In 2015, CAD affected 110 million people and resulted in 8.9 million deaths. It makes up 15.6% of all deaths, making it the most common cause of death globally. The risk of death from CAD for a given age decreased between 1980 and 2010, especially in developed countries. The number of cases of CAD for a given age also decreased between 1990 and 2010. In the United States in 2010, about 20% of those over 65 had CAD, while it was present in 7% of those 45 to 64, and 1.3% of those 18 to 45; rates were higher among men than women of a given age.
Angina that changes in intensity, character or frequency is termed unstable. Unstable angina may precede myocardial infarction. In adults who go to the emergency department with an unclear cause of pain, about 30% have pain due to coronary artery disease.
Job stress appears to play a minor role accounting for about 3% of cases. In one study, women who were free of stress from work life saw an increase in the diameter of their blood vessels, leading to decreased progression of atherosclerosis. In contrast, women who had high levels of work-related stress experienced a decrease in the diameter of their blood vessels and significantly increased disease progression. Having a type A behavior pattern, a group of personality characteristics including time urgency, competitiveness, hostility, and impatience, is linked to an increased risk of coronary disease.
High blood cholesterol (specifically, serum LDL concentrations). HDL (high density lipoprotein) has a protective effect over development of coronary artery disease.
The number of categories of adverse childhood experiences (psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill, suicidal, or incarcerated) showed a graded correlation with the presence of adult diseases including coronary artery (ischemic heart) disease.
Hemostatic factors: High levels of fibrinogen and coagulation factor VII are associated with an increased risk of CAD.
Limitation of blood flow to the heart causes ischemia (cell starvation secondary to a lack of oxygen) of the heart's muscle cells. The heart's muscle cells may die from lack of oxygen and this is called a myocardial infarction (commonly referred to as a heart attack). It leads to damage, death, and eventual scarring of the heart muscle without regrowth of heart muscle cells. Chronic high-grade narrowing of the coronary arteries can induce transient ischemia which leads to the induction of a ventricular arrhythmia, which may terminate into a dangerous heart rhythm known as ventricular fibrillation, which often leads to death.
Typically, coronary artery disease occurs when part of the smooth, elastic lining inside a coronary artery (the arteries that supply blood to the heart muscle) develops atherosclerosis. With atherosclerosis, the artery's lining becomes hardened, stiffened, and accumulates deposits of calcium, fatty lipids, and abnormal inflammatory cells – to form a plaque. Calcium phosphate (hydroxyapatite) deposits in the muscular layer of the blood vessels appear to play a significant role in stiffening the arteries and inducing the early phase of coronary arteriosclerosis. This can be seen in a so-called metastatic mechanism of calciphylaxis as it occurs in chronic kidney disease and hemodialysis (Rainer Liedtke 2008). Although these people suffer from a kidney dysfunction, almost fifty percent of them die due to coronary artery disease. Plaques can be thought of as large "pimples" that protrude into the channel of an artery, causing a partial obstruction to blood flow. People with coronary artery disease might have just one or two plaques, or might have dozens distributed throughout their coronary arteries. A more severe form is chronic total occlusion (CTO) when a coronary artery is completely obstructed for more than 3 months.
For symptomatic people, stress echocardiography can be used to make a diagnosis for obstructive coronary artery disease. The use of echocardiography, stress cardiac imaging, and/or advanced non-invasive imaging is not recommended on individuals who are exhibiting no symptoms and are otherwise at low risk for developing coronary disease.
The diagnosis of "Cardiac Syndrome X" – the rare coronary artery disease that is more common in women, as mentioned, is a diagnosis of exclusion. Therefore, usually the same tests are used as in any person with the suspected of having coronary artery disease:
The diagnosis of coronary disease underlying particular symptoms depends largely on the nature of the symptoms. The first investigation is an electrocardiogram (ECG/EKG), both for "stable" angina and acute coronary syndrome. An X-ray of the chest and blood tests may be performed.
