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  Coronary artery diseaseHighlightsGuidelines for Management of Chronic Stable Angina In 2007, the American College of Cardiology and the American Heart Association updated their guidelines for the management of patients with chronic stable angina. Guideline recommendations include:
FDA Approves Genetic Lab Test for Warfarin Sensitivity In 2007, the Food and Drug Administration (FDA) approved a test to help doctors determine which patients are genetically predisposed to a higher risk of bleeding when taking the anticoagulant drug warfarin (Coumadin). Although a third of patients are especially sensitive to warfarin’s effects, all patients who take this drug need to have regular blood tests to make sure their blood does not become too thick or too thin. IntroductionAccording to a 2007 report, nearly 16 million Americans have coronary artery disease (CAD). In the U.S., coronary artery disease is the leading killer of both men and women. Each year, nearly 500,000 people die because of CAD. On the positive side, heart attack mortality rates have been declining. Half of men and 63% of women who die of heart disease do not have angina or other warning symptoms prior to their fatal attacks. Although at this time no tests can reliably predict whether a heart attack will occur, experts estimate that up to 30% of fatal attacks and many follow-up surgeries could be avoided with healthy lifestyle changes and by sticking to medical treatments. Two-thirds of patients who have suffered a first heart attack, however, do not take the necessary steps to prevent another. The heart is the human body's hardest working organ. Throughout life it continuously pumps blood enriched with oxygen and vital nutrients through a network of arteries to all tissues of the body.  The external structures of the heart include the ventricles, atria, arteries, and veins. Arteries carry blood away from the heart while veins carry blood into the heart. The vessels colored blue indicate the transport of blood with relatively low content of oxygen and high content of carbon dioxide. The vessels colored red indicate the transport of blood with relatively high content of oxygen and low content of carbon dioxide. To perform the difficult task of pumping blood to the rest of the body, the heart muscle itself needs a plentiful supply of oxygen-rich blood, which is provided through a network of coronary arteries. These arteries carry oxygen-rich blood to the heart's muscular walls (the myocardium).  Click the icon to see an image of the anterior heart arteries. If blood flow to the myocardium is interrupted, an injury known as an infarct occurs. This is called myocardial infarction or, more commonly, a heart attack.  Click the icon to see an animation about coronary artery disease. The Process of AtherosclerosisCoronary artery disease is the end result of a complex process known as atherosclerosis (commonly called "hardening of the arteries"). This causes blockage of arteries (ischemia) and prevents oxygen-rich blood from reaching the heart. There are many steps in the process leading to atherosclerosis, some not fully understood.  Click the icon to see an image of atherosclerosis. Increasingly, however, researchers are studying the interactions between cholesterol and processes known as oxidation and the inflammatory response. Cholesterol and Lipoproteins. The story begins with cholesterol and sphere-shaped bodies called lipoproteins that transport cholesterol.
 Click the icon to see an image of cholesterol inside an artery. Oxidation. The damaging process called oxidation is an important trigger in the atherosclerosis story.
Inflammatory Response. For the arteries to harden there must be a persistent reaction in the body that causes ongoing harm. Researchers now believe that this reaction is an immune process known as the inflammatory response.  Click the icon to see an image of atherosclerosis. Thre is growing evidence that the inflammatory response may be present not only in local plaques in single arteries but also throughout the arteries leading to the heart. Blockage in the Arteries. Eventually these calcified (hardened) arteries become narrower (a condition known as stenosis).
 Click the icon to see an image of coronary artery blockage The End Result: Heart Attack. Heart attack can occur as a result of one or two effects of atherosclerosis.
 Click the icon to see an image of the developmental process of atherosclerosis. SymptomsAnginaAngina is the primary symptom of coronary artery disease and, in severe cases, of a heart attack. It is typically experienced as chest pain and occurs when the heart muscle does not get as much blood (and, as a result, as much oxygen) as it needs for a given level of work (ischemia). Angina is usually referred to as one of two states:  Click the icon to see an image about angina.
The intensity of the pain does not always relate to the severity of the medical problem. Some people may feel a crushing pain from mild ischemia, while others might experience only mild discomfort from severe ischemia. Angina itself is not a disease. Much evidence indicates that onset of angina fewer than 48 hours before a heart attack may be protective, possibly by conditioning the heart to resist the damage resulting from the attack. Angina may be experienced in different ways and can be mild, moderate, or severe.  Click the icon to see an image of angina. Stable Angina and Chest PainStable Angina. Stable angina is predictable chest pain. Although less serious than unstable angina, it can be extremely painful or uncomfortable. It is usually relieved by rest and responds well to medical treatment (typically nitroglycerin). Any event that increases oxygen demand can cause an angina attack. Some typical triggers include:
Angina attacks can happen at any time during the day, but most occur between 6 a.m. and noon. Specific symptoms that are more likely to indicate angina include:
Other symptoms that may indicate angina or accompany the pain or pressure in the chest include:
Unstable Angina and Symptoms of Possible Heart AttackUnstable angina is a much more serious situation and is often an intermediate stage between stable angina and a heart attack, in which an artery leading to the heart (a coronary artery) becomes completely blocked. A patient is usually diagnosed with unstable angina under one or more of the following conditions:
Unstable angina is now usually discussed as part of a condition called acute coronary syndrome (ACS). ACS also includes people with a condition called NSTEMI (non ST-segment elevation myocardial infarction) -- also referred to as non-Q wave heart attack. With NSTEMI, blood tests suggest a developing heart attack. These conditions are less severe than heart attacks but may develop into full-blown attacks without aggressive treatment. [For more information, see In-Depth Report #12: Heart attack and acute coronary syndrome.] Doctors use a number of factors to help predict which patients with unstable angina or acute coronary syndrome are most at risk for developing a heart attack. First, patients are categorized by whether they have a history of heart disease or risk factors for heart disease (such as diabetes, high blood pressure, and peripheral artery disease) or other complicating conditions (such as lung disease and heart failure). The doctor also evaluates the severity of the angina. Other factors that pose a high risk for ACS include:
Heart Attack. A full-blown heart attack occurs with severe damage to the heart, which blocks oxygen. People with known heart disease and any unusual chest pain or other symptoms described above that do not clear up with medications should call 911. The degree of pain and the specific symptoms before a heart attack vary greatly among individuals. Symptoms can be abrupt, gradual, or intermittent. Some studies suggest that nearly half of patients having a heart attack do not have chest pain as the primary symptom. Patients most likely to have atypical symptoms are women and the very elderly (although they can certainly have classic heart attack symptoms as well). Symptoms That Are Less Likely to Indicate Angina or a Heart Attack. The following symptoms are less likely to be due to coronary artery disease:
