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Causes and Risk Factors

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Coronary artery disease is a very common condition in the United States. The famous Framingham Study has tracked the health of men and women for more than 4 decades and has given us a great deal of information about risk factors and the development of the disease.

The risk for developing CAD is higher in men than in women – but only before a woman goes through menopause, which takes place at around age 50. The risk of angina and heart attack increases with age for everyone, with women lagging about 10 years behind men.

Women and heart disease

We know that coronary artery disease is the major cause of death in men, but CAD is also the number one cause of death for U.S. women. After menopause, women's risk of developing serious heart disease increases rapidly.

More than a third of women who have had a heart attack die within one year, compared with a quarter of men who experience a heart attack. Women, people with diabetes, and some older adults may have symptoms that make it more difficult to diagnose coronary artery disease. Because the symptoms are not as typical, sometimes getting care is delayed.

Plaque buildup

Coronary artery disease, or atherosclerosis, is the condition that most often causes heart attacks. As you age, fatty deposits, called plaque, form inside your coronary arteries. If severe enough, this may cause symptoms of angina (chest pain during exercise or other stress on the heart), or you may not have any symptoms at all.

If you experience added stress or injury, such as high blood pressure, severe infection, or severe emotional distress, the area of the artery that has the plaque buildup could break open and form a clot in response to the injury. This clot can cause a sudden total blockage of the artery and be the immediate cause of a heart attack.

Risk factors

Risk factors are attributes that may increase your risk of experiencing CAD. The risks are increased if you:

• Are male.
• Are female over the age of 55 and/or in menopause.
• Have a family history of heart disease.
• Have high cholesterol.
• Have high blood pressure.
• Have an inactive lifestyle.
• Use tobacco.
• Have diabetes.
• Are overweight.

Symptoms

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Coronary artery disease usually develops slowly over many years. By being familiar with the symptoms, you may be able to avoid a heart attack or heart failure.

Symptoms of angina usually last several minutes rather than several seconds and can include:

• Chest pain or pressure that is brought on by your normal activities or by hard work
• Tingling or numbness behind your breastbone and/or across your chest
• Tingling or numbness across your chest that travels to your jaw, arms, shoulders, shoulder blades, or neck

Unfortunately, sometimes the first sign of coronary artery disease is a heart attack. There are some people who are not getting enough blood flow to the heart muscle (ischemia), who do not have any symptoms. We call this "silent ischemia." On rare occasions, you can even have a heart attack without any symptoms, called a "silent heart attack."

Heart attack symptoms may or may not be brought on by activity. They last longer than 20 minutes or longer than 3 to 5 minutes after resting or taking nitroglycerin (a medication taken when you have chest pain to reduce the chance of a heart attack). They may not disappear even after taking nitroglycerin. The symptoms of a heart attack are:

• Same as angina but more severe
• Sweating, often described as a cold sweat
• Aching, crushing, or squeezing feeling over the chest
• Severe burning over the chest or upper abdomen
• Unusual shortness of breath
• Dizziness or fainting
• Nausea and/or vomiting
• Unusual weakness
• Fast or irregular heartbeat
• Change in heart rate or rhythm
• A sense of impending (coming) doom

If you think you might be having a heart attack, act quickly. Getting medical attention right away – within 1 hour – can save your life and lessen the amount of heart muscle that gets damaged. 

• Call 911 emergency services before you call anyone else if your symptoms are not relieved in 3 to 5 minutes by nitroglycerin and rest.
• Stop what you are doing.
• Sit or lie down.
• Take nitroglycerin. If you have not taken Viagra, Levitra, or Cialis in the past 72 hours, and you have a prescription for nitroglycerin, place one nitroglycerin tablet (0.4 mg) under your tongue. Let it dissolve. Do not chew or swallow the pill.
• Continue to put one nitroglycerin tablet under your tongue every 5 minutes until your symptoms are relieved or until the ambulance arrives.
• Do not drive yourself to the Emergency Department.
• Chew one adult strength (325 mg) uncoated aspirin tablet or 4 "baby" aspirins (81 mg each) if you have them, are not allergic to aspirin, and are not already taking daily aspirin.

Report your symptoms to us if:

• You have any of the above symptoms and have never told us about them.
• You normally have some pain when you exercise (that you have told us about) and you start having pain at rest or pain wakes you from sleep.
• You begin to have more frequent attacks of angina than you normally have.
• Your angina pain is worse.
• You have had an angioplasty or stent placement, bypass surgery, or any other procedure that is supposed to open the coronary arteries and you are still having pain.