Stable coronary artery disease (SCAD) is also often called stable ischemic heart disease (SIHD). A 2015 monograph explains that "Regardless of the nomenclature, stable angina is the chief manifestation of SIHD or SCAD." There are U.S. and European clinical practice guidelines for SIHD/SCAD.
Acute coronary syndrome
Diagnosis of acute coronary syndrome generally takes place in the emergency department, where ECGs may be performed sequentially to identify "evolving changes" (indicating ongoing damage to the heart muscle). Diagnosis is clear-cut if ECGs show elevation of the "ST segment", which in the context of severe typical chest pain is strongly indicative of an acute myocardial infarction (MI); this is termed a STEMI (ST-elevation MI) and is treated as an emergency with either urgent coronary angiography and percutaneous coronary intervention (angioplasty with or without stent insertion) or with thrombolysis ("clot buster" medication), whichever is available. In the absence of ST-segment elevation, heart damage is detected by cardiac markers (blood tests that identify heart muscle damage). If there is evidence of damage (infarction), the chest pain is attributed to a "non-ST elevation MI" (NSTEMI). If there is no evidence of damage, the term "unstable angina" is used. This process usually necessitates hospital admission and close observation on a coronary care unit for possible complications (such as cardiac arrhythmias – irregularities in the heart rate). Depending on the risk assessment, stress testing or angiography may be used to identify and treat coronary artery disease in patients who have had an NSTEMI or unstable angina.
There are various risk assessment systems for determining the risk of coronary artery disease, with various emphasis on different variables above. A notable example is Framingham Score, used in the Framingham Heart Study. It is mainly based on age, gender, diabetes, total cholesterol, HDL cholesterol, tobacco smoking and systolic blood pressure.
Most guidelines recommend combining these preventive strategies. A 2015 Cochrane Review found some evidence that counselling and education in an effort to bring about behavioral change might help in high risk groups. However, there was insufficient evidence to show an effect on mortality or actual cardiovascular events.
Aerobic exercise, like walking, jogging, or swimming, can reduce the risk of mortality from coronary artery disease. Aerobic exercise can help decrease blood pressure and the amount of blood cholesterol (LDL) over time. It also increases HDL cholesterol which is considered "good cholesterol".
Although exercise is beneficial, it is unclear whether doctors should spend time counseling patients to exercise. The U.S. Preventive Services Task Force found "insufficient evidence" to recommend that doctors counsel patients on exercise but "it did not review the evidence for the effectiveness of physical activity to reduce chronic disease, morbidity and mortality", only the effectiveness of counseling itself. The American Heart Association, based on a non-systematic review, recommends that doctors counsel patients on exercise.
There are a number of treatment options for coronary artery disease:
It is recommended that blood pressure typically be reduced to less than 140/90 mmHg. The diastolic blood pressure however should not be lower than 60 mmHg. Beta blockers are recommended first line for this use.
In those with no previous history of heart disease, aspirin decreases the risk of a myocardial infarction but does not change the overall risk of death. It is thus only recommended in adults who are at increased risk for coronary artery disease where increased risk is defined as "men older than 90 years of age, postmenopausal women, and younger persons with risk factors for coronary artery disease (for example, hypertension, diabetes, or smoking) are at increased risk for heart disease and may wish to consider aspirin therapy". More specifically, high-risk persons are "those with a 5-year risk ≥ 3%".
Clopidogrel plus aspirin (dual anti-platelet therapy ) reduces cardiovascular events more than aspirin alone in those with a STEMI. In others at high risk but not having an acute event the evidence is weak. Specifically, its use does not change the risk of death in this group. In those who have had a stent more than 12 months of clopidogrel plus aspirin does not affect the risk of death.
