Coronary Heart Disease

1. Introduction
Heart is a pump that circulates blood to lungs and rest of the body. The surface of heart is covered with blood vessels called coronary arteries, which supply your heart muscle with blood. Coronary heart disease happens when fatty deposits build up on the walls of your coronary arteries. This is known as atherosclerosis. CHD is the abbreviation of coronary heart disease.

In atherosclerosis, fat and cholesterol in blood builds up on the artery walls, forming a plaque or atheroma. The plaque can prevent heart muscle from getting the blood supply it needs. Because of the reduced blood flow and the rough edges of the plaque, a blood clot sometimes forms, blocking the artery.

Sometimes the plaque may rupture, which also causes blood to clot. This is called atherothrombosis. Atherothrombosis stops an area of heart muscle receiving blood and oxygen, leading to a heart attack. If a lot of heart muscle is damaged, the heart may stop beating regularly. Sometimes the damage causes the heart to stop beating altogether, which is fatal.

The heart consists of 4 chambers: an atrium and a ventricle on the right, and an atrium and ventricle on the left .Blood returning to the heart from veins all over the body flows into the right atrium. From there the blood flows into the right ventricle, which pumps it out to the lungs for oxygenation. The oxygen-rich blood returns to the left atrium. From there the blood flows into the left ventricle, which pumps it at high pressure into the arteries This entire process constitutes one heartbeat .The pumping, or contraction, of the left ventricle must be very powerful because that is what keeps the blood flowing throughout the body. The strength of the heart muscle depends on the oxygen and nutrient supply coming via the coronary arteries. These arteries are usually strong, elastic, and quite flexible. The heart has 3 major coronary arteries. Two of these arteries arise from a common stem, called the left main coronary artery .The left main coronary artery supplies the left side of the heart.

Its left anterior descending (LAD) branch supplies the front part of the heart. The left circumflex (LCX) branch supplies the left lateral and back side of the heart. Finally, the right coronary artery (RCA) is separate and supplies the right and the bottom parts of the heart.

As a child, the inner lining of the coronary arteries is quite smooth, allowing blood to flow easily. As a person ages, the cholesterol and calcium content in the walls of the coronary arteries increases, making them thicker and less elastic Unhealthy habits, such as a diet high in cholesterol and other fats, smoking, and lack of exercise accelerate the deposit of fat and calcium within the inner lining of coronary arteries. This process is known as atherosclerosis, or hardening of the arteries. The deposits, or plaques, eventually obstruct the blood vessel, which begins to restrict blood flow. Plaque is like a firm shell with a soft inner core containing cholesterol. As blood hits it during each heartbeat, the plaque may crack open and expose its inner cholesterol core, which promotes blood clotting. Clots may further reduce blood flow, causing severe pain (angina), or even block it all together.

A coronary artery affected by arthrosclerosis

2. Types of coronary heart disease

Coronary heart disease develops slowly over many years. In some people, breathlessness when exercising is the only symptom. People may not know anything is wrong until he\she develops angina (chest pains) or have a heart attack. These are the main symptoms of CHD

2.1 Angina
The most common symptom of coronary artery disease is angina (also called angina pectoris). Angina is often referred to as chest pain. It is also described as chest discomfort, heaviness, tightness, pressure, aching, burning, numbness, fullness, or squeezing. It can be mistaken for indigestion or heartburn. Angina is usually felt in the chest, but may also be felt in the left shoulder, arms, neck, back or jaw. It happens when blood flow in the pulmonary arteries is restricted. Angina typically starts while walking or feeling upset. It can also be brought on after a meal and by cold weather.

Cause:
Angina is caused when blood flow to an area of the heart is decreased. This impairs the delivery of oxygen and vital nutrients to the heart muscle cells. When this happens, the heart muscle must use alternative, less efficient forms of fuel so that it can perform its function of pumping blood to the body. The byproduct of using this less efficient fuel is a compound called lactic acid that builds up in the muscle and causes pain. Some medications used to treat angina work by inhibiting the use of this fuel source.

Symptoms:
Pain or discomfort in other areas of the upper body including the arms, left shoulder, back, neck, jaw, or stomach Difficulty breathing or shortness of breath Sweating or cold sweat Fullness, indigestion, or choking feeling (may feel like heartburn) Nausea or vomiting Light-headedness, dizziness, extreme weakness or anxiety Rapid or irregular heart beats

Types of Angina

Stable angina:
A type of angina brought on by an imbalance between the hearts need for oxygen-rich blood and the amount available. It is "stable," which means the same activities bring it on; it feels the same way each time; and is relieved by rest and/or oral medications. Stable angina is a warning sign of heart disease and should be evaluated by a doctor. If the pattern of angina changes, it may progress to unstable angina.
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Unstable angina:
This type of angina is considered an acute coronary syndrome. It may be a new symptom or a change from stable angina. The angina may occur more frequently, occur more easily at rest, feel more severe, or last longer. Although this angina can often be relieved with oral medications, it is unstable and may progress to a heart attack. Usually more intense medical treatment or a procedure is required. Unstable angina is an acute coronary syndrome and should be treated as an emergency.

