What is a heart attack?

A heart attack (also known as a myocardial infarction or MI) is the damage and death of heart muscle from the sudden blockage of a coronary artery by a blood clot. Coronary arteries are blood vessels that supply the heart muscle with blood and oxygen.

Blockage of a coronary artery deprives the heart muscle of blood and oxygen, causing injury to the heart muscle. Injury to the heart muscle causes chest pain and chest pressure sensation. If blood flow is not restored to the heart muscle within 20 to 40 minutes, irreversible death of the heart muscle will begin to occur. Muscle continues to die for six to eight hours at which time the heart attack usually is “complete.” The dead heart muscle is eventually replaced by scar tissue.

What causes a heart attack?

Plaque can occur in coronary and other arteries. Cholesterol plaques cause the hardening of the arterial walls and narrowing of the inner channel (lumen) of the artery.

Atherosclerosis

Atherosclerosis is a gradual process by which plaques (collections) of cholesterol are deposited in the walls of arteries. Cholesterol plaques cause the hardening of the arterial walls and narrowing of the inner channel (lumen) of the artery.

Arteries that are narrowed by atherosclerosis cannot deliver enough blood to maintain the normal function of the parts of the body they supply. For example, atherosclerosis of the arteries in the legs causes reduced blood flow to the legs. Reduced blood flow to the legs can lead to pain in the legs while walking or exercising leg ulcers, or a delay in the healing of wounds to the legs. Atherosclerosis of the arteries that furnish blood to the brain can lead to vascular dementia (mental deterioration due to gradual death of brain tissue over many years) or stroke (sudden damage and death of brain tissue).

In many people, atherosclerosis can remain silent (causing no symptoms or health problems) for years or decades. Atherosclerosis can begin as early as the teenage years, but symptoms or health problems usually do not arise until later in adulthood when the arterial narrowing becomes severe. Smoking cigarettes, high blood pressure, elevated cholesterol, and diabetes mellitus can accelerate atherosclerosis and lead to the earlier onset of symptoms and complications, particularly in those people who have a family history of early atherosclerosis.

Coronary atherosclerosis (or coronary artery disease) refers to atherosclerosis that causes the hardening and narrowing of the coronary arteries. Diseases caused by the reduced blood supply to the heart muscle from coronary atherosclerosis are called coronary heart diseases (CHD). Coronary heart diseases include heart attacks, sudden unexpected death, chest pain (angina), abnormal heart rhythms, and heart failure due to the weakening of the heart muscle.

Atherosclerosis and angina pectoris

Angina pectoris (also referred to as angina) is chest pain or pressure that occurs when the blood and oxygen supply to the heart muscle cannot keep up with the needs of the muscle. When coronary arteries are narrowed by more than 50 to 70 percent, the arteries may not be able to increase the supply of blood to the heart muscle during exercise or other periods of high demand for oxygen. An insufficient supply of oxygen to the heart muscle causes angina. Angina that occurs with exercise or exertion is called exertional angina. In some patients, especially in people with diabetes, the progressive decrease in blood flow to the heart may occur without any pain or with just shortness of breath or unusually early fatigue.

Exertional angina usually feels like pressure, heaviness, squeezing, or aching across the chest. This pain may travel to the neck, jaw, arms, back, or even the teeth, and may be accompanied by shortness of breath, nausea, or a cold sweat. Exertional angina typically lasts from one to 15 minutes and usually is relieved by rest or by placing a tablet of nitroglycerin under the tongue. Both resting and nitroglycerin decrease the heart muscle’s demand for oxygen, thus relieving angina. Exertional angina may be the first warning sign of advanced coronary artery disease. Chest pains that just last a few seconds rarely are due to coronary artery disease.

Angina also can occur at rest. Angina at rest more commonly indicates that a coronary artery has narrowed to such a critical degree that the heart is not receiving enough oxygen even at rest. Angina at rest infrequently may be due to the spasm of a coronary artery (a condition called Prinzmetal’s or variant angina). Unlike a heart attack, there is no permanent muscle damage with either exertional or rest angina although the angina is a warning sign that there is an increased chance of a heart attack in the future.

