Coronary Artery Disease

Overview

What is coronary artery disease?

Coronary artery disease occurs when fatty deposits called plaque (say "plak") build up inside the coronary arteries. The coronary arteries wrap around the heart and supply it with blood and oxygen. When plaque builds up, it narrows the arteries and reduces the amount of blood that gets to your heart. This can lead to serious problems, including heart attack.

Coronary artery disease (also called CAD) is the most common type of heart disease. It is also the number one killer of both men and women in the United States.

It can be a shock to find out that you have coronary artery disease. Many people only find out when they have a heart attack. Whether or not you have had a heart attack, there are many things you can do to slow coronary artery disease and reduce your risk of future problems.

What causes coronary artery disease?

Coronary artery disease is caused by hardening of the arteries, or atherosclerosis. Atherosclerosis occurs when plaque builds up inside the arteries. (Arteries are the blood vessels that carry oxygen-rich blood throughout your body.) Atherosclerosis can affect any arteries in the body. When it occurs in the arteries that supply blood to the heart, it is called coronary artery disease.

Plaque is a fatty material made up of cholesterol, calcium, and other substances in the blood. To understand why plaque is a problem, compare a healthy artery with an artery with atherosclerosis:

• A healthy artery is like a rubber tube. It is smooth and flexible, and blood flows through it freely. If your heart has to work harder, such as when you exercise, a healthy artery can stretch to let more blood flow to your body’s tissues.
• An artery with atherosclerosis is more like a clogged pipe. Plaque narrows the artery and makes it stiff. This limits the flow of blood to the tissues. When the heart has to work harder, the stiff arteries can't flex to let more blood through, and the tissues don't get enough blood and oxygen.

See a picture of a normal artery and an artery narrowed by plaque.

When plaque builds up in the coronary arteries, the heart doesn't get the blood it needs to work well. Over time, this can weaken or damage the heart. If a plaque tears, the body tries to fix the tear by forming a blood clot around it. The clot can block blood flow to the heart and cause a heart attack. See a picture of how plaque causes a heart attack.

What are the symptoms?

Usually people with coronary artery disease don't have symptoms until after age 50. Then they may start to have symptoms at times when the heart is working harder and needs more oxygen, such as during exercise. Typical first symptoms include:

• Chest pain, called angina (say “ANN-juh-nuh” or “ann-JY-nuh”).
• Shortness of breath.
• Heart attack. Too often, a heart attack is the first symptom of coronary artery disease.

Some people don't have symptoms. In rare cases, a person can have a “silent” heart attack, without symptoms.

To find out your risk for a heart attack in the next 10 years, use this Interactive Tool: Are You at Risk for a Heart Attack?

How is coronary artery disease diagnosed?

To diagnose coronary artery disease, doctors start by doing a physical exam and asking questions about your past health and your risk factors. Risk factors are things that increase the chance that you will have coronary artery disease.

Some common risk factors are being older than 65; smoking; having high cholesterol, high blood pressure, or diabetes; and having heart disease in your family. The more risk factors you have, the more likely it is that you have coronary artery disease.

If your doctor thinks you have coronary artery disease, you may have tests, such as:

• Electrocardiogram (EKG or ECG), which checks for problems with the electrical activity of your heart.
• Chest X-ray.
• Blood tests.
• Exercise electrocardiogram, commonly called a "stress test." This test checks for changes in your heart while you exercise.

Your doctor may order other tests to look at blood flow to your heart. You may have a coronary angiogram if your doctor is considering a procedure to remove blockages, such as angioplasty or bypass surgery.

How is it treated?

Treatment focuses on taking steps to manage your symptoms and reduce your risk for heart attack and stroke. Some risk factors you can't control, such as your age or family history. Other risks you can control, such as high blood pressure and high cholesterol. Lifestyle changes can help lower your risks. You may also need to take medicines or have a procedure to open your arteries.

Lifestyle changes are the first step for anyone with coronary artery disease. These changes may stop or even reverse coronary artery disease. To improve your heart health:

• Don't smoke. This may be the most important thing you can do. Quitting smoking can quickly reduce the risk of heart attack or death.
• Eat a heart-healthy diet that includes plenty of fish, fruits, vegetables, beans, high-fiber grains and breads, and olive oil. This is sometimes called a Mediterranean diet. See a dietitian if you need help making better food choices.
• Get regular exercise on most, preferably all, days of the week. Your doctor can suggest a safe level of exercise for you. Walking is great exercise that most people can do.
• Lower your stress level. Stress can damage your heart.

Changing old habits may not be easy, but it is very important to help you live a healthier and longer life. Having a plan can help. Start with small steps. For example, commit to eating five servings of fruits and vegetables a day. Instead of having dessert, take a short walk. When you feel stressed, stop and take some deep breaths.

Medicines may be needed in addition to lifestyle changes. Medicines that are often prescribed for people with coronary artery disease include:

• Statins to help lower cholesterol.
• Beta-blockers or ACE inhibitors to lower blood pressure.
• Aspirin or other medicines to reduce the risk of blood clots.
• Nitrates to relieve chest pain.

Procedures may be done to improve blood flow to the heart.

• Angioplasty is the treatment doctors prefer, because it isn't major surgery. During angioplasty, the doctor guides a thin tube (catheter) into the narrowed artery and inflates a small balloon. This widens the artery to help restore blood flow. Often a small wire-mesh tube called a stent is placed to keep the artery open. See a picture of angioplasty with stent placement. The doctor may use a stent that is coated with medicine, called a drug-eluting stent. When the stent is in place, it slowly releases a medicine that prevents the growth of new tissue. This helps keep the artery open.
• Bypass surgery may be a better choice in some cases, such as if more than one coronary artery is blocked. It uses healthy blood vessels to create detours around narrowed or blocked arteries. Bypass surgery is usually an open-chest procedure.

What else can you do?

To stay as healthy as possible, it is important to:

• See your doctor for regular follow-up appointments. This lets your doctor keep track of your risk factors and adjust your treatment as needed.
• Take your medicines exactly as prescribed. Do not stop or change medicines without talking to your doctor.
• Keep nitroglycerin with you at all times, if your doctor prescribed it for chest pain.
• Tell your doctor about any chest pain you have had, even if it went away.
• Get the support you need to succeed in making lifestyle changes. Ask family or friends to share a healthy meal or join a stop-smoking program. Or ask your doctor about a cardiac rehab program. In cardiac rehab, a team of health professionals provides education and support to help you make new, healthy habits.