Variant angina (also called Prinzmetal's angina or coronary spasm):

A coronary artery can go into spasm, disrupting blood flow to the heart muscle (ischemia). It can occur in people without significant coronary artery disease. However, two thirds of people with variant angina have severe disease in at least one vessel, and the spasm occurs at the site of blockage. This type of angina is not common and almost always occurs when a person is at rest during sleep. You are at increased risk for coronary spasm if you have: underlying coronary artery disease, smoke, or use stimulants or illicit drugs (such as cocaine). If a coronary artery spasm is severe and occurs for a long period of time, a heart attack can occur. Angina can be treated with lifestyle changes and medicines. Left untreated, it will become more frequent and the pain will get worse. Angina leads to higher risk of getting a heart attack.

2.2 Heart attack

The medical term for a heart attack is Myocardial Infarction. A heart attack occurs when blood vessels that supply blood to the heart are blocked, preventing enough oxygen from getting to the heart. The heart muscle dies or becomes permanently damaged. Most heart attacks cause severe pain in the centre of the chest and can feel like very bad indigestion. Symptoms can happen suddenly, but sometimes the pain develops more slowly.

Cause:
Most heart attacks are caused by a blood clot that blocks one of the coronary arteries. The coronary arteries bring blood and oxygen to the heart. If the blood flow is blocked, the heart starves for oxygen and heart cells die. In atherosclerosis, plaque builds up in the walls of your coronary arteries. This plaque is made up of cholesterol and other cells. A heart attack can occur as a result of the following: The slow buildup of plaque may almost block one of your coronary arteries. A heart attack may occur if not enough oxygen-containing blood can flow through this blockage. This is more likely to happen when you are exercising. The plaque itself develops cracks (fissures) or tears. Blood platelets stick to these tears and form a blood clot (thrombus). A heart attack can occur if this blood clot completely blocks the passage of oxygen-rich blood to the heart. This is the most common cause.

Symptoms:

A feeling of heaviness, squeezing or crushing in the centre of chest or feelings like something heavy sitting on the chest.

Pain may spread to the arms, neck, jaw, face, back or stomach, lasting for hours Loss of consciousness Sweatiness and breathlessness feeling or being sick anxiety, cough palpitation; feeling like heart is beating too fast or irregularly

Sometimes there are no symptoms at all. This is called a silent myocardial infarction. Older people and people with diabetes are more likely to have this kind of heart attack.

2.3 Arrhythmia
An arrhythmia is an irregular heartbeat. Sometimes this can be felt as a heart palpitation (a sensation of a skipping or thumping heart beat). Sometimes palpitations are a symptom of coronary heart disease. However, heart palpitations are common, and don't necessarily mean that you have either coronary heart disease or an arrhythmia.

Cause:
Coronary artery disease. Electrolyte imbalances in your blood (such as sodium or potassium). Changes in your heart muscle. Injury from a heart attack. Healing process after heart surgery. Irregular heart rhythms can also occur in "normal, healthy" heart

Symptoms:
An arrhythmia can be silent and not cause any symptoms. A doctor can detect an irregular heartbeat during a physical exam by taking your pulse or through an electrocardiogram (ECG). When symptoms of an arrhythmia occur, they may include: Palpitations (a feeling of skipped heart beats, fluttering or "flip-flops," or feeling that your heart is "running away"). Pounding in your chest Dizziness or feeling light-headed. Fainting. Shortness of breath. Chest discomfort.

2.4 Heart failure

Over time, coronary heart disease may weaken the heart, leading to heart failure. Heart failure means that ones heart isn't strong enough to pump blood around his body effectively and gets tired and out of breath easily. It can also lead to swelling in the ankles and legs.

Cause:
Coronary artery disease or CAD is the most reason for heart failure.CAD causes obstruction to the coronary arteries preventing blood flow and, therefore, oxygen delivery to the heart. Sometimes heart can not get enough blood to pump. Previous heart attack can also cause heart failure.

Symptoms:
dizziness, shortness of breath specially when lying flat fatigue or tiredness swelling in the ankles and legs intolerance of exercise coughing

3. Causes and Risk Factors of Coronary Heart Disease

Coronary heart disease is caused by the buildup of fatty deposits on the artery walls that prevents the heart of getting enough oxygen. The most common cause by far for CHD is atherosclerosis. Lack of sufficient blood is called ischemia, so coronary heart disease is sometimes called ischemic heart disease. Coronary heart disease is more common in older people. Up to the age of 65, it is more common in men than women. It is also common among the people of India and Pakistan. Factors that increase the risk of developing coronary heart disease include:

Smoking , passive smoking or chewing tobacco Obesity; being overweight, especially excess fat around tummy
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An inactive lifestyle Diabetes High blood pressure High cholesterol (Levels of cholesterol in the blood are above healthy levels. This usually involves high levels of low-density lipoprotein (LDL), the bad cholesterol, and low levels of high-density lipoprotein (HDL), the good cholesterol.)