Revascularization for acute coronary syndrome has a mortality benefit. Percutaneous revascularization for stable ischaemic heart disease does not appear to have benefits over medical therapy alone. In those with disease in more than one artery coronary artery bypass grafts appear better than percutaneous coronary interventions. Newer "anaortic" or no-touch off-pump coronary artery revascularization techniques have shown reduced postoperative stroke rates comparable to percutaneous coronary intervention. Hybrid coronary revascularization has also been shown to be a safe and feasible procedure that may offer some advantages over conventional CABG though it is more expensive.
Deaths due to ischaemic heart disease per million persons in 2012
As of 2010, CAD was the leading cause of death globally resulting in over 7 million deaths. This increased from 5.2 million deaths from CAD worldwide in 1990. It may affect individuals at any age but becomes dramatically more common at progressively older ages, with approximately a tripling with each decade of life. Males are affected more often than females.
It is estimated that 60% of the world's cardiovascular disease burden will occur in the South Asian subcontinent despite only accounting for 20% of the world's population. This may be secondary to a combination of genetic predisposition and environmental factors. Organizations such as the Indian Heart Association are working with the World Heart Federation to raise awareness about this issue.
Coronary artery disease is the leading cause of death for both men and women and accounts for approximately 600,000 deaths in the United States every year. According to present trends in the United States, half of healthy 40-year-old men will develop CAD in the future, and one in three healthy 40-year-old women. It is the most common reason for death of men and women over 20 years of age in the United States.
Society and culture
Other terms sometimes used for this condition are "hardening of the arteries" and "narrowing of the arteries". In Latin it is known as morbus ischaemicus cordis (MIC).
Research efforts are focused on new angiogenic treatment modalities and various (adult) stem-cell therapies. A region on chromosome 17 was confined to families with multiple cases of myocardial infarction. Other genome-wide studies have identified a firm risk variant on chromosome 9 (9p21.3). However, these and other loci are found in intergenic segments and need further research in understanding how the phenotype is affected.
A more controversial link is that between Chlamydophila pneumoniae infection and atherosclerosis. While this intracellular organism has been demonstrated in atherosclerotic plaques, evidence is inconclusive as to whether it can be considered a causative factor. Treatment with antibiotics in patients with proven atherosclerosis has not demonstrated a decreased risk of heart attacks or other coronary vascular diseases.
Since the 1990s the search for new treatment options for coronary artery disease patients, particularly for so called "no-option" coronary patients, focused on usage of angiogenesis and (adult) stem cell therapies. Numerous clinical trials were performed, either applying protein (angiogenic growth factor) therapies, such as FGF-1 or VEGF, or cell therapies using different kinds of adult stem cell populations. Research is still going on – with first promising results particularly for FGF-1 and utilization of endothelial progenitor cells.
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Atherectomy is a minimally invasive endovascular surgery technique for removing atherosclerosis from blood vessels within the body. It is an alternative to angioplasty for the treatment of peripheral artery disease, but the studies that exist are not adequate to determine if it is superior to angioplasty. It has also been used to treat coronary artery disease, albeit ineffectively.
Cardiac magnetic resonance imaging perfusion (cardiac MRI perfusion, CMRI perfusion), also known as stress CMR perfusion, is a clinical magnetic resonance imaging test performed on patients with known or suspected coronary artery disease to determine if there are perfusion defects in the myocardium of the left ventricle that are caused by narrowing of one or more of the coronary arteries.
Cardiac nursing is a nursing specialty that works with patients who suffer from various conditions of the cardiovascular system. Cardiac nurses help treat conditions such as unstable angina, cardiomyopathy, coronary artery disease, congestive heart failure, myocardial infarction and cardiac dysrhythmia under the direction of a cardiologist.
Cardiac nurses perform postoperative care on a surgical unit, stress test evaluations, cardiac monitoring, vascular monitoring, and health assessments. Cardiac nurses must have Basic Life Support and Advanced Cardiac Life Support certification. In addition, cardiac nurses must possess specialized skills including electrocardiogram monitoring, defibrillation, and medication administration by continuous intravenous drip.