However, the presence of these symptoms does not always rule out a serious heart event. Other Types of AnginaPrinzmetal's Angina. A third type of angina, called variant or Prinzmetal's angina, is caused by a spasm of a coronary artery. It almost always occurs when the patient is at rest. About two-thirds of people with it have severe atherosclerosis in at least one major blood vessel. Irregular heartbeats are common, but the pain is generally relieved immediately with standard treatment. Silent Ischemia. Some people with severe coronary artery disease do not have angina pain. This condition is known as silent ischemia, which some experts attribute to the brain abnormaly processing heart pain. This is a dangerous condition because patients have no warning signs of heart disease. Some studies suggest that people with silent ischemia have higher complication and mortality rates than those with angina pain. (Angina pain may actually protect the heart by conditioning it before a heart attack.) Syndrome X. Syndrome X is a condition that occurs when patients have atypical angina chest pain. Their electrocardiograms are abnormal during a stress test, but they have no signs of blocked arteries. It is more likely to occur in women. Although it is unclear what causes this condition, imaging tests suggest that Syndrome X may also be caused by ischemia, as is angina Other Causes of Chest Pain or DiscomfortChest pain is a very common symptom in the emergency room, but heart problems account for only 10 - 33% of all episodes. Other causes of chest pain or discomfort include:
What to Do When Symptoms OccurIndividuals who experience symptoms of a heart attack should take the following actions:
 Click the icon to see an image about heart attack symptoms.  Click the icon to see another image about heart attack symptoms. Risk FactorsOver the past decades, heart disease rates declined in both men and women as they quit smoking and improved dietary habits. This rate, however, has stabilized in recent years, most likely because of the dramatic increase in obesity in the U.S. and other industrialized nations. There have also been minimal changes in other risk factors, including smoking, sedentary behavior, and blood pressure control. Some risk factors cannot be changed, including age, gender, and genetics. Nevertheless, their effects can still be modified with healthy lifestyle changes. AgeAbout 85% of people who die from heart disease are over the age of 65. GenderCoronary artery disease and heart attacks are much more common in middle-aged men. Women have, on average, 10 - 15 more years of heart disease-free life than do men, but as women age, they catch up to men. Women, in fact, are more likely to have angina than men. Younger women with heart disease often do not have the same symptoms as their male counterparts and may be less likely to be diagnosed correctly. They are also more likely than men to die after a heart attack. Genetic FactorsGenetics are involved in increasing the likelihood of developing important risk factors, such as diabetes and high blood pressure. For example, one genetic variant called apolipoprotein E4 (ApoE4) affects cholesterol levels, particularly those associated with heart disease. EthnicityAfrican-American women face the highest risk for death from heart disease, and their rate of heart attacks is increasing. (Mortality rates in men do not differ much by race.) Native American men have a lower risk for heart disease than Caucasian men, and Hispanics have the lowest risk for heart disease of all major American population groups. African-Americans face a number of biologic and social dangers to their hearts, including;
 Click the icon to see an image about ethnicity and heart disease risks. Cholesterol and Other LipidsCholesterol. In spite of its bad press, cholesterol is an essential nutrient necessary for many cellular functions. However, when certain cholesterol levels rise in the blood, they can have dangerous consequences, depending on the type of cholesterol. Low-density lipoprotein (LDL) cholesterol is the "bad" cholesterol responsible for many heart problems. Triglycerides are another type of lipid (fat molecule) that can be bad for the heart. High-density lipoprotein (HDL) cholesterol is the "good" cholesterol that helps protect against heart disease. Doctors test for a "total cholesterol" profile that includes measurements for LDL, HDL, and triglycerides. The ratio of these lipids can affect heart disease risk.  Click the icon to see an image about serum cholesterol. Cholesterol Goals. In 2004, the National Cholesterol Education Program updated its clinical practice guidelines. The new recommendations set lower treatment goals for LDL levels based on a patient's risk factors for heart disease. LDL cholesterol, together with other risk factors for heart disease, is the best determinant for whether cholesterol therapy is needed or is working properly. In particular, the new guidelines emphasize lower LDL levels and earlier treatment for people with coronary artery disease, or other forms of atherosclerosis, and diabetes.
[For more information, see In-Depth Report #23: Cholesterol and In-Depth Report #43: Heart-healthy diet.] EstrogenEstrogen therapy, either alone or in combination with a progesterone drug, is no longer recommended as a strategy for preventing heart disease. Studies published over the last 5 - 8 years have identified a potential increased risk for stroke and heart disease with chronic estrogen replacement therapy. Estrogen replacement therapy still probably has a role for treatment of severe perimenopausal and postmenopausal symptoms. High Blood PressureHigh blood pressure, or hypertension, has long been a proven cause of coronary artery disease. Blood pressure is categorized as normal, prehypertensive, and hypertensive (which is further divided as Stage 1 or 2 according to severity). High blood pressure is generally considered to be a blood pressure reading greater than or equal to 140 mm Hg (systolic) or greater than or equal to 90 mm Hg (diastolic). Blood pressure readings in the prehypertension category (120 - 139 systolic or 80 - 89 diastolic) indicate an increased risk for developing hypertension. [See Table: Blood Pressure Ranges.] A normal blood pressure reading is 120/80 mm Hg or lower. Most people with high blood pressure should aim for a goal of below 140/90 mm Hg. Patients with certain health problems should aim lower (blood pressure in patients with kidney disease, heart failure, or diabetes should be equal to or lower than 130/80 mm Hg).  Click the icon to see an image about hypertension.
Obesity and Metabolic SyndromeAmerican obesity is at epidemic levels in all age groups. The effect of obesity on cholesterol levels is complex. Although obesity does not appear to be strongly associated with overall cholesterol levels, among obese individuals triglyceride levels are usually high while HDL (beneficial cholesterol) levels tend to be low, both risk factors for heart disease. Obesity has other effects (hypertension, increase in inflammation) that pose major risks to the heart.  Click the icon to see an image of childhood obesity. Obesity is particularly hazardous when it is part of the metabolic syndrome. This syndrome is diagnosed when three of the following are present:
Metabolic syndrome is a pre-diabetic condition that is significantly associated with heart disease and higher mortality rates from all causes. Over 20% of the population is estimated to have this condition. Obesity is highly linked with type 2 diabetes, and diabetes itself poses a significant risk for high cholesterol levels and heart disease. Insulin resistance alone is also probably a risk factor for heart disease. [For more information, see In-Depth Report #53: Weight control and diet.] Sedentary Lifestyle and ExercisePeople who are sedentary are almost twice as likely to suffer heart attacks as are people who exercise regularly. Exercise has a number of effects that benefit the heart and circulation, including:
Studies continue to show that physical activity and avoiding high-fat foods are the two most successful means of reaching and maintaining heart healthy levels of fitness and weight. Diabetes and Insulin ResistanceHeart disease and stroke are the leading causes of death in people with diabetes. People with diabetes are at risk for the following heart-risk conditions, and the more of these conditions they have, the worse the outlook.