Atherosclerosis and heart attack

Occasionally the surface of a cholesterol plaque in a coronary artery may rupture, and a blood clot forms on the surface of the plaque. The clot blocks the flow of blood through the artery and results in a heart attack (see picture below). The cause of rupture that leads to the formation of a clot is largely unknown, but contributing factors may include cigarette smoking or other nicotine exposure, elevated low-density lipoprotein (LDL) cholesterol, elevated levels of blood catecholamines (adrenaline), high blood pressure, and other mechanical and biochemical stimuli.

Unlike exertional or rest angina, heart muscle dies during a heart attack and loss of the muscle is permanent, unless blood flow can be promptly restored, usually within one to six hours.

While heart attacks can occur at any time, more heart attacks occur between 4 A.M. and 10 A.M. because of the higher blood levels of adrenaline released from the adrenal glands during the morning hours. Increased adrenaline, as previously discussed, may contribute to the rupture of cholesterol plaques.

Only half of the patients who develop heart attacks have warning signs such as exertional angina or rest angina prior to their heart attacks, but these signs may be mild and ignored as unimportant.

What are the signs and symptoms of a heart attack?

Symptoms of a heart attack include chest pain, jaw pain, toothache, headache shortness of breath, nausea, and more. Early diagnosis and treatment save lives, and delays in reaching medical assistance can be fatal.

Although chest pain or pressure is the most common symptom of a heart attack, heart attack victims may experience a variety of symptoms including:

Pain, fullness, and/or squeezing sensation of the chest
Jaw pain, toothache, headache
Shortness of breath
Nausea, vomiting, and/or general epigastric (upper middle abdomen) discomfort
Sweating
Heartburn and/or indigestion
Arm pain (more commonly the left arm, but maybe either arm)
Upper back pain
General malaise (vague feeling of illness)
No symptoms (Approximately one-quarter of all heart attacks are silent, without chest pain or new symptoms. Silent heart attacks are especially common among patients with diabetes mellitus.)

Even though the symptoms of a heart attack at times can be vague and mild, it is important to remember that heart attacks producing no symptoms or only mild symptoms can be just as serious and life-threatening as heart attacks that cause severe chest pain. Too often patients attribute heart attack symptoms to “indigestion,” “fatigue,” or “stress,” and consequently delay seeking prompt medical attention.

One cannot overemphasize the importance of seeking prompt medical attention in the presence of new symptoms that suggest a heart attack. Early diagnosis and treatment save lives, and delays in reaching medical assistance can be fatal. A delay in treatment can lead to permanently reduced function of the heart due to more extensive damage to the heart muscle. Death also may occur as a result of the sudden onset of arrhythmias such as ventricular fibrillation.

Symptoms in women

Women are more likely to encounter delays in establishing the diagnosis of heart attack than men. This is in part because women tend to seek medical care later than men, and in part because diagnosing heart attacks in women can sometimes be more difficult than diagnosing heart attacks in men. The reasons include:

Women are more likely than men to have atypical heart attack symptoms such as:
- Neck and shoulder pain
- Abdominal pain
- Nausea
- Vomiting
- Fatigue
- Shortness of breath
Silent heart attacks (heart attacks with little or no symptoms) are more common among women than among men.
Women have a higher occurrence than men of chest pain that is not caused by heart disease, for example, chest pain from spasm of the esophagus.
Women are less likely than men to have the typical findings on the ECG that are necessary to diagnose a heart attack quickly.
Women are more likely than men to have angina (chest pain due to lack of blood supply to the heart muscle) that is caused by spasm of the coronary arteries or caused by disease of the smallest blood vessels (microvasculature disease). Cardiac catheterization with coronary angiograms (X-ray studies of the coronary arteries that are considered the most reliable tests for CAD) will reveal normal coronary arteries and therefore cannot be used to diagnose either of these two conditions.
Women are more likely to have misleading, or “false positive” noninvasive tests for CAD than men that don’t disclose the arterial disease that is present.

Because of the atypical nature of symptoms and the occasional difficulties in diagnosing heart attacks in women, women are less likely to receive aggressive thrombolytic therapy or coronary angioplasty and are more likely to receive it later than men. Women also are less likely to be admitted to a coronary care unit.

What are the risk factors for atherosclerosis and heart attack?

Factors that increase the risk of developing atherosclerosis and heart attacks include:

High blood cholesterol
High blood pressure
Tobacco use
Diabetes mellitus
Male sex (although women may still be very much at risk)
Family history of coronary heart disease.

While family history and male gender are genetically determined, the other risk factors can be modified through changes in lifestyle and medications.