Health Tools

Health tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Should I have an angiogram to test for coronary artery disease?
	Should I have angioplasty for stable angina?
	Should I stop life-prolonging treatment?
	Actionsets are designed to help people take an active role in managing a health condition.
	Eating a heart-healthy diet
	Exercising for a healthy heart
	Tips for following the Dietary Approaches to Stop Hypertension (DASH) diet
	Walking for a healthy heart
	Interactive tools are designed to help people determine health risks, ideal weight, target heart rate, and more.
	Interactive Tool: Are You at Risk for a Heart Attack?

Frequently Asked Questions

Cause

Coronary artery disease is caused by the buildup of plaque on the inside of your coronary arteries. In most people, plaque buildup begins early in life and gradually develops over a lifetime.¹

Coronary artery disease (CAD) typically begins when the inside walls of the coronary arteries are damaged, due to one or more underlying conditions, such as:

• High cholesterol.
• High blood pressure.
• Diabetes.
• Smoking.

Plaque, which is made up of excess cholesterol, calcium, and other substances in your blood, builds up on the damaged inner walls of your coronary arteries. This process usually occurs throughout the body and is called atherosclerosis, or "hardening of the arteries." (See a picture of atherosclerosis.)

Over time, plaque buildup narrows the coronary arteries and can lead to ischemia (insufficient blood flow to the heart muscle). Ischemia can weaken the heart muscle, but it usually does not cause heart muscle cells to die.

However, heart muscle cells can die if blood flow is severely reduced or completely blocked for a period of time. This is called myocardial infarction, or heart attack.

Symptoms

Typically, the earliest symptoms of coronary artery disease (CAD) are chest pain, also called angina, and shortness of breath with exertion. Other symptoms of coronary artery disease include a fast heartbeat, weakness, dizziness, nausea, and increased perspiration.

Heart attack symptoms in men and women often differ. Men usually have the typical type of chest pain that feels like squeezing or pressure. But the pain is more severe than usual and does not go away with rest. Women, older adults, and people with diabetes may have symptoms different from chest pain. These groups of people may have symptoms like breathlessness, heartburn, nausea, fatigue, jaw pain, or back pain.

In one study, many women reported warning symptoms 1 month before having a heart attack. These symptoms included unusual fatigue, sleep disturbances, and shortness of breath. Only 30% reported chest pain, which the majority of men report.² For more information about the differences between coronary artery disease in women and men, see women and coronary artery disease.

Unfortunately, sometimes a heart attack is the first sign of coronary artery disease. According to the large, 50-year Framingham Heart Study, over 50% of men and 63% of women who died suddenly of coronary artery disease (mostly from heart attack) had no previous symptoms of this disease.³

Some people who have coronary artery disease and insufficient blood flow to the heart muscle (ischemia) do not have any symptoms. This is called "silent ischemia." In rare instances, you can even have a "silent heart attack," a heart attack without symptoms.

Angina

Chest pain is the most common symptom of coronary artery disease. Many people have chest pain, although it may be caused by conditions other than coronary artery disease. Angina, the chest pain related to coronary artery disease, may have a distinct pattern.

The chest pain of angina can be described as:

• A feeling of pressure, heaviness, weight, tightness, squeezing, discomfort, burning, or a dull ache in the chest (people often put their fist to their chest when describing the pain).
• Difficult to pinpoint (you cannot point to the exact location of the pain). Pressing on the chest wall does not cause the pain.

The chest pain of angina usually begins at a low level, then gradually increases over several minutes to a peak. Angina that starts with an activity usually will decrease when the activity is stopped. Chest pain that begins suddenly or lasts only a few seconds is less likely to be angina.

Angina usually begins in the chest, but it can also start or spread to different areas of the body, such as:

• Down the left arm (most common site).
• To the left shoulder.
• To the neck or lower jaw.
• To the mid-back.
• Down the right arm.

Some people may experience tingling or numbness in the arm, hand, or jaw when angina is present.

See a picture of areas that may be affected by angina.

Angina is often brought on by activities that make the heart work harder because the heart needs more oxygen than can be delivered through the narrowed arteries supplying it. Some of these activities include:

• Strenuous exercise (especially if you ordinarily do not exercise).
• Use of cocaine or amphetamines.
• Exposure to cold temperatures.
• Sudden, intense emotions such as anger or fear.
• Smoking.
• Eating a heavy meal.

Many people have stable angina, which is predictable and diminishes after they rest and take nitroglycerin, a medication that opens blood vessels to improve blood flow. But if there is a change in the usual pattern of your angina, you may have unstable angina. In unstable angina, chest pain occurs at rest or with less and less exertion, may be more severe and last longer, or takes longer or fails to respond to nitroglycerin. Because unstable angina can progress to a heart attack, it requires immediate medical attention.

For information about their differences, see stable versus unstable angina. For information about variant, or Prinzmetal's, angina and other kinds of angina, see types of angina. For more information, see the topic Heart Attack and Unstable Angina.

Chest pain can be a symptom of many other conditions. For example, anxiety, inflammation in or injury to the chest wall, or a blood clot in the lung can cause pain in the chest.

What Increases Your Risk

Some risk factors for coronary artery disease (CAD), such as your sex, age, and family history, cannot be changed. Other risk factors for CAD that are related to lifestyle often can be changed. Your chance of developing coronary artery disease increases with the number of risk factors you have.

Coronary artery disease risk factors include:

• Cigarette smoking.
• High blood pressure.
• High cholesterol.
• Diabetes.
• Obesity.
• Lack of exercise.
• Personality factors and high stress level.
• Using birth control pills and you smoke and are over age 35, or you have a family history of atherosclerosis or blood-clotting disorders.
• Using hormone therapy after menopause. This risk is higher for some women than others.

Smoking, high cholesterol, high blood pressure, and physical inactivity are all risk factors for coronary artery disease that can be modified and in some cases eliminated with lifestyle changes and medication. Diabetes and obesity can sometimes be prevented when lifestyle changes are made early in life.

Risk factors that you cannot change:

• Family history of heart disease. You have a first-degree male relative (for example, your father or brother) who got CAD when he was younger than age 55. Or you have a first-degree female relative (for example, your mother or sister) who got CAD when she was younger than 65.
• Family history of high cholesterol.
• Gender. Men generally develop CAD 10 years earlier than women. But women who have diabetes may develop CAD at a younger age. By age 60, CAD is one of the leading causes of death in both sexes.
• Age. People over 65 are more likely to have CAD.