People with both diabetes and heart disease may have a higher risk for silent ischemia, a condition in which people have blocked arteries but do not experience the angina, the chest pain that signals heart disease. [For more information, see In-Depth Report #9: Diabetes - type 1 or In-Depth Report #60: Diabetes - type 2.] Peripheral Artery DiseasePeripheral artery disease (PAD) occurs when atherosclerosis affects the extremities, particularly the feet and legs. The major risk factors for heart disease and stroke are also the most important risk factors for PAD. (The combination of such conditions with PAD also produces more severe forms of heart or circulatory disease.) Even though signs of heart disease are often not evident in the majority of patients with PAD, most of these patients also have coronary artery disease present. [For more information, see In-Depth Report #102: Peripheral artery disease.] SmokingSmoking is the most important risk factor for heart disease. Smoking can cause elevated blood pressure, worsen lipids, and make platelets very sticky, raising the risk of clots. Smokers in their 30s and 40s have a heart-attack rate that is five times higher than their nonsmoking peers. Cigarette smoking may be directly responsible for at least 20% of all deaths from heart disease, or about 120,000 deaths annually. Smoking cigars may increase the risk of early death from heart disease, although evidence is much stronger for cigarette smoking. Although heavy cigarette smokers are at greatest risk, people who smoke as few as three cigarettes a day are at higher risk for blood vessel abnormalities that endanger the heart. Regular exposure to passive smoke also increases the risk of heart disease in nonsmokers. [For more information, see In-Depth Report #41: Smoking.] Dietary Factors and Heart DiseaseDiet plays an important role in the health of the heart. [For more information, see In-Depth Report #43: Heart-healthy diet.] Stress and Psychologic FactorsStress. The effects of mental stress on heart disease are controversial. Stress can affect the heart when it activates the sympathetic nervous system (the automatic part of the nervous system that affects many organs, including the heart). Some studies suggest an association between acute stress and a higher risk for serious cardiac events, such as heart rhythm abnormalities and heart attacks, in people with active heart disease. However, not all studies report strong evidence that stress has any effect on the heart, particularly in people without any history of heart disease. [For more information, see In-Depth Report #31: Stress.] Depression. Noticeable depression is present in around 50% of patients after a heart attack, and one third or more of these patients experience what is called a major depression. Many patients with chronic heart disease, even when stable, also suffer from depression. People with depression have more severe cardiac symptoms. Depression also may have a negative effect on patients' ability and willingness to follow their treatment plans. The risk of heart attacks and even death from heart disease is increased in patients with chronic angina and depression. Although people with heart disease may become depressed, this does not explain entirely the link between the two problems. Data suggest that depression itself may be a risk factor for heart disease as well as its increased severity. A number of studies indicate that depression has biologic effects on the heart, including blood clotting and heart rate. [For more information, see In-Depth Report #8: Depression.] AlcoholBenefits of Moderate Drinking. Several studies have found heart protection from moderate intake of alcohol (one or two glasses a day). Moderate alcohol consumption can help boost HDL levels. Alcohol may also prevent blood clots and inflammation. Although red wine is most often cited for healthful properties, any type of alcoholic beverage appears to have similar benefit. However, this benefit must be considered against all the risks of patients who are unable to limit their alcohol intake. Adverse Effects of Heavy Drinking. By contrast, heavy drinking harms the heart. In fact, heart disease is the leading cause of death in alcoholics. Evidence suggests that people who consume more than three drinks a day have abnormal blood clotting factors. Heavy alcohol consumption can raise blood pressure, and binge drinking may increase the risk for hemorrhagic stroke (caused by bleeding in the brain). Large doses of alcohol can trigger irregular heartbeats, which can be dangerous in people with heart disease. Pregnant women and people who can't drink moderately should not drink at all. Risk Factors with Unclear RolesHomocysteine and Vitamin B Deficiencies. Deficiencies in the B vitamins folate (known also as folic acid), B6, and B12 have been associated with a higher risk for heart disease in some studies. Such deficiencies produce higher blood levels of homocysteine, an amino acid that has been associated with a higher risk for heart disease, stroke, and heart failure. Researchers have been studying whether vitamin B supplements can reduce homocysteine levels and, consequently, heart disease risks. However, studies have shown that while B vitamin supplements do help lower homocysteine levels, they have no effect on heart disease outcomes. Results of these studies have shown a similar number of heart attacks and strokes among patients who took B vitamins and those who received placebo. Some experts think that homocysteine may be a marker for heart disease rather than a cause of it.  Click the icon to see the benefits of vitamin B.  Click the icon to see the food sources of vitamin B. C-Reactive Protein. C-reactive protein is a product of the inflammatory process. Evidence increasingly suggests that high levels may predict future heart disease. It is not known if the protein plays any causal role or whether it is simply a marker for other factors in the disease process. C. pneumoniae and Other Infectious Organisms. Some microorganisms and viruses have been under suspicion for triggering the inflammation and damage in the arteries that contribute to heart disease. The strongest evidence to date supports a possible role from Chlamydia (C.) pneumoniae (a non-bacterial organism that causes mild pneumonia in young adults). C. pneumoniae has been detected in plaques in the arteries of patients with heart disease. In some studies, evidence of previous infection has been associated with a higher risk for heart events. However, treatment with appropriate antibiotics is not found to reduce the risk of future heart problems for patients infected with this organism. Other studies also suggest that cytomegalovirus (CMV), a common virus, may have similar effects. Many people, however, have been infected with these organisms, and no clear association has been found with any of these infections. Sleep Apnea. Obstructive sleep apnea is a condition in which tissues in the upper throat collapse at intervals during sleep, thereby blocking the passage of air. About 50% of patients with high blood pressure (hypertension) also have obstructive sleep apnea. The relationship between sleep apnea and hypertension has been thought to be largely due to obesity, but studies are finding a higher rate of hypertension in people with sleep apnea regardless of their weight. The use of a device known as nasal continuous positive airway pressure (CPAP) to treat patients with both sleep apnea and hypertension has been found to have only a small benefit for high blood pressure. About a third of patients with coronary artery disease also have obstructive sleep apnea. Patients with severe, untreated apnea have been found to have an increased incidence of stroke and cardiac events (such as heart attack). However, there is no evidence to date that identifies obstructive sleep apnea as an independent cause of cardiac events or stroke. Factors before Birth and in Infancy. Low birth weight, particularly in girls, has been associated with high blood pressure in both childhood and adulthood. Seasonal Differences. More deaths from heart disease occur in December and January, with the fewest happening in the summertime. Although lower temperatures and snow shoveling may play a role in some cases, more winter deaths have been reported even in warm regions. DiagnosisMany tests can diagnose possible heart disease. The choice of which (and how many) tests to perform depends on the patient's risk factors, history of heart problems, and current symptoms. Usually the tests begin with the simplest and may progress to more complicated ones. Routine Tests to Determine Risk for Heart DiseaseDoctors routinely check for high blood pressure and unhealthy cholesterol levels in all older adults. Specific tests are also important in people who may have risk factors or symptoms of diabetes. Electrocardiograms (ECGs)An electrocardiogram (ECG) measures and records the electrical activity of the heart. Between 25 - 50% of people who suffer from angina or silent ischemia, however, have normal ECG readings. The waves measured by the ECG correspond to the contraction and relaxation pattern of the different parts of the heart. Specific waves seen on an ECG are named with letters:  The electrocardiogram (ECG, EKG) is used extensively in the diagnosis of heart disease, from congenital heart disease in infants to myocardial infarction and myocarditis in adults. Several different types of electrocardiogram exist.