Become familiar with your angina pattern

If you have angina, you will probably notice that you have a particular pattern that is typical for you. It is important for you to be aware of your own pattern and to tell us if any of these factors change:

• What causes it
• How often it happens
• How severe it is
• How long it lasts
• What it feels like
• What makes it go away

Diagnosis

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In order to diagnose your angina, we will ask you certain questions about your chest discomfort:

• When it started
• How long it lasts
• What it feels like
• If it spreads to any other parts of your body
• What activities bring it on
• What makes it feel better or go away

The angina may be due to heartburn or another underlying cause. After a full medical exam and conducting a full medical history, we may:

• Start you on medications to prevent angina and work with you to modify your risk factors for coronary artery disease.
• Order more tests to check out your heart. These include:
  • An electrocardiogram (EKG/ECG)
  • A treadmill exercise stress test
  • A radioactive scan of the heart (perfusion scan), if an exercise stress test is not possible for any reason
  • An echocardiogram 
• Order tests to check out other reasons for the chest pain, like heartburn, a stomach ulcer, or blood clots in the lungs.
• Recommend further evaluation in the Emergency Department that same day.

In the Emergency Department

Once you arrive at the Emergency Department, we will do a number of tests to confirm or rule out the diagnosis. These include:

• An electrocardiogram (EKG/ECG), which tests the electrical activity of your heart 
• A brief physical examination of the heart, lungs, and abdomen
• Blood tests to look for heart damage
• Chest X-rays

Depending on the results of the evaluation, there are several possible next steps. It may be that there is no problem with your heart. If the chest pain is stable, you may be discharged with follow-up instructions. Depending on the severity, you may be asked to undergo further evaluations or even additional emergency treatments.

Treatment

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If you have evidence of a heart attack, the treatment you receive in the Emergency Department will depend upon:

• How long ago your chest pain started
• The size of your heart attack
• What area of your heart is affected
• The pattern of your electrocardiogram (EKG/ECG)

In the Emergency Department you will probably have:

• A catheter (IV) placed into a vein
• Oxygen
• Medication to dissolve the blood clot, relieve your pain, and lower your heart rate and your blood pressure

You may receive additional nitroglycerin from the paramedic or Emergency Department staff. It is important that you notify all of these caregivers immediately if you have taken Viagra, Levitra, or Cialis within the prior 72 hours, since these medicines can have a fatal interaction with nitroglycerin. 

You may be transferred to another hospital. If the electrocardiogram and blood tests determine that the best treatment would be to open or repair the artery responsible for the blockage right away, you may need a cardiac catheterization or bypass surgery.

A cardiac catheterization allows us to see what blockages exist. During this procedure, a catheter is placed in a large artery of your leg or arm and guided into the arteries of your heart. The arteries can often be opened with a small balloon (angioplasty) and held open with a small expandable wire tube, called a stent.

Coronary artery bypass graft (CABG) surgery is sometimes needed. If the angioplasty is unable to reach or open a blockage, this surgical procedure removes veins from another part of your body and grafts them around the blocked artery (a bypass).

Recovery and Medications

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Recovery

Expect to stay in the hospital for a few days to a week or more. This will depend upon the type of heart attack you had and the treatment you received, as well as your general health before your heart attack.

Make the most of your recovery while you are in the hospital. You may receive physical therapy, occupational therapy, and respiratory therapy while you are in the hospital. We may also give you a stress test to help us evaluate your recovery and make physical activity recommendations.

We will help you prevent another heart attack and avoid future problems. When you are discharged from the hospital, you will receive instructions about medications to take and suggestions for a healthy lifestyle that will support your recovery.

Medications

Medications include:

• Aspirin
• Beta blockers
• Statins
• Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB)
• Antiplatelets (if you have a stent)

Certain types of medications to cut down on stomach acid should not be taken with antiplatelet medication. Please discuss this with us if you are taking any type of antacids.

Prevention

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Heart attacks can happen without any warning signs, so it is important to pay attention to possible risk factors to prevent the development of coronary artery disease.

You should be aware of your risk factors and do everything you can to decrease your risk for a heart attack or stroke:

• Know your family history. You should find out the specifics of the health history of your parents, siblings, and other relatives since you may have inherited the same tendencies.
• Maintain an ideal weight. The goal of your body mass index (BMI) is between 18.5 and 24.9 kg/m².
• Exercise the equivalent of a brisk walk on most days of the week for at least 30 minutes.
• Eat a heart-healthy diet rich in omega-3 fatty acids, high in fiber, and low in simple sugars and starches.
• Maintain your blood pressure. Discuss your individual target with us.
• Maintain your LDL, or bad cholesterol, at 100 or lower and your HDL, or good cholesterol, as high as possible above 45. Ideally, your total cholesterol should be 200 or below.
• Check your fasting blood sugar periodically to make sure that you do not have diabetes.

Lifestyle Changes and Management

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It’s never too late to make lifestyle changes that can improve the health of your heart. A heart-healthy lifestyle consists of maintaining a healthy weight, managing your diabetes, staying active, managing stress, and avoiding tobacco.

