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Coronary Artery Disease (CAD)

Brief Overview: According to Medline Plus, “Coronary artery disease (CAD) is the most common type of heart disease. It is the leading cause of death in the United States in both men and women. CAD happens when the arteries that supply blood to heart muscle become hardened and narrowed. This is due to the buildup of cholesterol and other material, called plaque, on their inner walls. This buildup is called atherosclerosis. As it grows, less blood can flow through the arteries. As a result, the heart muscle can't get the blood or oxygen it needs. This can lead to chest pain (angina) or a heart attack. Most heart attacks happen when a blood clot suddenly cuts off the hearts' blood supply, causing permanent heart damage. Over time, CAD can also weaken the heart muscle and contribute to heart failure and arrhythmias. Heart failure means the heart can't pump blood well to the rest of the body. Arrhythmias are changes in the normal beating rhythm of the heart.”

Prevalence: According to Cleveland Clinic, “Coronary artery disease is very common. Over 18 million adults in the U.S. have coronary artery disease. That’s roughly the combined populations of New York City, Los Angeles, Chicago and Houston. In 2021, coronary artery disease killed 375,500 people in the U.S. Coronary artery disease is the leading cause of death in the U.S. and around the world.”

Etiology: According to Merck Manuals, “The most common cause of coronary artery disease is atherosclerosis, commonly known as hardening of the arteries. In atherosclerosis, cholesterol and other fatty material slowly build up in your arteries. Less common causes include a sudden spasm of a coronary artery, usually from using illicit drugs such as cocaine. During a spasm, the artery suddenly squeezes shut. If it stays shut long enough, you can have a heart attack. Usually the spasm stops and the artery opens up again.”

Risk Factors:

  • Hypertension
  • Hyperlipidemia
  • Diabetes mellitus
  • Tobacco use
  • Obesity and physical inactivity
  • Family history of premature CAD
  • Increasing age
  • Male sex
  • Chronic stress and poor sleep

Commonly Associated Conditions:

  • Stable or unstable angina
  • Myocardial infarction
  • Heart failure
  • Atrial fibrillation
  • Peripheral arterial disease
  • Cerebrovascular disease (stroke, TIA)
  • Chronic kidney disease

Common Medications:

  • Antiplatelet therapy – aspirin, clopidogrel, prasugrel, ticagrelor, cangrelor
  • Beta-blockers – metoprolol, carvedilol
  • Ace-inhibitors/ARBs – lisinopril, losartan
  • Calcium-channel blockers – amlodipine, diltiazem
  • Nitrates – nitroglycerin (short-acting), isosorbide mononitrate (long-acting)
  • Lipid-lowering drugs – statin, ezetimibe, PCSK9 inhibitors
  • GLP-1 receptor agonists – semaglutide

Common Labs, Imaging, and Tests:

  • ECG
  • Stress test
  • Echocardiogram
  • Coronary CT angiography or cardiac catheterization
  • Chest x-ray
  • Coronary artery calcium scan
  • Cardiac biomarkers
  • Lipid panel
  • HgbA1c, glucose

Common Symptoms:

  • Can be asymptomatic
  • Angina – chest pain or discomfort
  • Dyspnea – shortness of breath
  • Weakness, fatigue
  • Lightheadedness
  • Nausea
  • Diaphoresis
  • Arm/shoulder/jaw pain or discomfort

Common Treatments:

  • Lifestyle changes – physical activity, dietary modifications, weight loss, smoking cessation
  • Cardiac rehab
  • Optimal management/control of any comorbidities
  • Medication (see above)
  • Revascularization, if indicated
    • Percutaneous coronary intervention (PCI/stent)
    • Coronary artery bypass grafting (CABG)
  • Regular cardiology follow up

Physical Findings:

  • Often normal at rest
  • Signs of heart failure in advanced disease (edema, crackles)
  • Abnormal heart sounds or murmurs
  • Elevated blood pressure
  • Diminished peripheral pulses (systemic atherosclerosis)

Potential Complications and Contraindications:

  • Potential complications:
    • Myocardial infarction
    • Heart failure
    • Life-threatening arrhythmias
    • Sudden cardiac death
    • Stroke
  • Contraindications / cautions:
    • Nitrates contraindicated with recent PDE-5 inhibitors
    • Monitor renal function and potassium with ACE inhibitors/ARBs
    • Bleeding risk with antiplatelet therapy
    • Beta-blocker use requires caution in severe asthma/COPD

General Health and Lifestyle Guidance:

  • Follow a heart-healthy diet (Mediterranean or DASH typically recommended)
  • Engage in regular aerobic physical activity, as tolerated, and as approved by healthcare provider
  • Achieve and maintain a healthy weight, as directed by healthcare provider
  • Strict smoking cessation
  • Manage stress and sleep quality
  • Adhere to medications consistently, as prescribed
  • Participate in cardiac rehabilitation when available and recommended by healthcare provider
  • Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.  

Suggested Questions to Ask Patients:

  1. Do you experience chest pain or shortness of breath with activity?
  2. Have you used nitroglycerin recently? Did it help?
  3. Are you taking your heart medications daily as prescribed?
  4. Any side effects such as dizziness, bleeding, or muscle pain?
  5. Any recent ER visits or hospitalizations for heart symptoms?
  6. Do you monitor your blood pressure or cholesterol at home?
  7. Do you smoke or have difficulty with lifestyle changes?

Suggested Talking Points:

  • Coronary artery disease is chronic, but progression can be slowed or stabilized.
  • Medications help protect the heart even when you feel well.
  • Chest pain that is new, severe, or unrelieved by nitroglycerin is an emergency.
    • Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.  
  • Lifestyle changes are just as important as medications.
  • Cardiac rehab improves survival and quality of life.

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.