The most important wave patterns in diagnosing and determining treatment for heart disease and heart attack are called ST elevations and Q waves.
Exercise Stress TestExercise stress test for evaluation of coronary artery disease may be performed in the following situations:
Basic Procedure. A stress test (exercise tolerance test) monitors the patient's heart rhythms, blood pressure, and clinical status. It can tell how well the heart handles work and if parts of the heart have decreased blood supply. A typical stress test involves:
An ECG is used to monitor heart rhythms during a stress test. (An echocardiogram or more advanced imaging technique may also be used to visualize the actions of the heart and blood flow.) More than 25% of patients stop exercising before they reach their own maximum limits because of fear of a heart event. Patients should be reassured that the activities performed in the test under the guidance of a professional are safe. Interpreting Results. To accurately assess heart problems, a variety of factors are measured or monitored using the ECG and other tools during exercise. They include:
Using these and other measures, doctors can determine risk fairly accurately, particularly for men with chronic stable angina. The test has limitations, however, and some are significant. In patients with suspected unstable angina, normal or low risk results may not be as accurate in predicting future risk of cardiac events. In addition, for many reasons, the test is less accurate in women, and an echocardiogram may be a more accurate procedure for them. About 10% of patients, particularly younger people, will have false positive test results. In such cases, test results indicate abnormalities when there are no heart problems. EchocardiogramsAn echocardiogram is a noninvasive test that uses ultrasound images of the heart. This test is more expensive than an ECG, but it can be very valuable, particularly in identifying whether there is damage to the heart muscle and the extent of heart muscle damage. A stress echocardiogram may be performed to further evaluate abnormal findings from an exercise treadmill test or a routine echocardiogram. Examples include identifying exactly which part of the heart may be involved and quantifying how much muscle has been infected. It may be the first test done when the exercise treadmill test cannot be performed due to certain abnormal rhythms. Radionuclide ImagingRadionuclide procedures use imaging techniques and computer analyses to plot and detect the passage of radioactive tracers through the region of the heart. Such tracing elements are typically given intravenously. Radionuclide imaging is useful for diagnosing and determining:
Various imaging techniques may be used with radionuclide procedures, including:
Myocardial Perfusion (Blood Flow) Imaging Test (also called the Thallium Stress Test). This radionuclide test is typically used with an exercise stress test to determine blood flow to the heart muscles. It is a reliable measure of severe heart events. It may be useful in determining the need for angiography if CT scans have detected calcification in the arteries. About a minute before the patient is ready to stop exercising, the doctor administers a radioactive tracer into the intravenous line. (Tracers include thallium, technetium, or sestamibi.) Immediately afterwards, the patient lies down for a heart scan, usually with a planar scintigraphy or with SPECT. If the scan detects damage, more images are taken 3 or 4 hours later. Damage due to a prior heart attack will persist when the heart scan is repeated. Injury caused by angina, however, will have resolved by that time. Radionuclide Angiography. This is a technique for visualizing the chambers and major blood vessels of the heart. It uses an injected radioactive tracer and can be performed during exercise, at rest, or with use of stress-inducing drugs. It is an excellent test for assessing the heart's pumping action and determining the severity of coronary artery disease. It is an alternative to echocardiograms in certain situations.  Click the icon to see an internal view of the heart.  Click the icon to see an image of a MRI. AngiographyAngiography is an invasive test. It is used for patients who show strong evidence for severe obstruction on stress and other tests, and for patients with acute coronary syndrome. It is required when there is a need to know the exact anatomy and disease present within the coronary arteries. A limitation of angiography is that it is not always the most occluded (blocked) blood vessel that causes the next heart attack. In an angiography procedure:
 Click the icon to see an image of dye in the coronary artery. Major complications include stroke, heart attacks, and kidney damage. These risks are very low (about 0.1%), however, if the procedure is done in an experienced medical center (one that performs at least 300 of these operations every year). Allergic reactions can also occur. The procedure is expensive, and 10 - 30% of patients who have this procedure have normal results. Magnetic Resonance Angiography (MRA). MRA is a very promising noninvasive imaging technique that can provide three-dimensional images of the major arteries to the heart and identify disease with high accuracy. Experts believe this approach will eventually be a good alternative to angiography. Computed TomographyComputed tomography (CT) scans continue to be evaluated for several uses regarding coronary artery disease. Calcium Scoring CT Scans of the Heart. May be used to detect calcium deposits on the arterial walls. The presence of calcium correlates well with the presence of atherosclerosis of the heart. If the calcium score is very low, a patient is unlikely to have coronary artery disease. A higher calcium score may indicate an increased risk of current and future coronary artery disease. However, the presence of calcium does not necessarily signify narrowing of the arteries that would need further immediate evaluation or treatment. Results may unnecessarily lead to increased anxiety and may also lead to further unnecessary testing and treatment. CT Angiography. CT scans are also used to visualize the coronary arteries. When compared to invasive angiography, CT angiography is not as accurate in identifying who truly has coronary artery disease and who does not. Studies have shown that a negative CT angiography is fairly accurate in predicting patients who do not have coronary artery disease. However, its exact role in evaluation of patients with suspected heart disease is not clearly defined. More research is needed to determine the benefits of CT scanning in specific individuals. Advanced CT techniques are improving accuracy, including:  Click the icon to see an image of a CT scan.
