Coronary Heart Disease
Heart disease is a catch-all phrase for a variety of conditions that affect the heart’s structure and how it works. Coronary heart disease is a type of heart disease where the arteries of the heart cannot deliver enough oxygen-rich blood to the heart. It is the leading cause of death in the United States. About 18.2 million American adults have coronary artery disease, making it the most common type of heart disease in the United States, according to the Centers for Disease Control and Prevention.
Coronary artery disease affects the larger coronary arteries on the surface of the heart. Another type of heart disease, called coronary microvascular disease, affects the tiny arteries in the heart muscle. Coronary microvascular disease is more common in women.
The cause of coronary heart disease depends on the type. Coronary artery disease is often caused by cholesterol, a waxy substance that builds up inside the lining of the coronary arteries forming plaque. This buildup can partially or totally block blood flow in the large arteries of the heart. Coronary microvascular disease happens when the heart’s tiny blood vessels do not work normally. For most people, coronary heart disease is preventable with a heart-healthy lifestyle.
Symptoms of coronary heart disease may be different from person to person even if they have the same type of coronary heart disease. However, because many people have no symptoms, they do not know they have coronary heart disease until they have chest pain, blood flow to the heart is blocked causing a heart attack, or the heart suddenly stops working, also known as cardiac arrest.
What causes coronary heart disease?
Coronary heart disease may have more than one cause, including plaque buildup or problems that affect how the heart’s blood vessels work.
Plaque buildup: Plaque buildup in the arteries is called atherosclerosis. When this buildup happens in the heart’s arteries over many years, the arteries become narrower and harden, reducing oxygen-rich blood flow to the heart. This is the main cause of obstructive coronary artery disease.
Small amounts of plaque can also develop in the small blood vessels in the heart, causing coronary microvascular disease.
Problems with how the blood vessels work: Problems with how the heart’s blood vessels work can cause of coronary heart disease. For example, the blood vessels may not respond to signals that the heart needs more oxygen-rich blood. Normally, the blood vessels widen to allow more blood flow when a person is physically active or under stress. If you have coronary heart disease, the size of these blood vessels may not change, or the blood vessels may even narrow.
The cause of these problems is not fully clear. But it may involve damage or injury to the walls of the arteries or tiny blood vessels from chronic inflammation, high blood pressure, or diabetes, all of which can cause blood vessels to narrow over time.
Damage to the inner walls of the larger coronary arteries can cause them to spasm (suddenly tighten). This is called vasospasm. The spasm causes the arteries to narrow temporarily and blocks blood flow to the heart.
Symptoms of a heart attack
A sudden heart problem, such as a heart attack, may cause the following symptoms:
- Angina, or chest pain caused by the heart can feel like pressure, squeezing, indigestion, burning, or tightness, and is sometimes related to physical activity. The pain or discomfort usually starts behind the breastbone, but it can also occur in the arms, shoulders, jaw, throat, or back.
- Cold sweats
- Nausea or a feeling of indigestion
- Neck pain
- Shortness of breath, especially with activity
- Sleep disturbances
Women are less likely than men to experience chest pain with a heart attack. Instead, they are more likely to experience:
- Extreme tiredness
- Pressure or tightness in the chest
- Stomach pain
You may also have some symptoms of a sudden heart problem, such as chest pain, shortness of breath, or neck pain, that go away with rest and come back with activity. These symptoms may get worse as the buildup of plaque continues to narrow the coronary arteries. Chest pain or discomfort that does not go away or happens more often or while you are resting might be a sign of a heart attack.
If you do not know whether your chest pain is angina or a heart attack, call 9-1-1 right away. All chest pain should be checked by a healthcare provider.
Screening for coronary heart disease
Heart disease can be a silent condition, meaning you may not have any symptoms until you have a serious health problem, such as a heart attack. Having regular check-ups is important to help your doctor know your risk and recommend healthy lifestyle changes to prevent heart disease.
You should start getting screening tests and risk assessments for coronary heart disease around age 20 if you do not have any risk factors for it. Children may need screening if they have risk factors, such as obesity, low levels of physical activity, or a family history of heart problems.
Your doctor may recommend preventive treatments such as heart-healthy lifestyle changes to help you lower your risk of coronary heart disease.
To screen for coronary heart disease, your doctor will:
- Assess risk factors to help evaluate your risk of developing coronary heart disease
- Check blood pressure readings to see whether you have high blood pressure
- Calculate your body mass index and waist circumference to see whether you have an unhealthy weight
- Order blood tests to see whether you have high blood cholesterol, high blood triglycerides, or diabetes
Screening usually happens in a provider’s office, but sometimes screenings are done at health fairs, drugstores, or other places. Blood samples might be collected at the provider’s office, a hospital, or a laboratory.
Ask whether you need to fast (not eat or drink anything besides water) before the blood tests.
