Coronary Heart Disease Symptoms

Coronary heart disease overview

Coronary Heart Disease (CHD), also known as Coronary Artery Disease (CAD) or Ischaemic Heart Disease (IHD), is a disease that causes the main vessels, or coronaries, responsible for taking blood, nutrients, and oxygen to the heart muscle to become narrow, due to fatty plaques and inflammation.^1,2 It is one of the most common heart diseases worldwide. 

The fatty material that accumulates inside the heart arteries is called atheroma, and this process is called atherosclerosis. These plaques cause the narrowing of the lumen, the internal space of the vessels, of the coronaries. Over time, the plaque can break and a blood clot can be formed, leading to a total blockage of the artery.³

The narrowing of the arteries limits the blood flow to the heart muscle, preventing it from receiving the oxygen it needs to function properly. When this happens the person might present with chest pain. However, if a total blockage occurs, the person can have a heart attack.¹

Lifestyle changes may help to prevent Coronary Heart Disease and its consequences, but if you are already diagnosed with CHD, these changes are still effective in helping control the disease and avoiding a heart attack.

In severe cases, however, you may require medication or even surgical intervention to best manage the condition. 

Symptoms of coronary heart disease

Angina Pectoris is the most common symptom of Coronary Artery Disease. Presented most of the time as chest pain, it can also be felt as tightness, pressure, heaviness, or a squeezing sensation mostly on the central or left side of the chest.⁵  However, this discomfort can also occur or radiate to the shoulders, arms (especially the left side), neck, jaw, abdomen, and back.⁴ 

Some other symptoms associated with angina are dizziness, breathlessness, nausea, sweating, and fatigue.⁶ Stable angina is categorised by attack symptoms that are mainly triggered by exertion or stress and tend to go away when resting. However, if symptoms are felt without triggers and even when resting, it is usually diagnosed as unstable angina.⁷

For some people, the first symptom of heart disease will be experiencing a heart attack,  where the symptoms above might be present, but would last longer and would not be relieved. In some cases, a heart attack can present symptoms similar to indigestion, leading to confusion between the two.⁸

When a heart attack is not identified, the first symptoms of Ischaemic Heart Disease might already be heart failure symptoms. This happens because the heart muscle becomes weak after a heart attack, and the heart pump stops  working properly, causing a fluid overload that presents itself with shortness of breath, swelling of your lower legs and hands (peripheral oedema), breathlessness when lying down (orthopnoea), and a symptom that causes you to wake up in the middle of the night with shortness of breath, that then improves when standing or sitting up (paroxysmal nocturnal apnoea).⁸

Causes and diagnosis

Causes of coronary heart disease

This disease is caused by the build-up of plaques in the blood vessel wall. These plaques are mainly formed by cholesterol, but can also contain other substances as well. .⁹

These fatty deposits are known as atheroma and this role process of building up plaques is known as atherosclerosis.¹⁰ These plaques take years to develop, usually decades, and cause narrowing and blockage of the vessels, limiting the blood flow to the heart muscle.¹ This process is also related to having high cholesterol since that is the main component of these plaques.

This narrowing can lead to angina symptoms, and if not treated, the blockage can lead to myocardial infarction causing damage to the heart, which sometimes might be irreversible and can result in heart failure.

Atherosclerosis is not the only disease that affects the coronaries that might lead to CHD. Problems with how these arteries work are also a cause of heart disease. The vessels respond when the heart signals a need for more oxygen, and are then able to widen their lumen to provide a better flow. However, an impaired blood vessel is not able to respond properly to this signal. This happens due to chronic inflammation of the wall, often caused by diabetes, high blood pressure, or smoking.¹¹

How is it diagnosed

Coronary heart disease can often be spotted by its symptoms alone, which can be identified with a good history taking and examination. However, the proper diagnosis involves performing some tests. The tests that might be performed to help identify coronary heart disease are:

•  ECG- a test that checks the heart’s rhythm and electrical activity. Some changes in the pattern can be used to diagnose angina.
• Exercise ECG or stress ECG- monitors the electrical activity of the heart during exercise. Changes in the electrical pattern or chest pain can indicate angina.
• Coronary Calcium scan- measures the amount of calcium inside your arteries. This helps to identify the plaques that are becoming calcified and therefore identify the narrowing inside the arteries.
• Computed Tomography Coronary Angiography- a scan used to check inside the heart’s blood vessels and identify blockages or narrowing.
• MRI- helps to check reduced blood flow into cardiac areas.
• Echocardiogram- helps to identify heart damage caused by reduced blood flow.
• Nuclear stress test- also helps to identify areas where the blood is not flowing normally.¹²

Not all of these tests will necessarily need to be performed to identify Angina. The doctor will identify which ones will be the most effective on an individual basis. 