PreventionHeart disease prevention is considered important before and after someone is diagnosed with heart disease. Primary prevention refers to measures that should be done to reduce the risk of heart disease in everyone. Secondary prevention refers to measures to reduce the risk of progression of heart disease in a patient who has already been diagnosed. Many of these measures are similar or the same as those recommended for primary prevention. Key prevention measures include:
Smoking CessationYour doctor should ask about your smoking habits at every visit. Smoking is a chronic condition and often requires repeat therapy using more than one technique. Cholesterol and Other Lipid DisordersAll patients should start following a heart-healthy diet and exercise regularly, after talking to their doctors. [For more information on diet, see In-Depth Report #43: Heart-healthy diet.]  Healthy diet, regular exercise, and quitting smoking (if you smoke) may prevent heart disease. Follow your health care provider's recommendations for treatment and prevention of heart disease. For patients without heart disease, the doctor will start or consider medication, increase dosage of medication, or add new medication when:
For patients with heart disease, the doctor will start or consider medication, increase dosage of medication, or add new medication when:
Statins are the most important of the cholesterol-lowering drugs. Brands include lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor), fluvastatin (Lescol), atorvastatin (Lipitor), and rosuvastatin (Crestor). A major analysis of over 200 studies found that statins reduced the risk for heart problems by 60% and stroke by 17%. [For more information, see In-Depth Report #23: Cholesterol.]  Click the icon to see an image of cholesterol. Manage High Blood PressureKeep Blood Pressure Low. People in normal health should have a blood pressure reading of 120/80 mm Hg or less. According to the latest guidelines, blood pressure readings of 120/80 are considered normal, readings of 140/90 or higher indicate hypertension, and readings in between the two are called pre-hypertension. Patients with diabetes or chronic kidney disease should maintain blood pressure readings of 130/80 mm Hg or less, while others should be no higher than 140/90 mm Hg. Depending on blood pressure levels and presence of either risk factors for heart disease or known coronary artery disease, patients may be recommended to try lifestyle changes first or to immediately begin medications. Several of the medications used to treat coronary artery disease also reduces blood pressure. [For more information, see In-Depth Report #14: High blood pressure.] DiabetesAll patients with diabetes should be well managed. A goal would be to bring HbA1c levels down to around 7%. [For more information, see In-Depth Report #09: Diabetes - type 1 and In-Depth Report #60: Diabetes - type 2.] Heart-Healthy DietCurrent American Heart Association (AHA) guidelines recommend:
[For more information on diet, see In-Depth Report #43: Heart-healthy diet.] Weight ReductionPeople should aim for a BMI index of 18.5 - 24.9. Weight reduction is recommended for obese patients who have high blood pressure, high cholesterol levels, metabolic syndrome, or diabetes. Some obese patients with coronary artery disease may consider having bariatric surgery (stomach bypass) to lose excess weight. The weight lost after surgery can help improve blood pressure, cholesterol, blood sugar and other factors associated with CAD. Exercise and Cardiac RehabilitationEveryone in normal health should engage in at least moderate physical activity for a minimum of 30 - 60 minutes on most, if not all, days of the week Even low amounts of moderate or high intensity exercise (walking or jogging 12 miles a week) can help produce beneficial changes in cholesterol and lipid levels. However, more intense exercise is required to significantly change cholesterol levels, notably by increasing HDL ("good cholesterol"). Overweight people who have trouble losing pounds can still achieve considerable heart benefits by exercising. Resistance (weight) training has also been associated with heart protection. Exercises that train and strengthen the chest muscles may be very important for patients with angina. Click the icon to see an image about angina. Some studies suggest that for the greatest heart protection, it is not the duration of a single exercise session that counts but the total daily amount of energy expended. Therefore, the best way to exercise may be in multiple short bouts of intense exercise, which can be particularly helpful for older people. Sudden strenuous exercise (such as snow shoveling and mowing lawns) puts many people at risk for angina and heart attack. Activities that involve raising the arms above the head may also be risky. Patients with angina should never exercise shortly after eating. People with risk factors for heart disease should seek medical clearance and a detailed exercise prescription. And all people, including healthy individuals, should listen carefully to their bodies for signs of distress as they exercise. [For more information, see In-Depth Report #29: Exercise.] Influenza Vaccination (Flu Shot)Influenza Vaccinations (Flu Shots). Patients with CAD are considered at high risk for complications from influenza. People with CAD should get an annual flu shot. Evidence suggests influenza vaccinations help protect against adverse heart events (including after heart surgeries), stroke, and death from all causes in the elderly. Still, studies suggest that only two-thirds of at risk people are vaccinated, mostly because of unwarranted fears of ineffectiveness or side effects. Anti-Platelet and Anticoagulant DrugsAnti-clotting drugs that inhibit or break up blood clots are used at every stage of heart disease. They are generally classified as either anti-platelets or anticoagulants. All anti-clotting therapies carry the risk of bleeding, which can lead to dangerous situations, including stroke.  A thrombus is a blood clot that forms in a vessel and remains there. An embolism is a clot that travels from the site where it formed to another location in the body. Thrombi or emboli can lodge in a blood vessel and block the flow of blood in that location depriving tissues of normal blood flow and oxygen. This can result in damage, destruction (infarction), or even death of the tissues (necrosis) in that area. Aspirin. Aspirin is known as a nonsteroidal anti-inflammatory drug (NSAID). It stops blood platelets, which are major clotting factors, from sticking together to form a blood clot. A daily low-dose aspirin (75 - 162 mg) is usually the first choice for preventing heart disease in high-risk individuals. Aspirin can prevent by 25 - 50% the risk of heart attacks and death in people with existing heart disease and a history of heart attack. It also reduces the risk for stroke. According to a 2006 review, aspirin works equally well for both men and women. Aspirin is recommended for prevention of heart disease for the following groups:
Side effects from prolonged use of aspirin may include stomach ulcers and bleeding. (There may be a slight increased risk for bleeding-related strokes, which are very uncommon, however. Furthermore, this risk may be outweighed by protection against the more common type of stroke, which is caused by artery blockage.)  Click the icon to see an image about stomach ulcers. Clopidogrel. Clopidogrel (Plavix) is an anti-platelet drug known as a thienopyridine. For most patients, the addition of Clopidogrel to aspirin for the prevention of heart disease is not recommended, as it adds no significant benefit, adds significantly to the cost, and increases the risk of bleeding. It may be used in place of aspirin for patients who are aspirin allergic or who cannot tolerate aspirin. When taken with aspirin, clopidogrel is recommended for patients with acute coronary syndrome (unstable angina or early signs of heart attack) or those who have had a drug-eluting stent inserted. According to a 2007 American Heart Association advisory, patients who have a drug-eluting stent must take both aspirin and a thienopyridine for at least 1 year after the stent is inserted. Clopidogrel is also recommended for patients who are undergoing angioplasty. For patients having coronary bypass surgery, it should be withheld for at least 5 -7 days prior to surgery because of a significant bleeding risk. Researchers are investigating whether clopidogrel and aspirin together are better than aspirin alone in reducing the risks following coronary bypass surgery. Warfarin and Anticoagulants. Anticoagulants are drugs that prevent or delay blood coagulation and the formation of blood clots. Warfarin (Coumadin) is an oral anticoagulant. It prevents clots by inhibiting vitamin K. Warfarin is used for patients with certain types of prosthetic heart valves and to prevent blood clots in patients with atrial fibrillation. Warfarin therapy poses a dangerous risk for bleeding, and blood coagulation must be monitored with frequent blood tests. A third of all people are genetically predisposed to a higher bleeding risk with warfarin. In 2007, the Food and Drug Administration approved a genetic test to help doctors determine which patients may be especially sensitive to this drug. TreatmentLifestyle changes are the first approach for all degrees of coronary artery disease. Depending on severity and individual conditions, patients may also need one or more medications, surgery, or both. Many types of medications are used to treat angina and CAD. Beta-BlockersBeta-blockers are useful for preventing angina attacks and reducing high blood pressure. They reduce the heart's oxygen demand by slowing the heart rate and lowering blood pressure. They are recognized for reducing deaths from heart disease and from heart surgeries, including angiography and coronary bypass. Beta-blockers are used or recommended in a number of situations:
Specific Beta-blockers. Beta-blockers include propranolol (Inderal), carvedilol (Coreg), bisoprolol (Zebeta), acebutolol (Sectral), atenolol (Tenormin), labetalol (Normodyne, Trandate), metoprolol (Lopressor, Toprol-XL), and esmolol (Brevibloc). A nasal spray form of propranolol appears to be very helpful in reducing exercise-induced angina attacks. Side Effects. Beta-blocker side effects include fatigue, lethargy, vivid dreams and nightmares, depression, memory loss, and dizziness. They can lower HDL (“good”) cholesterol. Beta blockers are categorized as non-selective or selective. Non-selective beta blockers, such as carvedilol and propranolol, can narrow bronchial airways. These beta-blockers should not be used by patients with asthma, emphysema, or chronic bronchitis. PATIENTS SHOULD NEVER ABRUPTLY STOP TAKING THESE DRUGS. The sudden withdrawal of beta-blockers can rapidly increase heart rate and blood pressure. The doctor may advise a patient to slowly decrease the dose before stopping completely. Angiotensin Converting Enzyme (ACE) InhibitorsAngiotensin converting enzyme (ACE) inhibitors are important heart-protective drugs, particularly for people with diabetes and high blood pressure. They reduce the production of angiotensin, a chemical that causes arteries to narrow, and so are commonly used to lower blood pressure. They may also reduce risk for heart attack, stroke, complications of diabetes, and death in patients at high risk for heart disease. ACE inhibitors are indicated for:
ACE inhibitors include captopril (Capoten), ramipril (Altace), enalapril (Vasotec), quinapril (Accupril), benazepril (Lotensin), perindopril (Aceon), and lisinopril (Prinivil, Zestril). Side Effects. Side effects of ACE inhibitors are uncommon but may include an irritating cough, excessive drops in blood pressure, and allergic reactions. In the past, doctors sometimes avoided giving aspirin to patients who were taking ACE inhibitors because the combination was believed to cause kidney problems. But, a 2005 study of patients with both coronary artery disease and heart failure found that taking aspirin and ACE inhibitor together is safe. The researchers also noted that taking aspirin with an ACE inhibitor can significantly reduce the risk of death for older patients with CAD and heart failure. [For more information, see In-Depth Report #14: High blood pressure.] NitratesNitrates have been used in the treatment of angina for over 100 years. These drugs release nitric oxide, thereby relaxing the smooth muscles in blood vessels. These medications are used primarily for control of angina symptoms. Many nitrate preparations are available. The most commonly used are nitroglycerin, isosorbide dinitrate, and isosorbide mononitrate. Nitrates can be absorbed from the gastrointestinal tract (oral tablet), skin (ointment or patch), or from under the tongue (sublingual tablet or spray).  Rapid Acting Nitrates. Rapid-acting nitrates are used to treat acute attacks. Nitroglycerin is the most widely used drug for this purpose. It can be administered under the tongue (sublingually or as a spray) or pocketed between the upper lip and gum (buccally) and can relieve angina within minutes. The procedure for taking nitroglycerin during an attack is as follows:
Nitroglycerin is very volatile so its potency can be easily lost. Patients should take the following precautions:
Intermediate to Long-Term Nitrates. Sublingual tablets of isosorbide dinitrate have a somewhat slower onset of action than nitroglycerin and are useful for preventing exercise angina. Ointments, patches, and oral tablets are used for longer-term prevention of angina attacks:
Long-acting forms may lose their effectiveness over time, so doctors generally schedule nitrate-free breaks to prevent tolerance. Some concern exists that nitrate-free periods might increase the risk for angina and adverse heart events. One large study, however, found no increased danger when patients used a nitroglycerine patch with scheduled breaks. The use of high blood pressure drugs known as ACE inhibitors may help prevent tolerance to nitrates. Side Effects. Nitrates have many side effects, some of which can be serious. Common side effects of nitrates include headaches, dizziness, nausea and vomiting, blurred vision, fast heartbeat, sweating, and flushing on the face and neck. Low blood pressure and dizziness can be relieved by lying down with the legs elevated. These effects are significantly worsened by alcohol, beta-blockers, calcium channel blockers, sildenafil (Viagra), and certain antidepressants. The doctor may prescribe medicines to lessen these side effects. Patients should contact their doctor if these side effects are persistent or severe. Serious side effects requiring immediate medical help include fever, joint or chest pain, sore throat, skin rash (especially on the face), unusual bleeding or bruising, weight gain, and swelling of the ankles. Withdrawal. Withdrawal from nitrates should be gradual. Abrupt termination may cause angina attacks. Calcium Channel Blockers (CCBs)Calcium channel blockers reduce heart rate and slightly dilate the blood vessels of the heart, thereby decreasing oxygen demand and increasing oxygen supply. They also reduce blood pressure. CCBs vary chemically, however, and although some are helpful, others may even be dangerous for certain patients with angina. Click the icon to see an image of the anterior heart arteries.