Research has shown that having metabolic syndrome also increases your risk of coronary artery disease.⁴ People with metabolic syndrome have a group of abnormal findings related to their metabolism, including excess body fat (particularly abdominal obesity); high triglycerides, high blood pressure, and high fasting glucose; and low HDL.

The National Cholesterol Education Program (NCEP) has developed a risk assessment calculator to estimate your risk of having a heart attack or suffering from coronary death over 10 years. This tool is designed to estimate risk in adults age 20 and older who do not have heart disease or diabetes.

Click here to calculate your risk of having a heart attack in the next 10 years.

When to Call a Doctor

Call 911 or other emergency services immediately if you have any of the following symptoms:

• Chest pain that has not gone away within 5 minutes after you have taken one nitroglycerin and/or rested. After calling 911 , continue to stay on the phone with the emergency operator. He or she will give you further instructions. See how to take nitroglycerin.
• Chest pain or discomfort that is crushing or squeezing, feels like pressure on the chest, and lasts more than 5 minutes, especially if it occurs with any of the following symptoms:
  • Sweating
  • Shortness of breath
  • Nausea or vomiting
  • Pain that spreads from the chest to the neck, jaw, or one or both shoulders or arms
  • Dizziness or lightheadedness
  • Fast or irregular pulse
  • Signs of shock

Women are more likely to have symptoms such as shortness of breath, heartburn, nausea, jaw pain, back pain, or fatigue.

After calling 911 or other emergency services, you should chew 1 regular-strength aspirin (325 mg), if you are not allergic to aspirin or unable to take aspirin for some other reason. By calling 911 and taking an ambulance to the hospital, you may be able to start treatment before you arrive at the hospital. If any complications occur along the way, ambulance personnel are trained to evaluate and treat them.

If an ambulance is not readily available, have someone else drive you to the emergency room. Do not drive yourself to the hospital.

If you witness a person becoming unconscious, call 911 or other emergency services and start cardiopulmonary resuscitation (CPR). The emergency operator can coach you on how to perform CPR. For more information, see the CPR section in the topic Dealing With Emergencies.

You should contact your doctor immediately if you have new, more frequent, or severe episodes of chest pain or discomfort, which may indicate you have an increased risk for a heart attack.

Talk to your doctor if you have:

• Chest pain or discomfort for the first time with features similar to those of coronary artery disease (CAD) (see the Symptoms section of this topic).
• Episodes of chest pain or discomfort and your work involves responsibility for the lives of other people (such as a pilot, bus driver, or sole caregiver for small children).

Treat symptoms as early as possible to help prevent permanent damage to your heart. Chest pain and shortness of breath are more likely to be serious and related to your heart if:

• They are like previous symptoms you have had due to coronary artery disease
• You have one or more risk factors for coronary artery disease.

The following are clues that your chest pain is less likely to be caused by a heart problem:

• You have pinpointed pain (you can point to the exact spot that hurts).
• The pain gets worse when you take a deep breath, or holding your breath for a few seconds reduces the pain significantly.
• The pain is related to moving or pressing on a specific part of the chest wall, neck, or shoulder.
• Antacids dramatically relieve the pain.
• The pain lasts only a few seconds. This is unlikely to be caused by a problem with your heart.

If any type of chest pain continues, it needs to be evaluated by a doctor. Because many vital organs are found in the chest, even chest pain that is not caused by coronary artery disease may be a sign of a serious problem in the aorta (the large blood vessel that leads out of the heart), lungs, or digestive organs.

Never wait if you have symptoms of a heart attack

Many people are unsure whether they are having a heart attack and so they take a "wait and see" approach. Heart attack symptoms often vary. People often discount their symptoms if they do not fit into the expected "extreme chest pain" scenario. Some people are embarrassed or don't want to bother others by calling for help if they think it may not be a heart attack. Even if you're not sure it's a heart attack, you should still have it checked out. Rapid treatment can save your life.

Who to See

To see whether you are at risk for heart disease, have symptoms of coronary artery disease, or require long-term care for existing heart disease, see your family doctor or internist. For diagnosis of coronary artery disease, you may see a cardiologist. For ongoing care of stable angina, you will likely see your family doctor or an internist. For surgical intervention, you will be referred to a cardiovascular surgeon.

Exams and Tests

To diagnose coronary artery disease (CAD), your health professional will complete a medical history and physical exam. Usually, the need for further testing depends on your risk factors and symptoms. Testing strategies also vary from doctor to doctor.

If coronary artery disease is suspected, you may have tests to determine the diagnosis. The most common initial tests are electrocardiogram (EKG or ECG), chest X-ray, routine blood tests, and exercise electrocardiogram, also called a "stress test."

Additional tests may include:⁵

• Cardiac perfusion scan. This test shows whether blood flow to the heart muscle is adequate.
• Echocardiogram and stress echocardiogram. This ultrasound test can identify areas of poor blood flow in the heart and injury to the heart muscle caused by a previous heart attack. It can also be used to estimate the amount of blood pumped out of your left ventricle with each heartbeat (ejection fraction).
• Coronary angiogram, or heart catheterization, a test that uses a dye to create images of blood flow through the coronary arteries and heart chambers. This catheter-based test is usually done only if bypass surgery or angioplasty is a reasonable option. For more information, see:

  Should I have an angiogram to test for coronary artery disease?

Tests to measure risk for coronary artery disease

Blood pressure measurements determine if you have high blood pressure. High blood pressure is a risk factor for coronary artery disease.

Blood tests are often done to measure cholesterol levels. High cholesterol is also a risk factor for developing coronary artery disease.

The U.S. Preventive Services Task Force recommends that people with high blood pressure or high cholesterol be routinely screened for diabetes. This recommendation is based on studies that show people with diabetes benefit more from intensive treatment of high blood pressure and high cholesterol than people who do not have diabetes.⁶ The first screening test for diabetes is usually a fasting blood sugar test.