Risk factors

The main risk factors for developing cardiovascular disease are:

• High blood pressure – this can damage the arteries and make them stiff, and therefore they will not respond well to the heart’s demands.
• High cholesterol and triglycerides – increase the risk of atherosclerosis and atheroma.
• Smoking – also related to the damage of the artery walls.
• Getting older – as people age, the damage in the coronaries can build up, increasing the risk of narrowing these vessels.
• Sex – people assigned male at birth are generally more likely to develop CHD.
• Unhealthy diet – eating a lot of fat and sugar can lead to diseases like diabetes and high cholesterol, which are intimately related to CHD.
• Obesity – being obese overweight can lead to diabetes, high blood pressure, and high cholesterol.
• Lack of exercise – physical activity can improve the health of your vessels and heart, and not doing enough of it is related to developing CHD.
• Diabetes and insulin resistance – related to vessel damage and inflammation.
• Inflammation – caused by other diseases such as lupus, arthritis, inflammatory bowel disease, or an unknown source.
• Family history of coronary artery disease – having relatives with CHD increases the risk of developing it, even more so if it is a first-degree relative.
• Stress – stress can release hormones that can damage the arteries.
• Alcohol use – a high amount of alcohol consumption is related to the development of cardiovascular diseases.
• Sleep pattern – not having a good and balanced sleep pattern can lead to several diseases and has shown to be  related to CHD.¹

However, angina can also be caused by some other conditions not directly related to coronary heart disease.

Treatment and Prevention

Treatment for coronary heart disease

The treatment for coronary heart disease might include medications or even surgical interventions. Some of the medicines used are:

• Nitrates – these medicines help relax the blood vessels and widen the lumen of the vessel, increasing the blood flow to the heart muscle. It can come in the form of pills, tablets, sprays, and IV medication.
• Medicines to control cholesterol (Statins) – these help to control cholesterol levels and atherosclerosis, both risk factors for heart disease.
• Medicines to control high blood pressure – having high blood pressure can damage the vessels and increase the risk of heart disease, which is why it is so important to keep it under control with the right medication if you are suffering from hypertension.
• Medicines to control diabetes – like metformin, gliclazide, empagliflozin, or even in severe cases, insulin. 
• Antiplatelets (like Aspirin) – these reduce blood clotting, and therefore allow for the blood to flow easier.  It can also prevent clots that block the arteries.

Patients with a high risk of heart attack might need other interventions, such as:

• Percutaneous Coronary Intervention (PCI) – a procedure involving cardiac catheterisation in which a balloon is inserted to dilate the artery where it has narrowed, and a stent is placed inside to keep the arteries open.
• Coronary artery bypass graft (CABG) – open surgery where a vein or artery of another part of the body is used to replace the narrowed heart artery.¹³

How to prevent coronary heart disease

There are many lifestyle changes that can be implemented to prevent Coronary Heart Disease. Some of them include:

• Stopping smoking – if you are finding it challenging to  give up smoking, there are healthcare programs available that can help you.
• Practising physical activity – you should try to do at least 30 min of moderate activity 5 days a week.
• Controlling your weight – reducing your weight can help you to avoid and control angina.
• Eating a healthy diet – try to avoid salt and saturated fats, and eat more fibre and vegetables.
• Controlling other health issues – diseases such as diabetes, high blood pressure, and high cholesterol are risk factors for developing angina. Having them under control will help you to avoid angina.
• Managing your stress – controlling your stress levels and practising mindfulness, meditation, and other types of stress management exercises, can help you to prevent angina.
• Reducing alcohol consumption – consuming alcohol in moderation can help you in managing your angina.¹⁴

Summary

Coronary Heart Disease (CHD) is a cardiovascular disease caused by atherosclerosis, the process in which fatty plaques build up inside the heart arteries, or coronaries. These plaques, also known as atheroma, grow over the years and cause the narrowing of the lumen of these vessels, limiting the blood flow to the heart. Less blood flow means less oxygen, which can damage the heart muscle.

The main symptom of CHD is angina, which might manifest as chest pain, breathlessness, nausea, sweating, and dizziness. The diagnosis is done through history taking, examination and some additional tests that help in identifying blockages in the coronary vessels. There are several risk factors, but CHD can be prevented with lifestyle changes.

The treatment involves taking different types of medicines, but severe cases may require surgical intervention.