High blood cholesterol (hyperlipidemia)

A high level of cholesterol in the blood is associated with an increased heart attack risk because cholesterol is the major component of the plaques deposited in arterial walls. Cholesterol, like oil, cannot dissolve in the blood unless it is combined with special proteins called lipoproteins. (Without combining with lipoproteins, cholesterol in the blood would turn into a solid substance.) The cholesterol in the blood is either combined with lipoproteins as very-low-density lipoproteins (VLDL), low-density lipoproteins (LDL), or high-density lipoproteins (HDL).

The cholesterol that is combined with low-density lipoproteins (LDL cholesterol) is the “bad” cholesterol that deposits cholesterol in arterial plaques. Thus, elevated levels of LDL cholesterol are associated with an increased risk of a heart attack.

The cholesterol that is combined with HDL (HDL cholesterol) is the “good” cholesterol that removes cholesterol from arterial plaques. Thus, low levels of HDL cholesterol are associated with an increased risk of heart attacks.

Measures that lower LDL cholesterol and/or increase HDL cholesterol (losing excess weight, diets low in saturated fats, regular exercise, and medications) have been shown to lower the risk of a heart attack. One important class of medications for treating elevated cholesterol levels (the statins) has actions in addition to lowering LDL cholesterol which also protects against heart attack. Most patients at “high risk” for a heart attack should be on a statin no matter what the levels of their cholesterol.

High blood pressure (hypertension)

High blood pressure is a risk factor for developing atherosclerosis and heart attack. Both high systolic pressure (the blood pressure as the heart contracts) and high diastolic pressure (the blood pressure as the heart relaxes) increase the risk of a heart attack. It has been shown that controlling hypertension with medications can reduce the risk of a heart attack.

Tobacco use (smoking)

Tobacco and tobacco smoke contain chemicals that cause damage to blood vessel walls, accelerate the development of atherosclerosis, and increase the risk of a heart attack.

Diabetes (diabetes mellitus)

Both insulin-dependent and noninsulin-dependent diabetes mellitus (type 1 and 2, respectively) are associated with accelerated atherosclerosis throughout the body. Therefore, patients with diabetes mellitus are at higher risk for reduced blood flow to the legs, coronary heart disease, erectile dysfunction, and strokes at an earlier age than nondiabetic subjects. Patients with diabetes can lower their risk through rigorous control of their blood sugar levels, regular exercise, weight control, and proper diets.

Male sex

Men are more likely to suffer heart attacks than women if they are less than 75 years old. Above age 75, women are as likely as men to have heart attacks.

Family history of heart disease

Individuals with a family history of coronary heart disease have an increased risk of a heart attack. Specifically, the risk is higher if there is a family history of early coronary heart disease, including a heart attack or sudden death before age 55 in the father or other first-degree male relative, or before age 65 in the mother or other female first-degree female relative.

Coronary artery disease (CAD) and heart attacks are erroneously believed to occur primarily in men. Although it is true that the prevalence of CAD among women is lower before menopause, the risk of CAD rises in women after menopause. At age 75, a woman’s risk for CAD is equal to that of a man. CAD is the leading cause of death and disability in women after menopause. In fact, a 50-year-old woman faces a 46% risk of developing CAD and a 31% risk of dying from coronary artery disease. In contrast, her probability of contracting and dying from breast cancer is 12% and 3%, respectively.

The risk factors for developing CAD in women are the same as in men and include:

High blood cholesterol
High blood pressure
Smoking cigarettes
Diabetes mellitus
Family history of coronary heart disease at a young age

Smoking cigarettes

Even “light” smoking raises the risk of CAD. In one study, middle-aged women who smoked one to 14 cigarettes per day had a twofold increase in strokes (caused by atherosclerosis of the arteries to the brain) whereas those who smoked more than 25 cigarettes per day had a risk of stroke 3.7-fold higher than that of nonsmoking women. Furthermore, the combination of smoking and the use of birth control pills increases the risk of heart attacks even further, especially in women over 35.

Quitting smoking immediately begins to reduce the risk of heart attacks. The risk gradually returns to the same risk of nonsmoking women after several years of not smoking.

Cholesterol treatment guidelines in women

Current NCEP (National Cholesterol Education Program) treatment guidelines for undesirable cholesterol levels are the same for women as for men.