Taking drugs, alcohol Emotional stress Type A personality (competitiveness, impatient, time urgency, aggressiveness)

4. Diagnosis of Coronary Heart Disease

Your doctor will ask about symptoms and examine the patient. The patient will need to have some tests, which may include the following.

Blood tests. Electrocardiogram (ECG) - a test that measures the electrical activity of heart to see how well it's working. Patient may have an exercise ECG, which means the test is done while he is walking on a treadmill or pedaling on an exercise bike.

Echocardiogram - a test that uses ultrasound to produce a moving 'real-time' image of the inside of the heart.

A coronary angiogram - a test that uses an injection of a special dye into the blood vessels of heart to make them clearly visible on X-ray images.

Radionuclide tests - for this test the doctor will give patient a small, harmless injection of radioactive material, which passes through heart muscle. A large camera directed at heart picks up rays sent out by the radioactive material and creates an image of heart.

Chest X-ray. MRI scans. Electrophysiological tests - a catheter is put into a blood vessel in groin and guided to heart. The tip of the catheter stimulates the heart and records the electrical activity.

5. Treatment of Coronary Heart Disease

Treatment for coronary heart disease depends on how serious it is. There are several treatments available. For angina or patient having a heart attack, angioplasty or surgery may be the best treatment option.

5.1 Medicines
Medicines aim to stop coronary heart disease getting worse or prevent further heart attacks. Some examples are listed below.

Anti-platelet medicines such as aspirin. Taking a small (75 mg) daily dose of aspirin makes blood less likely to form clots, reducing the risk of having a heart attack.

Cholesterol-lowering medicines, such as statins, which slow down the process of atherosclerosis.

Beta-blockers reduce blood pressure and the amount of work that the heart does. Calcium channel blockers relax and widen the arteries. Anticoagulants help to stop blood clots forming. ACE inhibitors lower blood pressure and are often used in people with heart failure or after a heart attack.

Nitrates relax coronary arteries, allowing more blood to reach the heart. Anti-arrhythmic medicines help to control heart rhythm.

5.2 Surgical treatments

There are many surgical treatments available for coronary heart disease. Such as:

Angioplasty:
A coronary angioplasty involves passing a collapsed balloon through blood vessels until it reaches the arteries of the heart. The balloon is inflated to widen the narrowed coronary artery. A stent (flexible mesh tube) is sometimes inserted to help keep artery open afterward.
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Coronary Artery Bypass:

The surgeon may recommend a coronary artery bypass graft (CABG). This means he or she will take a piece of a blood vessel from the leg or chest and use it to bypass the narrowed coronary arteries. The bypass provides heart with more blood. Coronary artery bypass grafting (CABG) is the standard operation for blockages of coronary arteries. If multiple coronary arteries are blocked, or if the left main artery shows significant blockage, bypass surgery is usually the best treatment choice. The blocked parts of the arteries are detoured or bypassed with blood vessels "harvested" from the chest (internal mammary), arm (radial artery),or a leg ( saphenous vein). During the surgery, the heart is stopped temporarily and you are connected to a machine called a bypass pump that takes over the functions of the heart. These operations are very successful and have a low rate of complications.

Radiation Brachytherapy:
Another intense procedure is radiation brachytherapy. In radiation brachytherapy, the artery is exposed to radiation while open during angioplasty

Heart transplant:
Heart transplant is a surgical transplant procedure performed on a patients with end-stage heart failure or severe coronary artery disease. The most common procedure is to take a working heart from a recently deceased organ donor and implant it into the patient. The patient's own heart may either be removed, less commonly, left in to support the donor heart

6. Prevention of Coronary Heart Disease

There is an old saying prevention is better than cure. Coronary heart disease can be prevented in most people by adopting a healthy lifestyle. One can reduce his chance of having a heart attack by:

Abstaining from smoking, chewing tobacco Losing excess weight

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Doing regular physical activity, for 30 minutes at least five days a week Eating a low fat and high fiber diet with five portions of fruit and vegetables a day and two portions of fish a week

Not exceeding four units of alcohol a day for men or three units for women Try to cook food with olive or sunflower oil Fish oil consumption to increase omega-3 fatty acid intake Avoid eating fast food, dip fried food. Avoid taking stress; try to live a happy stress free life. Maintain a regular life.

7. Conclusion:
The rate of death for coronary heart disease is increasing day by day. It has become a serious problem for our society. The busy stressful lifestyle of todays people is one of the main reasons for the increasing rate for this disease. If people do not change their lifestyle and eating habit, this disease will take an acute situation. Therefore, heart foundation societies all over the world are trying to create awareness among people about this disease. By leading a regular discipline life and eating a healthy balanced diet one can easily avoid coronary heart disease which will lead one to a long happy life.

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