Cardiac nurses work in many different environments, including coronary care units (CCU), cardiac catheterization, intensive care units (ICU), operating theatres, cardiac rehabilitation centers, clinical research, cardiac surgery wards, cardiovascular intensive care units (CVICU), and cardiac medical wards.
Cardiology (from Greek καρδίᾱ kardiā, "heart" and -λογία -logia, "study") is a branch of medicine that deals with the disorders of the heart as well as some parts of the circulatory system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.
Although the cardiovascular system is inextricably linked to blood, cardiology is relatively unconcerned with hematology and its diseases. Some obvious exceptions that affect the function of the heart would be blood tests (electrolyte disturbances, troponins), decreased oxygen carrying capacity (anemia, hypovolemic shock), and coagulopathies.
Cardiomegaly is a medical condition in which the heart is enlarged. It is more commonly referred to as an enlarged heart. The causes of cardiomegaly may vary. Many times this condition results from high blood pressure (hypertension) or coronary artery disease. An enlarged heart may not pump blood effectively, resulting in congestive heart failure. Cardiomegaly may improve over time, but many people with an enlarged heart need lifelong treatment with medications. Having an immediate family member who has or had cardiomegaly may indicate that a person is more susceptible to getting this condition. Cardiomegaly is not a disease but rather a condition that can result from a host of other diseases such as obesity or coronary artery disease. Recent studies suggest that cardiomegaly is associated with a higher risk of sudden cardiac death (SCD).
Coronary CT angiography (CTA) is the use of computed tomography (CT) angiography to assess the coronary arteries of the heart. The subject receives an intravenous injection of radiocontrast and then the heart is scanned using a high speed CT scanner, allowing physicians to assess the extent of occlusion in the coronary arteries, usually in order to diagnose coronary artery disease.
CTA is superior to coronary CT calcium scan in determining the risk of Major Adverse Cardiac Events (MACE).
A coronary CT calcium scan is a computed tomography (CT) scan of the heart for the assessment of severity of coronary artery disease. Specifically, it looks for calcium deposits in the coronary arteries that can narrow arteries and increase the risk of heart attack. This severity can be presented as Agatston score or coronary artery calcium (CAC) score. The CAC score is an independent marker of risk for cardiac events, cardiac mortality, and all-cause mortality. In addition, it provides additional prognostic information to other cardiovascular risk markers. A typical coronary CT calcium scan is done without the use of radiocontrast, but it can possibly be done from contrast-enhanced images as well, such as in coronary CT angiography.
Degenerative disease is the result of a continuous process based on degenerative cell changes, affecting tissues or organs, which will increasingly deteriorate over time.In neurodegenerative diseases cells of the central nervous system stop working or die via neurodegeneration. An example of this is Alzheimer's disease. The other two common groups of degenerative diseases are those that affect circulatory system (e.g. coronary artery disease) and neoplastic diseases (e.g. cancers).Many degenerative diseases exist and some are related to aging. Normal bodily wear or lifestyle choices (such as exercise or eating habits) may worsen degenerative diseases, but this depends on the disease. Sometimes the main or partial cause behind such diseases is genetic. Thus some are clearly hereditary like Huntington's disease. Sometimes the cause is viruses, poisons or other chemicals. The cause may also be unknown.Some degenerative diseases can be cured, but not always. It might still be possible to alleviate the symptoms.
Diabetic cardiomyopathy is a disorder of the heart muscle in people with diabetes. It can lead to inability of the heart to circulate blood through the body effectively, a state known as heart failure, with accumulation of fluid in the lungs (pulmonary edema) or legs (peripheral edema). Most heart failure in people with diabetes results from coronary artery disease, and diabetic cardiomyopathy is only said to exist if there is no coronary artery disease to explain the heart muscle disorder.