The American Heart Association and the Centers for Disease Control and Prevention (CDC) have released recommendations for C-reactive protein (CRP) blood testing. An increase in CRP levels is associated with inflammation in the blood vessels, atherosclerosis, and increased risk of coronary artery disease (CAD) and heart attack.⁷

The AHA/CDC panel recommends that CRP testing be done on some people who are at risk for developing coronary artery disease. If you have any CAD risk factors, ask your doctor whether CRP testing would be helpful in guiding your treatment.⁸

Elevated homocysteine levels and mutations of a specific gene (MTHFR) may also indicate an increased risk of coronary artery disease and heart attack, although more study is needed to fully understand their role in heart disease. Tests for these factors may be indicated for some people (for example, those who have had a heart attack at a young age or those with a strong family history of heart disease), but they are not recommended for the general population.

Another test, the coronary artery calcium score, can help detect whether you have coronary artery disease and may predict whether you will develop symptoms. To calculate your score, a computed tomography (CT) scan is used to measure calcification, or plaque, in the coronary arteries, which supply blood to the heart. If you have a high coronary artery calcium score, you may need more tests to check to see if you have CAD or to find out how severe it is, especially if you have other risk factors for CAD. The coronary artery calcium score test is not recommended for routine screening, because it can show that you may have plaque in your coronary arteries even if you do not have CAD.

Early detection

The American Heart Association has released new guidelines for screening for coronary artery disease. Several expert groups worked with the American Heart Association in creating these guidelines, which may be different from those your doctor follows. Work with your doctor to determine which guidelines are appropriate for you.

Beginning at age 20. Your doctor should assess your risk factors for heart disease during every routine examination. Risk factors include your family history of CAD, whether you smoke or are exposed to secondhand smoke, whether you eat a high saturated-fat diet, your alcohol intake, and your level of physical activity.

During every routine examination—at least every 2 years—a health professional should check your blood pressure, body mass index, and pulse. Based on your risk of high cholesterol and diabetes, you should have a fasting lipoprotein analysis to measure your total and HDL cholesterol, and a fasting blood glucose test. If risk factors are present, these tests should be done every 2 years. If you don't have risk factors, these tests should be done every 5 years.

At age 40 and over. Every 5 years, your 10-year risk of developing coronary artery disease should be assessed using a multiple risk factor score. This should be done more frequently if your risk factors change or if you have two or more risk factors. For example, a nonsmoking, nondiabetic 55-year-old man who has a total cholesterol level of 200 mg/dL, an HDL level of 35 mg/dL, and a systolic blood pressure of 135 mm Hg has a 10% risk of developing CAD over the next 10 years. However, a 40-year-old man with the same risk factors but who smokes has the same risk of CAD as the 55-year-old nonsmoker.

Additionally, most doctors recommend that you be tested for coronary artery disease if you are one of the following:

• Over age 39, have diabetes or more than one risk factor for CAD, and want to start a vigorous exercise program or are going to have major surgery
• Responsible for the lives of other people as part of your daily life (such as a pilot, bus driver, or sole caregiver for small children)

Treatment Overview

Treatment for coronary artery disease (CAD) depends upon how far the disease has already progressed. Coronary artery disease is the buildup of plaque on the inside of the coronary arteries, the blood vessels that supply oxygen-rich blood to heart muscle. As you review your treatment options, consider the following:

• No matter what medical treatment you receive, lifestyle changes—including quitting smoking, following a heart-healthy diet, and exercising—are critical to managing the disease. For more information on lifestyle changes, see:

  Exercising for a healthy heart.

  Eating a heart-healthy diet.

• If your doctor approves, take an aspirin each day to reduce your risk of heart attack.
• If your high blood pressure and high cholesterol cannot be controlled with lifestyle changes, you and your doctor may consider a more aggressive approach, including medications to lower these risk factors.
• If you have frequent chest pain that makes normal everyday activities difficult, your doctor may recommend medicines.
• If medicines do not relieve your chest pain, your doctor may recommend angioplasty with stent placement to open clogged coronary arteries. Or sometimes coronary artery bypass surgery may be necessary.

Initial treatment

After you have been diagnosed with coronary artery disease, your doctor will strongly advise that you make lifestyle changes such as quitting smoking, following a heart-healthy diet, and exercising. With these measures, you may be able to halt the progression of the disease and improve the quality and length of your life.

Quitting smoking may be the most important step you can take to reduce your risk. Avoid secondhand smoke too. In one study, people with CAD who continued to smoke had a 43% greater chance of sudden death from a heart attack than those who quit.⁹ Your doctor will strongly advise that you quit and will possibly prescribe medicine and therapy to help you do so. Studies show that nicotine replacement therapy, use of the medicines bupropion (Zyban or Wellbutrin) or varenicline (Chantix), and supportive therapy significantly increase long-term success in quitting.¹⁰ For more information, see the topic Quitting Tobacco Use.

Aspirin is also recommended for almost everyone who has CAD to help reduce the risk of having a heart attack.¹¹ The best dose of aspirin has not been established, but 75 mg a day seems to be as effective in preventing heart attack as higher doses and has fewer side effects.¹² One low-dose aspirin contains 81 mg; one regular-strength aspirin contains about 325 mg. Talk with your doctor before starting aspirin therapy.

If you have average to high cholesterol, a cholesterol-lowering medicine such as a statin may be prescribed.

If you have angina, your doctor may prescribe medicines, including nitroglycerin and other nitrates which relax arteries and increase blood flow, and beta-blocker medicines, which decrease the heart's workload. Calcium channel blockers may be used to treat angina when beta-blockers are not tolerated or for other types of angina, including variant, or Prinzmetal's, angina. If these medicines do not relieve your chest pain, your doctor may prescribe a partial fatty acid oxidation inhibitor (ranolazine).

An angiotensin-converting enzyme (ACE) inhibitor is often prescribed, particularly for those with diabetes or heart failure. Studies have shown that ACE inhibitors save lives and reduce the risk of heart attack in people with CAD.⁵

Your doctor will recommend that you start an exercise program, such as walking, swimming, cycling, or jogging, for at least 30 minutes on most, preferably all, days of the week. Studies show that exercise effectively reduces the number of fatal heart attacks in people with CAD.¹³

If you have metabolic syndrome, your doctor will probably recommend that you increase your physical activity and lose weight. Metabolic syndrome—which is characterized by excess body fat and other factors—increases your risk of coronary artery disease.

Avoid getting sick from the flu. Get a flu shot every year.

Factors that affect the choice of treatment in coronary artery disease include the severity of your chest pain, the results of your tests, and your preferences.

