Common presenting symptoms:
Chest pain; angina pectoris; exertional breathlessness
Overview:
Coronary artery disease (CAD) remains a serious health burden worldwide. In the UK, cardiovascular disease contributes over a quarter of all-cause mortality, of which about 16% relates to coronary artery disease. The heart, in its simplest form, is a muscle pump that has it's own dedicated blood supplies running down the outside surface of the heart - they are the coronary arteries (so named because the shape of the vessels look like a crown around the heart!). If one imagines these coronary arteries being the "fuel line" to the pump, supply to the pump with vital oxygen and fuel (sugar and fatty acid); and if these fuel lines (coronary arteries) are interrupted, or narrowed down, the part of the pump supplied by the affected artery will be deprived of oxygen (and fuel), and may produce symptoms, such as chest pain / tightness; or it may affect the pumping function of the heart, giving rise to exertional breathlessness.
This analogy is helpful but the similarities between "fuel lines" and coronary arteries unfortunately end here. Instead of being made from plastic and metal as in mechanical fuel lines, our coronary arteries are made of individual layers of living cells. Determined by a number of risk factors, including genetic predisposition, diabetic status, blood pressure and serum cholesterol level, fatty deposits (atherosclerotic plaques) form within the layers in the artery wall and may progress slowly over many years or decades. These may not produce any symptom until the fatty deposits grow sufficiently large to obstruct the lumen and reduce coronary blood flow. If this obstruction occurs progressively over a period of time, the patient may experience predictable stable angina; alternatively, if the fatty deposits erode or rupture, it may cause a sudden complete occlusion of the artery, then a heart attack (myocardial infarction) may ensue.
How do we investigate?
The first step in the investigation pathway is to arrange an appointment to see our highly specialist cardiologists who will take a detailed history and perform clinical examination. Based on individual circumstances and the pre-test probabilities, our cardiologists will recommend one or more potential investigative tests such as:-
- Electrocardiogram (ECG)
- Ultrasound of the heart (echocardiography)
- Non-invasive CT coronary angiography
- Nuclear myocardial perfusion imaging
- Stress echocardiography (pharmacological vs exercise stress)
- Perfusion stress MRI
- Exercise treadmill test
- Direct invasive coronary angiography
What are the treatment options?
Treatment options depend on a number of factors. The presence of coronary artery disease does not always equate to the need of coronary stent implantation or bypass surgery. The location and severity of the occlusion is an important consideration, as well as the patient's symptom burden. The most important treatment modality here is aggressive optimal medical therapy (OMT), both in terms of risk factor modification and plaque stabilisation. If the extend of CAD is severe, or if your symptom fails to respond to OMT, then your cardiologist will discuss with you the merit of intervention - either percutaneously by coronary stenting (PCI) or by open-heart coronary artery bypass surgery (CABG).