Diagnostic tests and procedures
If you have symptoms of coronary heart disease, your healthcare provider may order tests to see if you have coronary heart disease. Your provider will also likely order blood tests to check the levels of cholesterol, triglycerides, sugar, lipoproteins, or proteins that are a sign of inflammation.
You can read more about the following tests and procedures on our Heart Tests and Heart Treatments pages:
- An electrocardiogram (EKG or ECG) determines whether the heart’s rhythm is steady or irregular. An EKG also records the strength and timing of electrical signals as they pass through the heart.
- A coronary calcium scan measures the amount of calcium in the walls of your coronary arteries. This test is a type of cardiac CT scan. Coronary calcium scans can also help assess coronary heart disease risk for people who smoke or for people who do not have heart symptoms.
- Stress tests check how your heart works during physical stress. During stress testing, you walk or run on a treadmill or pedal a stationary bike to make your heart work hard and beat fast. If you have a medical problem that prevents you from exercising, your doctor may give you medicine to make your heart work hard, as it would during exercise. To detect reduced blood flow to your heart muscle, while you exercise you will be monitored by ECG and possibly echocardiogram or CT scan.
- Cardiac MRI (magnetic resonance imaging) detects tissue damage or problems with blood flow in the heart or coronary arteries. It can help your doctor diagnose coronary microvascular disease as well as nonobstructive or obstructive coronary artery disease. Cardiac MRI can also help explain results from other imaging tests.
- Cardiac positron emission tomography (PET) scanning assesses blood flow through the small coronary blood vessels and into the heart tissues. This is a type of nuclear heart scan that can diagnose coronary microvascular disease.
- Coronary angiography shows the insides of your coronary arteries. To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization. This procedure is often used if other tests show that you are likely to have coronary artery disease. To diagnose coronary microvascular disease, your doctor will use coronary angiography with guidewire technology to help navigate to the smaller spaces.
- Coronary computed tomographic angiography is a non-invasive imaging test using CT scanning to show the insides of your coronary arteries rather than an invasive cardiac catheterization.
Heart-healthy lifestyle changes
Your provider may recommend adopting lifelong heart-healthy lifestyle changes.
- Aim for a healthy weight. Losing just 3% to 5% of your current weight can help you manage some coronary heart disease risk factors, such as high blood cholesterol and diabetes. Greater amounts of weight loss can also improve blood pressure readings.
- Be physically active. Routine physical activity can help manage coronary heart disease risk factors such as high blood cholesterol, high blood pressure, or overweight and obesity. Before starting any exercise program, ask about what level of physical activity is right for you.
- Heart-healthy eating may include the DASH (Dietary Approaches to Stop Hypertension) eating plan. A heart-healthy eating plan includes fruits, vegetables, and whole grains and limits saturated fats, sodium (salt), added sugars, and alcohol.
- Manage stress. Learning how to manage stress, relax, and cope with problems can improve your emotional and physical health.
- Quit smoking.
- Get enough good-quality sleep. The recommended amount for adults is 7 to 9 hours of sleep a day.
Medicines: Some medicines can reduce or prevent chest pain and manage other medical conditions that may contribute to your coronary heart disease.
- ACE inhibitors and beta blockers help lower blood pressure and decrease how hard your heart is working.
- Calcium channel blockers lower blood pressure by allowing blood vessels to relax.
- Medicines to control blood sugar, such as empagliflozin, canagliflozin, and liraglutide, can help lower your risk for complications if you have coronary heart disease and diabetes.
- Metformin controls plaque buildup if you have diabetes.
- Nitrates, such as nitroglycerin, dilate your coronary arteries and relieve or prevent chest pain from angina.
- Ranolazine treats coronary microvascular disease and the chest pain it may cause.
- Statins or non-statin therapies control high blood cholesterol. You may need statin therapy if you have a higher risk of coronary heart disease or stroke or if you have diabetes and are between ages 40 and 75.
- Non-statin therapies may be used to reduce cholesterol when statins do not lower cholesterol enough or cause side effects. Your healthcare provider may also prescribe non-statin drugs, such as ezetimibe, bile acid sequestrants, alirocumab, or evolocumab to lower cholesterol or gemfibrozil or fenofibrate to reduce triglycerides. They may also recommend omega-3 fatty acids as a supplement to your healthy diet.
Procedures: You may need a procedure or heart surgery to treat more serious coronary heart disease.
- Percutaneous coronary intervention (PCI) opens coronary arteries that are narrowed or blocked by the buildup of plaque. A small mesh tube called a stent is usually implanted after PCI to prevent the artery from narrowing again.
- Coronary artery bypass grafting (CABG) improves blood flow to the heart by using normal arteries from the chest wall and veins from the legs to bypass the blocked arteries. Surgeons typically use CABG to treat people who have severe coronary artery disease in multiple coronary arteries.
- Transmyocardial laser revascularization or coronary endarterectomy treats severe angina linked to coronary heart disease when other treatments are too risky or did not work.