An Einstein Perspective on Coronary Artery Disease
The number one killer in the U.S. and around the world, coronary artery disease, is responsible for about one out of every three deaths.
I’m Bill Fantini with Einstein Perspectives.
We turned to cardiologist Jon George, MD, to learn more about coronary artery disease, and its causes and treatment. A fellow of the American College of Cardiology, he serves as director of the Cardiac Catheterization Laboratory and Director of Interventional Research at Einstein Medical Center in Philadelphia.
Bill Fantini: What is coronary artery disease or CAD?
Dr. George: Coronary artery disease is just a buildup of plaque within the artery supplying blood and oxygen to the heart. The heart is a muscle just like any other muscular organ or any other muscle. It requires blood and oxygen to function.
The heart as a muscle pumps on a regular basis and requires oxygen to be able to function to supply blood to the rest of the body. And therefore, plaque builds up over time due to various risk factors within these arteries, creating a narrowing of the artery and preventing an adequate supply of blood and oxygen to the heart, which eventually causes ischemia, or lack of enough blood flow to the heart.
Heart attack occurs when there’s an accumulation of blood clots within a narrowed lumen or a narrowed artery, which causes complete disruption of flow into the heart muscle, causing a heart attack.
Bill Fantini: Actually, I think you’ve already answered my next two questions, which are: Are there specific causes and why is it a problem? Is there more you’d like to say on that?
Dr. George: There are various risk factors that lead to development of plaque buildup and coronary artery disease. That includes smoking, high blood pressure, high cholesterol, and age. As you get older, the risk is higher. Sedentary lifestyle, too, (is a risk), which is a big problem in this country, especially because of obesity and then family history. So you may be born into a family that already has a predisposition for coronary artery disease. So the combination of all of that leads to increased risk.
Bill Fantini: How common is it?
Dr. George: Extremely common. Cardiovascular disease accounts for the largest number of deaths in the United States and across the world. It’s known to cause about one out of every three death and so it’s very common.
Bill Fantini: What are the signs?
Dr. George: The classic sign that we look for is angina, and angina is a specific kind of chest pain that is a marker for coronary artery disease. And that chest pain is typically a pressure-like sensation in the center or left side of the chest and occasionally radiates down the left arm or the neck.
It can be associated with shortness of breath and sweating when it does occur, and it’s typically worsened by exertion, so activity makes it worse. Those are signs that would be concerning.
Now in patients who are diabetic or female patients, the symptoms tend to be more atypical and may not necessarily corroborate with all of what I just described, so it’s the features of this pain that have to be further investigated, and then that leads to a bunch of different tests to confirm or exclude coronary artery disease. But if a patient is having those symptoms, then that is something that needs attention and evaluation.
Bill Fantini: I have heard that hiatal hernia, for example, mimics heart problems in some ways.
Dr. George: There are a lot of things that can mimic chest pain. Actually, hiatal hernia is one of them. Hiatal hernia is when you have part of the organs or contents of the abdomen going through the diaphragm and extending into the thorax, the chest cavity, where the heart lies. That can cause friction and pain that could be similar to angina or pain related to coronary artery disease.
Other things that cause similar pains are gastroesophogeal reflux, or what we typically call heartburn. It’s called heartburn because the pain can feel like it’s originating from the heart, but it’s really from acidity, from the stomach, with reflux into the esophagus.
You have anxiety and panic attacks that can cause pain, that is similar to angina, and you can have musculoskeletal pain, pain in your bones or your muscles of your chest or shoulder. That could be similar to chest pain.
So there’s a variety of different things that can cause similar pain, but that needs to be elucidated with a physical exam from a doctor and some tests.
Bill Fantini: Is an exam the only way to tell the difference? Or is there some other clue?
Dr. George: Well, a lot of the things that we look for are all of those risk factors that I mentioned earlier. So if it’s a patient who smokes, if it’s a patient who is advanced in age, if it’s a patient who is obese or if it’s a patient who has diabetes or high blood pressure or high cholesterol, all of that adds to the risk of possibly having coronary artery disease.
So if those symptoms happen along with risk factors, then you know that is something that needs a closer evaluation than someone who is young and athletic and intermittently has symptoms that are atypical. That will be less likely to be coronary artery disease.
