising

You may also be referred to a cardiologist, a doctor specialising in treating the heart and circulatory system.

Coronary heart disease is more likely as you get older but it is often manageable with lifestyle changes and/or treatment. It is caused by fatty deposits building up along the walls of the arteries supplying your heart with blood. This is more likely to occur if you do not exercise enough. 

These fatty deposits harden to form plaques called atheromas through a  process called atherosclerosis. This narrows the arteries and reduces blood flow to the heart. 

Certain health conditions increase your risk of developing coronary heart disease. These are:

• Certain heart conditions, such as atrial fibrillation
• Diabetes — this more than doubles your risk of developing coronary heart disease
• High blood cholesterol — cholesterol is a type of fat made by your liver from saturated fat in your diet; your cells need cholesterol but too much increases your risk of coronary heart disease
• High blood lipoprotein (a) levels — lipoprotein (a) is a type of fat made by your liver; high levels increase your risk of atherosclerosis and coronary heart disease
• High blood pressure (hypertension) — this can strain your heart
• Other health conditions such as rheumatoid arthritis, kidney disease and gum infections (periodontitis)

Risk factors for coronary heart disease

Lifestyle factors can also increase your risk of coronary heart disease. You are more likely to have coronary heart disease if you:

• Are obese 
• Do not exercise enough
• Drink too much alcohol
• Eat an unhealthy, high-fat diet
• Smoke — nicotine and carbon monoxide which are produced when you smoke cigarettes or cigars, strain your heart and increase your risk of blood clots; other chemicals produced can damage the lining of your coronary arteries and cause atherosclerosis; smoking is, therefore, a major risk factor for coronary heart disease

Other factors that increase your risk but that you can’t control are:

• A family history of heart disease
• Being male, although women are just as likely to get coronary heart disease after the age of 75 
• Being of Asian ethnicity

You can reduce your coronary heart disease symptoms, improve your heart function and therefore reduce your risk of a heart attack or a stroke by:

• Eating healthily
• Exercising
• Losing weight
• Stopping smoking — quitting smoking after a heart attack rapidly reduces your risk of having a heart attack in the future to about that of a non-smoker

You may be prescribed medications to manage your coronary heart disease. Medications usually aim to reduce your blood pressure or widen your coronary arteries. Medications include:

• Angiotensin-converting enzyme (ACE) inhibitors to reduce the production of the hormone angiotensin-2 eg lisinopril and ramipril — this widens your blood vessels to improve blood flow and reduce the strain on your heart 
• Angiotensin-2 receptor blockers (ARBs) to reduce the activity of the hormone angiotensin-2 — this widens your blood vessels to improve blood flow and reduce the strain on your heart 
• Beta-blockers eg atenolol, bisoprolol, metoprolol and nebivolol — these drugs block the effects of adrenaline to slow down your heart rate and improve blood flow
• Blood thinners (eg antiplatelets) to prevent blood clots and therefore reduce your risk of a heart attack — these include aspirin, clopidogrel, prasugrel, rivaroxaban and ticagrelor
• Nitrates to relax your blood vessels, lower your blood pressure and improve your blood flow — this can reduce angina pain
• Statins to lower your cholesterol eg atorvastatin, pravastatin, rosuvastatin and simvastatin — statins block cholesterol production and increase the number of low-density lipoprotein (LDL) receptors in your liver which help keep cholesterol from entering your blood 

Other medications to regulate your heart rate, reduce your blood pressure and improve your blood flow include calcium channel blockers and diuretics. 

As these medications can have side effects, you may need to try several different ones to find the one that works best for you. 

Surgery for coronary heart disease

Bariatric (weight loss) surgery 

If you need to lose a lot of weight, your GP may consider whether obesity surgery, such as a gastric sleeve, might help.

Coronary angioplasty 

To check if a coronary angioplasty is an appropriate treatment for you, a special type of X-ray to check your blood vessels called a coronary angiogram will be performed. 

Coronary angioplasty involves removing the atheroma in your coronary artery using a small wire with a balloon on the end which is fed into the artery. Sometimes a mesh tube, called a stent, is placed in the artery afterwards to hold it open.

Coronary angioplasty is sometimes performed as an emergency treatment for a heart attack. 

Coronary artery bypass graft (CABG)

Also called a heart bypass, this treatment is used for more serious blockages of your coronary arteries. It involves redirecting blood flow from your blocked artery to your heart muscle using an artery from another part of your body.

To check if this treatment is appropriate for you, a coronary angiogram will first be performed. 

A coronary artery bypass graft is performed while your heart continues to pump blood by itself, ie a heart-lung machine is not needed.

Heart transplant

If your heart is severely damaged and medications are therefore not effective, or you have heart failure, you may need a heart transplant. This involves replacing your damaged heart with a healthy donor heart. 

Reducing your blood pressure and cholesterol levels will help reduce your risk of coronary heart disease and consequently your risk of a stroke or a heart attack. You can help do this by: 

• Eating a healthy, balanced diet that is low in fat, salt and sugar, and high in fibre — this includes lots of fruit, vegetables and whole grains; avoid saturated fats as they increase your cholesterol levels, sugar as this increases your risk of diabetes, and red meat and processed foods
• Maintaining a healthy weight to reduce your blood pressure — your GP can tell you what a healthy weight is for your height and build; eating a healthy diet and regularly exercising will help you maintain a healthy weight
• Quitting smoking to reduce your risk of atherosclerosis and thrombosis — smoking is the main cause of thrombosis affecting the heart in those aged under 50
• Reducing how much alcohol you drink — do not drink more than the recommended limit; avoid binge drinking as this increases your risk of a heart attack
• Reducing your blood pressure — eating a healthy diet low in saturated fat, regularly exercising and taking any prescribed medication to lower your blood pressure can help; your blood pressure should ideally be below 140/90mmHg
• Staying physically active to improve the efficiency of your heart and lower your cholesterol and blood pressure — try aerobic exercises such as dancing, swimming and walking

If you have diabetes, it is also important to control your blood sugar levels by taking any prescribed medication, regularly exercising and maintaining a healthy weight and blood pressure. If you have diabetes, your blood pressure level should ideally be below 130/80mmHg. 

If you are taking any prescribed medications for other health conditions, make sure you take them as instructed by your doctor and do not stop taking your medication without first speaking to your doctor.