What are the complications of a heart attack?

Heart failure

When a large amount of heart muscle dies, the ability of the heart to pump blood to the rest of the body is diminished, and this can result in heart failure. The body retains fluid, and organs, for example, the kidneys, begin to fail.

Ventricular fibrillation

Injury to the heart muscle also can lead to ventricular fibrillation. Ventricular fibrillation occurs when the normal, regular, electrical activation of heart muscle contraction is replaced by chaotic electrical activity that causes the heart to stop beating and pumping blood to the brain and other parts of the body. Permanent brain damage and death can occur unless the flow of blood to the brain is restored within five minutes.

Most deaths from heart attacks are caused by ventricular fibrillation of the heart that occurs before the victim of the heart attack can reach an emergency room. Those who reach the emergency room have an excellent prognosis; survival from a heart attack with modern treatment should exceed 90%. The 1% to 10% of heart attack victims who later die frequently had suffered major damage to the heart muscle initially or additional damage at a later time.

Deaths from ventricular fibrillation can be avoided by cardiopulmonary resuscitation (CPR) starting within five minutes of the onset of ventricular fibrillation. CPR requires breathing for the victim and applying external compression to the chest to squeeze the heart and force it to pump blood. In 2008, the American Heart Association modified the mouth-to-mouth instruction of CPR and recommends that chest compressions alone are effective if a bystander is reluctant to do mouth-to-mouth. When paramedics arrive, medications and/or an electrical shock (cardioversion) can be administered to convert ventricular fibrillation back to a normal heart rhythm and allow the heart to pump blood normally. Therefore, prompt CPR and a rapid response by paramedics can improve the chances of survival from a heart attack.

In addition, many public venues now have automatic external defibrillators (AEDs) that provide the electrical shock needed to restore a normal heart rhythm even before the paramedics arrive. This greatly improves the chances of survival.

How is a heart attack diagnosed?

When there is severe chest pain, a suspicion that a heart attack is occurring usually is high, and tests can be performed quickly that will confirm the heart attack. A problem arises, however, when the symptoms of a heart attack do not include chest pain. A heart attack may not be suspected, and the appropriate tests may not be performed. Therefore, the initial step in diagnosing a heart attack is to be suspicious that one has occurred so that the appropriate tests can be done.

Electrocardiogram. An electrocardiogram (ECG) is a recording of the electrical activity of the heart. Abnormalities in electrical activity usually occur with heart attacks and can identify the areas of the heart muscle that are deprived of oxygen and/or areas of muscle that have died. In a patient with typical symptoms of heart attack (such as crushing chest pain) and characteristic changes of a heart attack on the ECG, a secure diagnosis of heart attack can be made quickly in the emergency room and treatment can be started immediately. If a patient’s symptoms are vague or atypical and if there are pre-existing ECG abnormalities, for example, from old heart attacks or abnormal electrical patterns that make interpretation of the ECG difficult, the diagnosis of a heart attack may be less secure. In these patients, the diagnosis can be made only hours later through blood tests.
Blood tests. Cardiac enzymes are proteins that are released into the blood by dying heart muscles. These cardiac enzymes are creatine phosphokinase (CPK), special sub-fractions of CPK (specifically, the MB fraction of CPK), and troponin, and their levels can be measured in blood. These cardiac enzymes typically are elevated in the blood several hours after the onset of a heart attack. Currently, troponin levels are considered the preferred lab tests to use to help diagnose a heart attack, as they are indicators of cardiac muscle injury or death. A series of blood tests for the enzymes performed over a 24-hour period are useful not only in confirming the diagnosis of heart attack, but the changes in their levels over time also correlate with the amount of heart muscle that has died.

The most important factor in diagnosing and treating a heart attack is prompt medical attention. Rapid evaluation allows early treatment of potentially life-threatening abnormal rhythms such as ventricular fibrillation and allows early reperfusion (return of blood flow to the heart muscle) by procedures that unclog the blocked coronary arteries. The more rapidly blood flow is reestablished, the more heart muscle that is saved.

At this time, mechanical reperfusion with angioplasty and/or stenting to increase the flow of blood to the heart is the preferred way to preserve heart muscle if it can be performed within 90 minutes of arrival at the hospital; if there will be a delay, thrombolytic agents (clot busters) are preferred.