So I think that a lot of factors go into it from the history alone and then you do the physical exam, and then we do basic tests. An EKG (or electrocardiogram) is a basic test that can be done in the office that just looks at the heart rhythm in the electrical conduction of the heart and that would give us some clues as to where there are issues with blood flow into the heart or not. It may not be definitive and may require further testing, like a stress test, and the stress test would be, simply speaking, a test that stresses the heart and evaluates the blood flow to the heart during a stress to determine if there are issues with blood flow.
Bill Fantini: If you have the CAD, what are the treatments?
Dr. George: Treatment requires a cardiac catheterization and coronary angiography, which is what we do in the cardiac cath lab these days. These are minimally invasive procedures where you can go in from the wrist or the groin.
Typically the wrist carries much less risk and the patient can sit up right after the procedure and even go home the same day. It’s just putting it into the artery in the wrist and taking a catheter all the way up to the heart and injecting dye or contrast into the arteries to the heart to light them up, and that’ll give us a picture on X-ray as to what the blood flow is like. If there is an issue with the blood flow to those arteries, most of the time that can be fixed directly through that catheter in the wrist. We take a balloon over a wire into the area that has a blockage and open up the balloon to open up the blockage and then put a stent in.
A stent is a metal scaffold that keeps that artery open after it’s opened up by the balloon, and so those are typical treatments.
If there are severe blockages in critical areas or multiple blockages, they may require a coronary artery bypass. That’s a surgical procedure and an open heart surgery procedure where they bypass the blockages in the arteries to the heart by taking veins from the legs or from the arm to provide a different pathway for the blood to flow across the blockage there.
There are minimal restrictions, especially when you go in from the wrist, depending on what was done during the procedure. If a blockage was fixed and there’s no residual blockage just left to treat, then the restrictions would just be no heavy lifting with that arm for 24 to 48 hours.
Beyond that, there’s no restrictions here back to regular activity.
If you have a heart attack, then that means the injury to the heart muscle has already occurred and so there will be some restrictions as far as the degree of exertion over the next month or so, so just light activity and slowly increased activity as tolerated over the month.
If it is done from the groin, then there will be restrictions in climbing stairs and lifting weights because there’d be a lot of pressure put in at the groin, but from a heart standpoint, once the arteries are completely fixed, there’s no real restrictions other than gradually increase your activity to see what your tolerance is.
We also, after a heart attack, typically refer patients to cardiac rehab. There are patients that are deconditioned and they’re not really used to activity. Then we encourage gradual onset of activity under a supervised setting with a rehab program.
Bill Fantini: That’s all of my questions, but is there anything else you’d like to add?
Dr. George: Yes, I would. I just want to talk about cardiovascular disease as a whole.
People tend to get focused on the heart because the heart is the organ that pumps blood throughout the body, but the fact is that it’s cardiovascular and it doesn’t just involve the heart, but it involves the entire system of blood flow throughout the body, and people who develop blockages in the arteries to the heart can also develop blockages in the arteries to the legs, to the kidneys, to the brain, and all of those have significant consequences.
Heart disease has gotten a lot of attention, but cardiovascular disease as a whole still remains to be treated aggressively. So the concern about developing severe blockages to the legs is that you develop peripheral vascular disease and we have a high rate of amputations in this country and limb loss because of those blockages.
We also have a high risk of stroke, which accounts for one out of 20 deaths in the U.S., and that could be because of blockages in the arteries in the neck, going to the brain, so while we talk about heart disease, we also have to talk about the same disease that occurs in the entire vascular system to the rest of the body. There are ways to address all of those things individually, but people need to be educated that it’s an entire system.
Bill Fantini: Thank you for sharing your time and expertise with us. Dr. George. It’s been a pleasure speaking with you.
Dr. George: Thank you so much.
Bill Fantini: Cardiologist John George, M.D., is Director of Interventional Research at Einstein Medical Center Philadelphia, as well as serving as director of the Medical Center’s Cardiac Catheterization Laboratories. To make an appointment with Dr. George, contact 1-800-EINSTEIN. Thanks for listening. I’m Bill Fantini with Einstein perspectives.