Ongoing treatment

After your initial treatment, you will be monitored regularly by your doctor. He or she will want to know whether you have succeeded in making necessary lifestyle changes and whether those changes have been effective in controlling your risk factors for coronary artery disease.

For example, your blood pressure, cholesterol, and weight will be checked to see whether more aggressive treatment is needed. If you are taking medicines, your doctor will ask you whether you have any side effects. You will be asked whether the medicines you take for angina decrease the pain quickly, and whether your angina is less frequent.

You will probably have to continue the medicines you are taking, which may include a beta-blocker, angiotensin-converting enzyme (ACE) inhibitor, nitroglycerin, statins, and aspirin. These medicines reduce your risk of having a heart attack. Your doctor will assess how well these medicines are working and whether dosages need to be adjusted or alternative medications tried.

If you have not been successful in making healthy lifestyle changes on your own, your doctor may recommend that you attend a cardiac rehabilitation program. Your cardiac rehab team, consisting of several health professionals, will assist you with a supervised program of aerobic and resistance training exercises, education and programs to reduce your risk factors for heart problems, stress management programs and counseling for depression, and nutritional counseling.

If angina keeps you from exercising or enjoying other activities, you may want to talk to your doctor about having angioplasty to improve blood flow to your heart. You would also continue taking medicines and leading a healthy lifestyle. For more information, see:

Should I have angioplasty for stable angina?

Treatment if the condition gets worse

Sometimes coronary artery disease continues to progress despite treatment. This may be caused by continued smoking or other unhealthy choices. Other times, symptoms get worse because the coronary artery disease has already progressed to an advanced state.

If heart failure develops, your doctor will probably add an angiotensin-converting enzyme (ACE) inhibitor and a diuretic, which can prevent worsening of heart failure in addition to improving symptoms.

If you begin to have abnormal heart rhythms (arrhythmias), your doctor might recommend a pacemaker or medicines to control your heart rate.

Revascularization procedures that help restore blood flow to the heart may be recommended if you continue to have frequent or disabling chest pain despite the use of medicines, or you are found to have severe blockages in your coronary arteries. Revascularization procedures include angioplasty with or without stenting, and coronary artery bypass surgery (CABG).

When deciding between bypass surgery or angioplasty, your doctor will evaluate:

• Whether the left main coronary artery is blocked. Because the left main coronary artery performs the essential function of supplying blood to the left ventricle, the heart's main pump, bypass surgery rather than angioplasty is usually performed when it is blocked.
• The number of coronary arteries that are blocked. Bypass surgery may be needed if more than one coronary artery is blocked.
• The function of the left ventricle. People with mild to moderately reduced left ventricle function may benefit more from bypass surgery. On the other hand, people with significantly reduced function of the left ventricle may not be good candidates for surgery because of their greater risk of having complications.
• The function of the heart valves. If one of your heart valves is defective, bypass surgery combined with heart valve surgery may be required.
• Whether you have diabetes. If you have diabetes, the chances are higher that your arteries will become narrowed again (restenosis) after angioplasty. CABG is usually the preferred surgery for people with diabetes.

What to Think About

Keep the following questions in mind as you think about your treatment options for coronary artery disease.

• Will this treatment improve my symptoms?
• Will this treatment help prevent future heart problems?
• Am I likely to live longer with this treatment?
• What are the risks of this treatment?
• What are the long-term results of this treatment based on my current symptoms, risk factors, and test results? If I choose this treatment, will I need more surgery or tests? Can a heart attack or other problems be caused by this treatment?

Palliative care

If your coronary artery disease gets worse, you may want to think about palliative care. Palliative care is a kind of care for people who have diseases that do not go away and often get worse over time. It is different from care to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life—not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.

Palliative care may help you manage symptoms or side effects from treatment. It can also help you cope with your feelings about living with a long-term disease, make future plans around your medical care, or help your family better understand your disease and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Palliative Care.

Prevention

From 1993 to 2003, the death rate from coronary artery disease (CAD) declined by 22% in the United States.³ This decline is attributed to the steps people are taking to prevent coronary artery disease, including lowering blood pressure and cholesterol, changing diet and exercise habits, quitting smoking, and getting improved medical care.

Coronary artery disease is caused by the buildup of plaque on the inside of the coronary arteries, the blood vessels that supply oxygen-rich blood to heart muscle. You too can take measures to delay the progression and even reverse coronary artery disease.

Quitting smoking may be the most important step you can take to prevent coronary artery disease. According to the World Health Organization, after 1 year of not smoking, a person's risk of coronary artery disease decreases by 50%. After 15 years of not smoking, the risk of death due to coronary artery disease is equal to that of someone who has never smoked at all.³

Exercising regularly and eating a balanced diet that is low in saturated fats and rich in fruits and vegetables are also advised.

Lifestyle changes

• Quit smoking. Quitting smoking may be the most important step you can take to prevent coronary artery disease. Avoid secondhand smoke too.
• Control your cholesterol. This can be accomplished with diet, exercise, and medicines, if needed.
• Control your blood pressure. Follow the Dietary Approaches to Stop Hypertension (DASH) diet—which is designed to reduce high blood pressure with foods rich in potassium, calcium, and phosphorous—increase exercise, decrease alcohol intake, and take medicines, if needed, to control your blood pressure. For more information, see:

  Tips for following the DASH diet.

• Exercise. Exercise has many positive effects: weight management, cholesterol reduction, blood pressure control, blood sugar leveling in diabetes, triglyceride reduction, mood elevation, and increasing strength. Try to do activities that raise your heart rate. Exercise for at least 30 minutes on most, preferably all, days of the week. Talk to your doctor before starting an exercise program. For more information, see:

  Exercising for a healthy heart.

• Relax and reduce stress. Stress can negatively affect your heart in many ways, but you can lower your stress level through talking about your problems and your feelings, exercising, and doing deep breathing, meditation, or yoga.
• Manage depression and anger. Treating depression and managing anger are important steps in improving your overall health.
• Avoid getting sick from the flu. Get a flu shot every year.

General dietary considerations

• Therapeutic Lifestyle Changes (TLC) diet is recommended by the National Cholesterol Education Program of the National Institutes of Health. The diet's main focus is to reduce the amount of saturated fat you eat because it elevates your cholesterol.¹⁴
  • Nutrient composition of the TLC diet
  • Tips for success with the TLC diet
  • Sample menu for the TLC diet
• American Heart Association healthy diet guidelines recommend limiting saturated fat and cholesterol intake, increasing fruits and vegetables, and limiting salt and alcohol.