Healthy lifestyle recommendations:

• If you use tobacco, we strongly advise you to stop. Your risk of having a heart attack goes down within the first 24 hours after your last cigarette.
• Eat a diet low in saturated fat and trans fat, but one that is high in fiber with lots of fruits and vegetables.
• Make physical activity part of your daily routine.
• Maintain a healthy weight.
• Recognize and manage stress and depression.

We will work with you to:

• Control your blood pressure.
• Lower your cholesterol.
• Manage your blood sugar levels if you have diabetes.

Your doctor or cardiac rehabilitation team will give you specific guidelines about the type of activities you can do and when it will be safe to do them.

We might have you take an exercise stress test to determine what type of activity to recommend.

If you're not having chest discomfort or other complications, you will probably be able to return to your usual activities, including driving, within a few weeks. Ask your doctor when you will be able to resume sexual activity.

Depending on your occupation and the severity of your heart attack, you may be able to return to work in 2 to 6 weeks. Start slowly. Allow yourself the time to gradually get your strength and energy back.

We recommend that you participate in a cardiac rehabilitation program, such as MULTIFIT, to help you recover and support you in achieving a healthy lifestyle. You will learn about proper exercise and nutrition, medications, and the heart disease process to help prevent you from having another cardiac event. In MULTIFIT, your personal care manager, together with your physician, will support and guide you while you learn how to live better and healthier with your condition.

Your Care with Me

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If you think you may be having a heart attack, or if you have chest pain or pressure that lasts more than 5 minutes, call 911 or seek other emergency services immediately. This is not the time to e-mail or call your doctor.

If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If a cardiologist’s care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we will discuss your medical and family history and I will perform a physical exam. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options, and together we will create a treatment plan that is right for you.

If you have been seen before by a cardiologist outside of Kaiser Permanente, please bring those medical records with you. Also, please bring with you all your containers with any prescription medications and any over-the-counter medications you are taking.

I may order additional tests to be completed at a subsequent visit. I may also prescribe medications, and I will talk to you about how to take the medications.

If I prescribe nitroglycerin for you, keep a fresh prescription (filled within the past 6 months) with you at all times. If you have chest pain or discomfort, sit down and rest, and take the nitroglycerin as directed. If your chest pain does not get better in 5 minutes, call 911. 

If you have had a recent heart attack, heart surgery, or a procedure on your heart, I may refer you to our MULTIFIT cardiac rehabilitation program or other cardiac classes or programs to help you with your recovery. The nurse or pharmacist care manager will contact me regularly about your health. A good place to start is by attending a heart health class. If you have a weakened heart muscle, I may refer you to our Heart Failure Care Management Program. The nurse or pharmacist care manager will adjust your medications to help improve the function of your heart. We also have a series of classes to learn about heart failure.

Contacting Me

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

For general medical advice, our Appointment and Advice line is available 24 hours a day, 7 days a week.

If you have urgent concerns or issues while my office is closed, you can call the Appointment and Advice line. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

Seek immediate medical care if: 

• You are having chest pain of more frequency, duration, or severity than usual.
• You feel lightheaded or dizzy, have palpitations (sense that your heart is racing) for greater than 15 to 20 minutes, or feel you might faint.
• You are having worsening and/or sudden shortness of breath.

Also Call 911 if you have signs of a stroke. These may include:

• Sudden numbness or weakness in your face, arm, or leg, especially on only one side of your body
• New problems with walking or balance
• Sudden vision changes
• Slurred speech
• New problems with confusion, speaking, or understanding simple statements
• A sudden, severe headache that is different from past headaches

If you had surgery or a procedure, please call me if you notice any swelling, bleeding, redness, pain, or discharge at the incision site.

Take your medication exactly as prescribed. If you are having problems with or have any questions about any of the medications I have prescribed for you, let me know. Do not stop taking them without notifying me.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

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If Surgery or a Procedure Is a Treatment Option

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I will recommend that you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

If you are considering surgery or a procedure or want more information about your heart problem, please review our health tool called “Preparing for Your Procedure” (Emmi). Emmi programs are available for the following cardiology topics:

• Anesthesia for an Adult
• Angiogram with Possible Angioplasty
• Atrial Fibrillation Overview
• Aortic Valve Replacement
• Cardiac Catheter Ablation (SVT)
• Cardiac Catheter Ablation (VT)
• Cardiac Pacemaker
• Coronary Artery Bypass Surgery (CABG)
• Defib (Cardiac Resynchronization Therapy Defibrillator)
• Defib (Implantable Cardioverter Defibrillator)
• Mitral Valve Repair or Replacement
• Taking Warfarin (Coumadin®)

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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