There is no strong evidence that any calcium channel blockers improve survival rates. Overdose can cause dangerously low blood pressure and slow heart beats. Patients with heart failure have a higher risk for death with these drugs and should not take them. No one taking any calcium channel blocker should withdraw abruptly because such action could dangerously increase the risk of high blood pressure. Note: Grapefruit and Seville oranges boost the effects of CCBs, sometimes to toxic levels. (Regular oranges do not appear to pose any hazard.) Other DrugsRanolazine (Ranexa) was approved in 2006 for treatment of chronic angina. It is recommended for patients who have not responded to other angina drugs. Ranolazine is taken in combination with amlodipine, beta-blockers, or nitrates. The drug appears to work better in men than in women Experimental DrugsGene Therapy and Angiogenesis. Proteins known as growth factors are being investigated for their ability to grow new blood vessels for supplying oxygen to the heart. After promising small trials, two large studies of genetically engineered forms of vascular endothelial growth factor (VEGF) and fibroblast growth factor [FGF (GenerX)] failed to detect any benefits. Studies on therapies that actually genetically encode these proteins are underway. SurgerySurgery is usually recommended for patients who have:
 Atherosclerosis is a disease of the arteries in which fatty material is deposited in the vessel wall, resulting in narrowing and eventual impairment of blood flow. Severely restricted blood flow in the arteries to the heart muscle leads to symptoms such as chest pain. Atherosclerosis shows no symptoms until a complication occurs. Choosing either Angioplasty or BypassTwo effective surgical procedures for heart patients are:
 Click the icon to see an image about bypass grafting.  Click the icon to see an image about bypass grafting. Each of these procedures is described below. Studies have generally reported similar survival rates with either procedure. There are some differences, however, and the decision often depends on individual conditions. These conditions may include both the number of and which coronary arteries are involved, the stability of the patient, previous procedures, patient choice, and more. Patients considering surgery should discuss all options and risks with their doctors. No surgical procedure cures coronary artery disease, and patients must continue to rigorously maintain a healthy lifestyle and any necessary medications. For some patients, lifestyle changes and medications may be able to control the disease without surgery or angioplasty. Considerations for Choosing Angioplasty with Stent Placement. Angioplasty has the following advantages for most patients. It is:
It has the following disadvantages:
Considerations for Choosing Bypass. Bypass is usually the appropriate procedure in patients with high-risk conditions, such as:
Considerations for Women. Studies have reported higher mortality rates in women than in men after any heart surgery. Some experts theorize that on average women may be older and sicker when they have a heart operation. A 2002 study, however, suggested that when women with acute coronary syndromes are given the same aggressive and early treatment as men are, their survival rates are equal or even better. Other ProceduresIn addition to angioplasty and bypass procedures, a number of other procedures are available or under investigation for coronary artery disease. They include:
Coronary Artery Bypass Graft SurgeryCoronary artery bypass graft surgery (CABG) is a good alternative to angioplasty for many patients, but it is very invasive. The surgery involves the following processes:  Click the icon to see an animation about CABG.
 Click the icon to see an illustrated series detailing a heart bypass surgery. ComplicationsIn spite of the invasive nature of this procedure, elective bypass procedures produce better long-term survival rates than angioplasty, particularly in patients with diabetes and multi-vessel blockage. Overall mortality rates after this procedure range from 1% to slightly over 2%. The risk for stroke or heart attack after a bypass operation ranges from 1.3 - 5%. Finding a surgeon who performs at least 100 of the procedures a year helps reduce the risk for complications. Blood clots may form in the new graft, closing it up or narrowing the treated vessel over time. Therapy with aspirin and other anti-clotting drugs help keep the graft open and working properly. For long-term prevention of closure, as well as for slowing progression of atherosclerosis, aggressive treatment with cholesterol-lowering drugs may be more beneficial than standard anti-clotting drugs. Bleeding is also a potential complication of CABG. Anti-bleeding (also called hemorrhage-sparing) drugs are sometimes used to limit blood loss in patients who undergo this surgery. Concerns have been raised about one of these drugs, aprotinin (Trasylol). Data suggested that aprotinin seriously increased the risks for kidney failure, heart failure, and stroke. The other two anti-fibrinolytic drugs, aminocaproic acid (Amicar) and tranexamic acid (Cyklokapron), which are also used to control blood loss, have been found to have much lower complication rates. Because aprotinin is more expensive as well as potentially more dangerous than other anti-bleeding drugs, experts are now recommending against its use in CABG. Minimally Invasive BypassMinimally invasive bypass (also called buttonhole or keyhole bypass) surgeries are exciting advances in basic bypass surgery. Studies indicate good success of these procedures for patients with disease in single vessels. They are also being investigated for multiple vessels. There are four major categories of less invasive or minimally invasive bypass surgeries based on the anatomic approach and whether cardiopulmonary bypass is used. Techniques employing robotic systems are being used in some medical centers. Eventually, minimally invasive bypass procedures may prove to be less expensive, require a shorter hospital stay, and have fewer complications than conventional coronary artery bypass surgery or even angioplasty. At this time, however, they are investigational procedures, performed in only a few medical centers for select candidates. Long term-success rates are unknown. Angioplasty and StentsPercutaneous coronary intervention (PCI), also called angioplasty, involves procedures such as percutaneous transluminal coronary angioplasty (PTCA) that help open the blocked artery.  Click the icon to see an animation about percutaneous transluminal coronary angioplasty. A typical angioplasty procedure follows these steps:
 Click the icon to see an animation about percutaneous transluminal coronary angioplasty.  Complications occur in about 10% of patients (about 80% of them happening within the first day). Success rates are better in hospital settings with experienced teams and backup.  Click the icon to see an illustrated series detailing coronary artery balloon angioplasty surgery. The most important long-term complication is reclosure (restenosis), which can lead to heart attack if not treated with a repeat procedure. Stenting and other advances have helped significantly in preventing reclosure and reducing heart attack rates. Nevertheless, a repeat procedure is still needed to restore the opening in 10 - 15% of procedures that use stents. PCI (angioplasty) has been proven to help reduce the frequency of angina attacks. It is commonly recommended for patients who have critically blocked arteries or have already had a recent, acute heart attack. PCI can also help improve survival and prevent heart attacks in patients with acute coronary syndrome (ACS). However, doctors have been uncertain about angioplasty’s benefits for survival and heart attack prevention in lower-risk patients with stable coronary artery disease. PCI works no better than standard heart medication (drugs to control blood pressure, lower cholesterol, and prevent blood clots) in preventing heart attack, stroke, and hospitalization in patients with stable coronary artery disease. Doctors are now recommending angioplasty only for patients who have severe heart disease. For patients with stable heart disease, drug therapy may be sufficient enough treatment and allow them to safely defer having surgery. RecuperationAngioplasty is less invasive than bypass surgery, requiring only one night in the hospital. Recuperation takes about a week. Chest pain after the procedure is very common and usually due to problems other than ischemia. Mild chest pain is even more common when a stent is used, possibly because the artery is stretched. Preventing Reclosure and Blockage During or Shortly after AngioplastyReclosure of the artery during or shortly after angioplasty often occurs. A number of anti-clotting drugs are used to help prevent this problem.