Specific dietary considerations

• Antioxidants and heart disease. Some experts believe antioxidants may be helpful in treating coronary artery disease. But there is not enough proof that antioxidants reduce the risk of coronary artery disease. Most doctors recommend that you get antioxidants from food,and they do not recommend taking antioxidant supplements. Fruits, red wine, and some teas contain flavonoids which may have especially potent antioxidant effects.
• Fish oil and heart disease. The American Heart Association recommends that healthy adults eat at least two servings of fish a week, particularly oily fish such as albacore tuna, salmon, mackerel, lake trout, herring, and sardines, all of which contain omega-3 fatty acids. In people with heart problems, omega-3 fatty acids may help reduce their risk of death.¹⁵
• Fiber to lower cholesterol. Eat foods that are high in soluble and insoluble fiber.
• Soy protein. Eating soy protein does not significantly reduce LDL cholesterol. Soy protein does not affect HDL cholesterol, triglycerides, or blood pressure. But substituting soy protein for animal protein should be beneficial to your overall health because of the fiber, vitamins, minerals, and low saturated fat in soy.¹⁶
• Mediterranean diet. This diet is similar to the Therapeutic Lifestyle Changes (TLC) diet, except that more fat is allowed, mainly from unsaturated oils, such as fish oils, olive oil, and certain nut or seed oils.
• Alcohol and heart disease. If you drink alcohol, drink moderately (1 alcoholic drink a day for women or 2 drinks a day for men). Moderate drinking may lower your risk of coronary artery disease. The American Heart Association cautions people who do not drink that they should not start drinking to lower their risk of heart disease. You can talk to your doctor about the benefits and risks of consuming alcohol in moderation.
• Cholesterol-lowering margarines. Marketed in the U.S. as Benecol and Take Control, these margarines can help lower cholesterol levels, particularly in people who have high cholesterol levels or who consume too much fat in their diet.

Lowering cholesterol

If diet and exercise are not effective in lowering your cholesterol to a safe level, your doctor will probably prescribe a cholesterol-lowering drug. These medicines have been proven effective in treating high cholesterol, and now doctors are beginning to prescribe them for people with only mildly elevated cholesterol levels. In these people, cholesterol-lowering drugs combined with lifestyle changes may slow the development of atherosclerosis and may lower the risk of heart attack or death.¹⁴

Cholesterol-lowering medicines appear to be the best protection against heart attack in postmenopausal women with moderate to high cholesterol levels. In the HERS study, women who took cholesterol-lowering medicines had significantly lower rates of heart attacks and death from CAD than the women who did not take cholesterol-lowering medicines.¹⁷

Aspirin

Aspirin may reduce the risk of stroke and heart attack in people with increased risk of coronary artery disease. Aspirin also is known to reduce the risk of developing blood clots, which can lead to a heart attack in people with known CAD or in people with multiple risk factors for CAD, such as diabetes, high blood pressure, and high cholesterol. There are some risks associated with aspirin therapy that you should discuss with your doctor before you begin this type of treatment.

Managing other diseases or conditions

Many diseases and conditions that increase your risk of developing CAD can be successfully managed with medicines and lifestyle changes.

Strategies that are not recommended to prevent coronary artery disease

• Hormone therapy. Taking estrogen with or without progestin does not prevent coronary artery disease. In fact, if you are 10 or more years past menopause, taking hormone therapy may raise your risk of coronary artery disease.¹⁸ Talk to your doctor about your risks with hormone therapy. And carefully weigh the benefits against the risks of taking it. If you need relief for symptoms of menopause, hormone therapy is one choice you can think about. But there are other types of treatment for problems like hot flashes and sleep problems. For more information, see the topic Menopause and Perimenopause.
• Low-carbohydrate diets. The American Dietetic Association and American Heart Association do not recommend low-carbohydrate diets, because they cause abnormal functioning of the metabolism that could have serious medical consequences for some people, especially those who have heart disease, type 2 diabetes, high cholesterol, or high blood pressure.¹⁹
• High-protein diets. The American Heart Association does not recommend high-protein diets, because they restrict healthful foods, such as fruits and vegetables, and do not provide essential vitamins, minerals, and fiber.
• Vitamin B supplements. Vitamin B and folic acid supplements do not appear to lower the risk of heart disease or stroke.²⁰ Most doctors recommend that you get B vitamins from a balanced diet, and they do not advise taking vitamin B supplements.

Ongoing Concerns

After being diagnosed with coronary artery disease (CAD), you will probably be most concerned about managing your symptoms and reducing the chance of heart attack, stroke, or other complications.

Symptoms of coronary artery disease often begin when less blood flows to the heart muscle. Sometimes collateral circulation develops to provide another source of oxygen-rich blood to the deprived heart muscle. Collateral circulation is tiny branches of the artery that form to "bypass" the area of narrowing and help to restore blood flow.

These blood vessels are often adequate unless the heart requires increased oxygen, such as during exercise or in stressful situations. During these times, you may have angina. Many people have stable angina, which is predictable and diminishes after they take nitroglycerin and get some rest. Although stable angina can be disturbing, it does not necessarily indicate heart muscle damage and can occur for years without harm.

In some cases, CAD can cause life-threatening conditions. Newly formed plaques tend to be more unstable and are more likely to break open (rupture). If a plaque ruptures, a blood clot may form and suddenly block the blood flow to your heart muscle, causing a heart attack or unstable angina.

Some people with CAD may have no symptoms, and the disease is only discovered during an electrocardiogram or stress test. Unfortunately, sometimes a heart attack is the first sign of coronary artery disease. According to the large, 50-year Framingham Heart Study, over 50% of men and 63% of women who died suddenly of coronary artery disease (mostly from heart attack) had no previous symptoms of this disease.³

Making healthy lifestyle changes and taking aspirin and other medicines, if needed to control your blood pressure and lower your cholesterol, are important measures you can take to reduce your chances of heart attack and stroke.

If coronary artery disease progresses, you may develop additional problems. Over time, reduced blood flow may weaken your heart muscle so that it is not able to pump effectively. This may cause heart failure and abnormal heartbeats (arrhythmia). Atrial fibrillation is one of the most common arrhythmias associated with CAD. You are at increased risk of stroke if you have atrial fibrillation. For more information, see the topics Atrial Fibrillation and Stroke.