Frank's sign is a diagonal crease in the ear lobe extending from the tragus across the lobule to the rear edge of the auricle. The sign is named after Sanders T. Frank MD.It has been hypothesised that Frank's sign is indicative of cardiovascular disease and/or diabetes. Some studies have described Frank's sign as a marker of cardiovascular disease but not linked to the severity of the condition. In contrast, other studies have rebutted any association between Frank's sign and coronary artery disease in diabetics. There have also been reported cases of Frank's sign assisting in the diagnosis of cerebral infarctions. A link between Frank's sign and premature aging and the loss of dermal and vascular fibers has also been hypothesized. Some studies have focused upon bilateral ELC.
Homocysteine is a non-proteinogenic α-amino acid. It is a homologue of the amino acid cysteine, differing by an additional methylene bridge (-CH2-). It is biosynthesized from methionine by the removal of its terminal Cε methyl group. Homocysteine can be recycled into methionine or converted into cysteine with the aid of certain B-vitamins.
A high level of homocysteine in the blood (hyperhomocysteinemia) makes a person more prone to endothelial cell injury, which leads to inflammation in the blood vessels, which in turn may lead to atherogenesis, which can result in ischemic injury. Hyperhomocysteinemia is therefore a possible risk factor for coronary artery disease. Coronary artery disease occurs when an atherosclerotic plaque blocks blood flow to the coronary arteries, which supply the heart with oxygenated blood.
Hyperhomocysteinemia has been correlated with the occurrence of blood clots, heart attacks and strokes, though it is unclear whether hyperhomocysteinemia is an independent risk factor for these conditions. Hyperhomocysteinemia has also been associated with early pregnancy loss and with neural tube defects.
Perindopril is a long-acting ACE inhibitor used to treat high blood pressure, heart failure, or stable coronary artery disease in form of perindopril arginine (trade names include Coversyl, Coversum) or perindopril erbumine (Aceon). According to the Australian government's Pharmaceutical Benefits Scheme website, based on data provided to the Australian Department of Health and Ageing by the manufacturer, perindopril arginine and perindopril erbumine are therapeutically equivalent and may be interchanged without differences in clinical effect. However, the dose prescribed to achieve the same effect differs due to different molecular weights for the two forms. A prodrug, perindopril is hydrolyzed to its active metabolite, perindoprilat, in the liver.
It was patented in 1980 and approved for medical use in 1988.
Radionuclide ventriculography, a type of cardiac ventriculography, is a form of nuclear imaging, where a gamma camera is used to create an image following injection of radioactive material, usually Technetium-99m (99mTc) labeled red blood cells. In radionuclide ventriculography, the radionuclide has the property of circulating through the cardiac chambers, availing for studies of the pumping function of the heart. In contrast, in myocardial perfusion imaging, the radionuclide is taken up by the myocardial cells, making its presence correlating with myocardial perfusion or viability of the cells.Radionuclide ventriculography is done to evaluate coronary artery disease (CAD), valvular heart disease, congenital heart diseases, cardiomyopathy, and other cardiac disorders. It exposes patients to less radiation than do comparable chest x-ray studies. However, the radioactive material is retained in the patient for several days after the test, during which sophisticated radiation alarms may be triggered, such as in airports. Radionuclide ventriculography has largely been replaced by echocardiography, which is less expensive, and does not require radiation exposure. Radionuclide ventriculography gives a much more precise measurement of left ventricular ejection fraction (LVEF) than a transthoracic echocardiogram (TTE). Transthoracic echocardiogram is highly operator dependant, therefore radionuclide ventriculography is a more reproducible measurement of LVEF. Its primary use today is in monitoring cardiac function in patients receiving certain chemotherapeutic agents (anthracyclines: doxorubicin or daunorubicin) which are cardiotoxic. The chemotherapy dose is often determined by the patient's cardiac function. In this setting, a much more accurate measurement of ejection fraction, than a transthoracic echocardiogram can provide, is necessary.