All of these drugs pose a risk for bleeding complications. Preventing Artery Narrowing (Restenosis) Over TimeNarrowing or reclosing of the artery (restenosis) can occur within a year of angioplasty or even longer in 15 - 60% of angioplasty patients. Coronary stents, anti-clotting drugs, and other advances have reduced these events significantly, but have not eliminated the problem. Symptoms of restenosis include chest pain on exertion. (Heart attacks, however, do not usually occur with such events.) The narrowing of the artery in this case is not due to blood clots, so anti-clotting drugs are not useful. Restenosis usually requires a repeat operation. A number of approaches, mostly investigative, have been developed to prevent restenosis after angioplasty. Drug-Coated Stents. Stents coated with the drugs sirolimus (Rapamune) or paclitaxel (Taxol) have been increasingly used in the last several years. Drug-eluting stents (as they are also called) can help prevent restenosis. However, because drug-eluting stents reduce arterial tissue growth, they can increase the risks of blood clots. Five studies published in the New England Journal of Medicine in March 2007 indicated that drug-eluting stents are safe and effective for patients with coronary artery disease when they are used for FDA-approved indications. Some studies have indicated that problems may arise when these stents are used for “off-label” purposes in patients with more complicated health problems, although other studies have found no increased risks. There is still some concern as to whether all stents (both bare metal and drug eluting) are used too frequently for patients who may be better served by drugs or bypass surgery. In February 2007, the American Heart Association and other professional organization issued an extremely important joint advisory statement. The statement advises that all patients who have drug-eluting stents must continue to take aspirin and clopidogrel (or, rarely, ticlopidine) for at least 1 year after the stent is inserted to reduce the risk of blood clots. Clopidogrel and ticlopidine are thienopyridine drugs that, like aspirin, help prevent blood platelets from clumping together. It is very important that patients who have drug-eluting stents take both aspirin and a thienopyridine drug. If for some reason patients cannot take a thienopyridine drug, they should receive a bare metal stent instead of a drug-eluting stent. Coronary Artery Brachytherapy. Radiation treatment called coronary artery brachytherapy (Gamma One, Beta-Cath) can slow the cell growth in the arteries that causes restenosis. With this approach, any blockage in the stent is first removed, and a tube with an inflatable balloon is inserted. The surgeon then implants a temporary device that delivers radiation. Brachytherapy has shown excellent results in preventing restenosis and significantly reducing heart events and improving survival. Brachytherapy is also showing promise in preventing restenosis in stented artery grafts that were put in place after bypass surgery and later failed. However, supportive evidence is not as strong for this technique as for drug eluting stents Medications. A number of medications are being studied for prevention of restenosis, although benefits to date have been modest. Other drugs under investigation include statins, various anti-clotting drugs, and B vitamins. Other Procedures. Other procedures under investigation to keep the arteries open use ultrasound, "soft" x-rays, and cryotherapy (very low temperatures). Other TreatmentsTransmyocardial laser revascularization (TMLR) applies laser energy directly to areas in the heart where blockage has occurred, creating 10 - 50 tiny channels. TMLR is recommended for patients with severe angina who have not responded to surgical bypass or angioplasty procedures. TMLR is not suitable for patients who have severely damaged heart muscles. A variant called percutaneous transmyocardial laser revascularization uses a small laser (a holmium YAG laser), which is smaller than the device used in TMLR and does not require open chest surgery and a general anesthetic. Patients report improved symptoms and exercise tolerance. Both procedures carry risks for serious complications, however, including some that can be life threatening. It is not clear if either TMLR procedure improves survival, and, in one study, the quality of life afterwards was less than with standard heart surgeries. Enhanced External Counterpulsation (EECP)A noninvasive technique called enhanced external counterpulsation (EECP) has been used successfully by over a million people in China. The technique uses an air pump that inflates and deflates pressurized cuffs around the legs, causing blood to be pushed into the heart. EECP may help patients with angina who have not had pain relief from nitrate drugs and who do not qualify as candidates for bypass or angioplasty. In different studies, it has relieved angina in over 75% of patients who used it and reduced the need for medication. The benefits persist, and there is some evidence that it produces actual cellular changes that benefit the heart. In 2002, the FDA approved EECP for the treatment of heart failure but some insurance companies still consider its use “experimental” and will not pay for it. EECP is not recommended for patients with arrhythmia, serious heart valve problems, or peripheral artery disease. AtherectomyAtherectomy procedures clear the narrowed arteries by using an approach called debulking. All of these procedures use a catheter (a thin tube) that is inserted into an artery (usually in the groin) and threaded up to the blockage. Devices are inserted through the tube to remove the plaque. They include:
Although they are successful in opening arteries, they offer no advantages over standard angioplasty and are used only for special cases. Resources
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Review Date:
4/17/2008 Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc. | ||||||||||||||||||||||||||||||