Atherosclerosis can affect other arteries of your cardiovascular system and cause other complications throughout your body. See an illustration of the cardiovascular system. Arteries that are commonly affected include those that supply blood to your heart, brain (cerebrovascular disease), and limbs (peripheral arterial disease). For more information, see the topic Peripheral Arterial Disease of the Legs.

If your CAD is severe or your symptoms cannot be controlled with medicines, you may need to consider the following surgery or procedures:

• Coronary artery bypass surgery
• Angioplasty
• Stenting
• Atherectomy

Living With CAD

A diagnosis of coronary artery disease (CAD) can be difficult to accept and understand. If you do not have symptoms, it may be especially hard to recognize that CAD is a serious disease that can lead to complications. Coronary artery disease is caused by the gradual buildup of plaque on the inside of the coronary arteries, the blood vessels that supply oxygen-rich blood to heart muscle.

It is important to talk with your doctor to learn about the disease and what you can do to help manage CAD and prevent its progression.

Making healthy lifestyle changes can delay and possibly reverse the course of CAD. Quitting smoking, eating a low-fat and low-cholesterol diet, and getting regular exercise are the most important steps you can take to reduce your risk of developing coronary artery disease.²¹ For more information, see:

Exercising for a healthy heart.

Eating a heart-healthy diet.

For more information on how to make healthy lifestyle changes, see the Prevention section of this topic.

Avoid getting sick from the flu. Get a flu shot every year.

Most people are able to control angina by taking medicines as prescribed and nitroglycerin when needed. See how to use nitroglycerin pills under the tongue. Remaining as active as possible is important for most people. But if angina is not controlled by the above, consider these tips:

• If an activity causes angina, slow it down.
• Ease into activities in the morning, and reduce activity immediately after meals.
• Change your eating patterns. Eat smaller, more frequent meals rather than 2 or 3 large meals.

When angina is more severe and cannot be controlled, the following tips may be useful:

• If it is feasible, it may help to move to a different home to avoid physical stress caused by climbing stairs, shoveling snow, or mowing lawns. Or find other ways to get chores done, such as hired help, family members, or trading for other services that are easier to do.
• It may be necessary to change the kind of work you perform to avoid physical stress. This may be especially important if your work involves heavy labor.

Taking nitroglycerin before an activity may reduce or eliminate the chest pain associated with the activity. Discuss with your doctor the use of nitroglycerin to prevent chest pain.

Do not use the erection-enhancing medicines sildenafil (Viagra), vardenafil (Levitra), or tadalafil (Cialis) if you are taking nitroglycerin or other nitrates. Combined, these two drugs can result in a life-threatening drop in blood pressure. If you are taking an erection-enhancing medicine and develop chest pain, be sure to alert the health professionals caring for you about your use of this medicine so that they do not inadvertently give you nitroglycerin or another type of nitrate. There are other oral antianginal medicines that may be appropriate.

Alert your doctor immediately if there is a sudden change in your angina symptoms or if angina begins to occur unpredictably or when you are at rest.

Medications

Many people have difficulty correctly taking their medicines for coronary artery disease (CAD). Often, they need to take several medicines at different times of the day. Also, for some people, the medicines are not affordable. But medicines are often an essential key to treatment, and people who do not take them as prescribed have an increased risk of complications and death.⁵

Medication Choices

Medications to treat symptoms and prevent complications

If you have symptoms of coronary artery disease, the following medicines may be prescribed to control symptoms and, in some cases, slow its progression:

• Aspirin or other antiplatelet medications help prevent blood clots in your coronary arteries.
• Beta-blockers slow your heart rate and lower your blood pressure to reduce the amount of work your heart has to do. They also reduce angina.
• Statins lower your blood cholesterol and may reduce your risk of a future heart attack. The National Cholesterol Education Program's (NCEP) guidelines provide a general reference to determine when to begin treatment with medicine to lower cholesterol.
• Nitrates (nitroglycerin and long-acting nitrates) relieve chest pain and other symptoms of angina.
• Calcium channel blockers slow your heart rate and lower your blood pressure to reduce your heart's workload. They also help dilate your coronary arteries and reduce angina.
• Partial fatty acid oxidation inhibitors (pFOX inhibitors), which include ranolazine (Ranexa), relieve chest pain and other symptoms of angina. This medicine does not affect heart rate or blood pressure, unlike the other medicines that relieve angina. Your doctor may prescribe ranolazine if your chest pain is not relieved by beta-blockers, nitrates, or calcium channel blockers.
• Angiotensin-converting enzyme (ACE) inhibitors lower your blood pressure and reduce the strain on the heart. They may also reduce your risk of a future heart attack or developing heart failure.
• Angiotensin II receptor blockers (ARBs) lower your blood pressure and reduce the strain on the heart. If you cannot tolerate certain side effects of an ACE inhibitor, your doctor may prescribe an ARB.

Anticoagulants may also be used following an angioplasty, atherectomy, or bypass surgery. The anticoagulant warfarin may be used if you have CAD as well as atrial fibrillation or other complications.

What to Think About

Stable angina can often be controlled using medicine. If angina symptoms become worse, medicines can be adjusted. But angioplasty or bypass surgery may be necessary if angina symptoms get worse despite appropriate medication therapy. For angina that gets worse quickly or occurs at rest (unstable angina), hospitalization and urgent angioplasty, stenting, or bypass surgery may be needed. For more information, see the topic Heart Attack and Unstable Angina.

Although nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, relieve pain and inflammation much like aspirin does, do not substitute NSAIDs for aspirin, because they will not decrease your risk of another heart attack. If you need to take NSAIDs for a long time, talk with your doctor to see if it is safe for you. Some research suggests that long-term use of these medicines may raise your risk for CAD.

If you need both aspirin and a pain reliever every day, talk to your doctor about what pain reliever you should take. If you take uncoated aspirin and ibuprofen at the same time, the aspirin may not work as well to prevent a heart attack. You may be able to use acetaminophen instead of ibuprofen to treat your pain. But if ibuprofen is your only option, avoid taking it during the 8 hours before and the 30 minutes after your aspirin dose.²² For example, you can take ibuprofen 30 minutes after your aspirin dose. If you take ibuprofen once in a while, it does not seem to cause problems.