Ramatroban (INN) is a thromboxane receptor antagonist.It is also a DP2 receptor antagonist.It is indicated for the treatment of coronary artery disease. It has also been used for the treatment of asthma.It was developed by the German pharmaceutical company Bayer AG and is co-marketed in Japan by Bayer and Nippon Shinyaku Co. Ltd. under the trade name Baynas.
Remnant cholesterol, also known as remnant lipoprotein, is a very atherogenic lipoprotein composed primarily of very low-density lipoprotein (VLDL) and intermediate-density lipoprotein (IDL). Stated another way, remnant cholesterol is all plasma cholesterol that is not LDL cholesterol or HDL cholesterol, which are triglyceride-rich lipoproteins. Nonetheless, remnant cholesterol is primarily chylomicron and VLDL from which most triglyceride has been removed, such that each remnant particle contains about 40 times more cholesterol than LDL.According to one study, high remnant cholesterol is more predictive of myocardial infarction than any other lipid particle. Remnant cholesterol is especially predictive of coronary artery disease in patients with normal total cholesterol.High plasma remnant cholesterol is associated with increased plasma triglyceride levels. Hypertriglyceridemia is characteristic of high plasma remnant cholesterol, but persons with high plasma triglycerides without high remnant cholesterol rarely have coronary artery disease.Remnant cholesterol has about twice the association with ischemic heart disease as LDL cholesterol. Although remnant cholesterol tends to be higher in people who are overweight (high body mass index, normal-weight persons with high remnant cholesterol tend to have a higher risk of myocardial infarction.Remnant cholesterol is associated with chronic inflammation, whereas LDL cholesterol is not.
Technetium (99mTc) tetrofosmin is a drug used in nuclear medicine cardiac imaging. It is sold under the brand name Myoview (GE Healthcare). The radioisotope, technetium-99m, is chelated by two 1,2-bis[di-(2-ethoxyethyl)phosphino]ethane ligands which belong to the group of diphosphines and which are referred to as tetrofosmin.Tc-99m tetrofosmin is rapidly taken up by myocardial tissue and reaches its maximum level in approximately 5 minutes. About 66% of the total injected dose is excreted within 48 hours after injection (40% urine, 26% feces).
Tc-99m tetrofosmin is indicated for use in scintigraphic imaging of the myocardium under stress and rest conditions. It is used to determine areas of reversible ischemia and infarcted tissue in the heart. It is also indicated to detect changes in perfusion induced by pharmacologic stress (adenosine, lexiscan, dobutamine or persantine) in patients with coronary artery disease. Its third indication is to assess left ventricular function (ejection fraction) in patients thought to have heart disease.
No contraindications are known for use of Tc-99m tetrofosmin, but care should be taken to constantly monitor the cardiac function in patients with known or suspected coronary artery disease.
Patients should be encouraged to void their bladders as soon as the images are gathered, and as often as possible after the tests to decrease their radiation doses, since the majority of elimination is renal.
The recommended dose of Tc-99m tetrofosmin is between 5 and 33 millicuries (185-1221 megabecquerels). For a two-dose stress/rest dosing, the typical dose is normally a 10 mCi dose, followed one to four hours later by a dose of 30 mCi. Imaging normally begins 15 minutes following injection.
Ubiquitin conjugating enzyme E2 Z (UBE2Z), also known as UBA6-specific E2 enzyme 1 (USE1), is an enzyme that in humans is encoded by the UBE2Z gene on chromosome 17. It is ubiquitously expressed in many tissues and cell types. UBE2Z is an E2 ubiquitin conjugating enzyme and participates in the second step of protein ubiquitination during proteolysis. A genome-wide association study (GWAS) revealed the UBE2Z gene to be associated with chronic kidney disease. The UBE2Z gene also contains one of 27 SNPs associated with increased risk of coronary artery disease.
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