An in-depth report on the causes, diagnosis, treatment, and prevention of coronary artery disease (CAD).
Angina; Atherosclerosis; Heart disease
Common symptoms of coronary artery disease (CAD) include angina, shortness of breath (particularly during physical exertion), and rapid heartbeat. Sometimes patients with CAD have few or no symptoms until they have heart attack or heart failure.
Angina is a symptom, not a disease. It is the primary symptom of coronary artery disease and, in severe cases, of a heart attack. It is typically felt as chest pain and occurs as a consequence of a condition called myocardial ischemia. Ischemia results 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. Angina is usually referred to as one of two states:
Angina may be experienced in different ways and can be mild, moderate, or severe. 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 feel only mild discomfort from severe ischemia.
Stable 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 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 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.]
Prinzmetal'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. 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 may occur when the brain abnormally processes 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.)
Chest pain is a very common symptom in the emergency room, but heart problems account for only 10 - 33% of all episodes. There are many other causes of chest pain or discomfort including injured muscles, arthritis, heartburn, and asthma.
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