Experts do not know if NSAIDs other than ibuprofen interfere with uncoated aspirin. Also, experts do not know if people who take a daily coated aspirin should be concerned about ibuprofen or other NSAIDs interacting with the aspirin. Talk to you doctor if you take these medicines every day.

Surgery

The goals of surgery for coronary artery disease (CAD) are to:

• Restore blood flow to the heart muscle.
• Relieve chest pain (angina).
• Allow you to maintain or resume a normal lifestyle. In some cases, surgery may allow you to live longer.

Although many people with CAD can be treated with medicine or the nonsurgical procedure angioplasty, sometimes coronary artery bypass surgery (CABG) is needed. This surgery routes blood flow around narrowed or blocked arteries by creating detours using healthy blood vessels. Coronary artery bypass surgery is usually an open-heart procedure.

Another type of surgery called transmyocardial laser revascularization (TMR) may be used along with CABG. TMR uses a laser beam to improve blood flow to heart muscle. TMR is not commonly used.

In angioplasty and stenting—also called percutaneous coronary intervention—thin flexible tubes (catheters) are inserted through arteries to open blood vessels. For more information on these procedures, see the Other Treatment section of this topic.

Surgery Choices

Coronary artery bypass surgery (coronary artery bypass grafting, or CABG) increases blood flow to the heart muscle tissue by using healthy artery or vein grafts to bypass diseased sections of coronary arteries.

In rare cases, transmyocardial laser revascularization (TMR) is used along with CABG surgery. TMR uses a laser beam to improve blood flow to heart muscle and may relieve chest pain.

What to Think About

Your choice of treatment depends on the number of blocked arteries you have and how badly they are blocked, the location of the blockage, as well as the specifics of your condition, your overall health, whether you have diabetes, and your personal preferences. In general, people with extensive CAD benefit more from bypass surgery than angioplasty.²³

• Significant blockage in the left main coronary artery usually requires surgery. Coronary artery bypass graft surgery, rather than angioplasty with stenting, is needed in most cases.
• If two or three heart arteries are blocked, the type of treatment will depend on the location and severity of the blockages, how they are affecting heart function, and how severe your symptoms are.
• If only one artery is blocked (other than the left main artery), medicine or angioplasty with stenting is most often used.
• If one of your heart valves is defective, bypass surgery combined with heart valve surgery may be required.

Understanding the advantages and disadvantages of each treatment is important in making the right decision. Consider:

• Other factors that affect the choice of treatment.
• Bypass versus angioplasty (usually with stenting).

Surgery is not the best option for everyone. Changing your lifestyle and taking medicine can be just as effective and may have less risk for some people.

People who have heart surgery at hospitals that do a large number of heart surgeries tend to have better results than those who have surgery at hospitals that do fewer heart surgeries.

Other Treatment

Several nonsurgical procedures are used to treat coronary artery disease (CAD). They are called nonsurgical procedures because the repair is done through a catheter inserted into an artery, and neither a large incision nor general anesthesia is needed. Such procedures include:

• Angioplasty and stenting (percutaneous coronary intervention), which is done to open a partially blocked blood vessel so that blood can flow through it more easily.
• Atherectomy, a procedure that removes fat and calcium buildup to open partially blocked coronary arteries and improve blood flow.
• Enhanced external counterpulsation (EECP), a relatively new treatment method for people with chronic angina who do not qualify for other treatment methods, such as angioplasty or surgery.

Angioplasty (often combined with stenting) and atherectomy are used to reopen blocked or narrowed coronary arteries.

Angioplasty is also known as percutaneous coronary intervention (PCI) or percutaneous transluminal coronary angioplasty (PTCA). Angioplasty has become a common procedure in large medical centers in the United States. The goal of this revascularization procedure is to increase blood flow to the heart muscle tissue.

Angioplasty is less invasive and has a shorter recovery time than bypass surgery, which requires open-heart surgery. Most of the time stents are placed during this procedure. Studies show that angioplasty with stent placement, compared to angioplasty alone, reduces the chance that the artery will renarrow (restenosis) and possibly the risk of death.²⁴ See a picture of angioplasty with stenting.

Drug-eluting stents can almost completely prevent restenosis.²⁵ These stents are coated with medicines that prevent the growth of cells around the stent, thereby keeping the artery open. But they are more expensive than conventional stents. And experts do not know yet how safe the drug-eluting stents are over the long term or how well they work over the long term.

Whether you have angioplasty (with or without stenting) or bypass surgery depends on a number of factors, including the number of blocked arteries and how badly they are blocked, as well as other heart problems you have and your personal preferences. Understanding the advantages and disadvantages of each treatment is important in making the right decision. For more information, see:

Should I have angioplasty for stable angina?

Atherectomy is done only in certain cases and only at large medical centers. During atherectomy, plaque is shaved away from the inside of the coronary arteries. Atherectomy may be needed because of the location, size, or type of plaque or during angioplasty and stenting. See a picture of different ways atherectomy can be done.

What to Think About

You may be advised to participate in a cardiac rehabilitation (rehab) program to help you recover from complications of or treatment for coronary artery disease. After a heart attack, or after you have had surgery or angioplasty, a rehab program often helps improve your heart function and overall health. For more information, see the topic Cardiac Rehabilitation.

End-of-Life Decisions

Although treatment for coronary artery disease (CAD) is increasingly successful at prolonging life and reducing complications and hospitalization, coronary artery disease can lead to a heart attack, stroke, and other fatal conditions. Many important end-of-life decisions can be made while you are active and able to communicate your wishes.

When you are diagnosed with coronary artery disease, your doctor will discuss treatment options with you. If your coronary artery disease is advanced and your life will most likely be shortened by the illness, your doctor may talk to you about your desire to be revived (resuscitated) when your illness progresses and your breathing stops. You may want to learn more about aggressive life-sustaining medical treatment and whether it is right for you. For more information, see:

Should I stop curative treatment?

Many other decisions about end-of-life issues, such as writing a living will and estate planning, can be made in advance, leaving valuable time for spending with loved ones and on other important matters. For more information, see the topics Care at the End of Life and Writing an Advance Directive.

Other Places To Get Help

Organizations

Related Information

• Care at the End of Life
• Chest Pain
• Early Disease Detection
• Heart Attack and Unstable Angina
• Heart Failure
• High Blood Pressure (Hypertension)
• High Cholesterol