Large and active medical centers often have a “chest pain unit” where patients suspected of having heart attacks are rapidly evaluated. If a heart attack is diagnosed, prompt therapy is initiated. If the diagnosis of heart attack is initially unclear, the patient is placed under continuous monitoring until the results of further testing are available.

What is the treatment for heart attack?

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) task force recommends a treatment guideline that they consider a preferred strategy to treat heart attacks; PCI (Percutaneous Coronary Intervention) or stenting is emphasized. For details about PCI, please see reference 2.

The 2013 ACCF/AHA guidelines for the treatment of a heart attack are summarized as follows:

Ideally, transport patient to a PCI capable hospital; if not PCI capable, transfer patient as soon as possible and less than 120 min; if the anticipated transfer is more than 120 min, give fibrinolytic agent within 30 min of arrival
Send to the cath lab
Diagnostic angiogram
PCI (Percutaneous Coronary Intervention) also termed stenting or stent placement
If an occlusion occurs or perfusion fails in a patient given a fibrinolytic, arrange transfer to a PCI capable facility; for other patients treated with a fibrinolytic, transfer to a PCI facility within about 3-24hrs
If step 5 occurs, step 3 should follow at a PCI-capable facility where either medical therapy, a PCI, or a CABG should be done Patients who are not candidates for PCI therapy usually undergo medical or surgical (CABG) therapy. For a more detailed presentation of the medical treatments and CABG, read the heart attack treatment article.

Medical treatment

Treatment for heart attacks may include antiplatelet, anticoagulant, and clot-dissolving drugs as well as angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and oxygen.
Interventional treatment for heart attacks may include coronary angiography with percutaneous transluminal coronary angioplasty (PTCA), coronary artery stents, and coronary artery bypass grafting (CABG).
Further heart attacks can be prevented by aspirin, beta-blockers, ACE inhibitors, discontinuing smoking, weight reduction, exercise, good control of blood pressure and diabetes, following low cholesterol and low saturated fat diet that is high in omega-3-fatty acids, taking multivitamins with an increased amount of folic acid, decreasing LDL cholesterol, and increasing HDL cholesterol.

After menopause, the production of estrogen by the ovaries gradually diminishes over several years. Along with this reduction, there is an increase in LDL (“bad” cholesterol) and a small decrease in HDL (“good” cholesterol). These changes in lipid levels are believed to be one of the reasons for the increased risks of developing CAD after menopause. Women who have had their ovaries surgically removed (oophorectomy) or experience early menopause, also have an accelerated risk of CAD.

Since treatment with estrogen hormone results in higher HDL and lower LDL cholesterol levels, doctors thought for many years that estrogen would protect women against CAD (as well protect against dementia and stroke). Many studies have found that postmenopausal women who take estrogen have lower CAD rates than women who do not.

Unfortunately, many of the studies were observational studies (studies in which women are followed over time but decide on their own whether or not they wish to take estrogen). Observational studies have serious shortcomings because they are subject to selection bias; for example, women who choose to take estrogen hormones may be healthier and have a lower risk of heart attacks than those who do not. In other words, something else in the daily habits of women who take estrogen (such as exercise or a healthier diet) may make them less likely to develop heart attacks. Therefore, only a randomized trial (a study in which women agree to be assigned to estrogen or a placebo or sugar pill at random but are not told which pills they took until the end of the study) can establish whether hormone therapy after menopause can prevent CAD.

HERS trial results

The Heart and Estrogen/progestin Replacement Study (HERS), was a randomized placebo-controlled trial of the effect of the daily use of estrogens plus medroxyprogesterone (progestin) on the rate of heart attacks in postmenopausal women who already had CAD. The HERS trial did not find a reduction in heart attacks in women who took hormone therapy. This lack of benefit in preventing heart attacks occurred despite an 11% lower LDL and a 10% higher HDL cholesterol level in the women treated with hormones.

The study also found that more women in the hormone-treated group experienced blood clots in the veins and gallbladder disease than women in the placebo-treated group. (Blood clots in the veins are dangerous because these clots can travel to the lungs and cause pulmonary embolism, a condition with chest pain, shortness of breath, and even shock and death.) However, the increase in gallbladder disease and blood clots among healthy users of estrogen who do not have heart disease is very small.

Based on the results of this study, researchers concluded that estrogen is not effective in preventing coronary artery disease and heart attacks in postmenopausal women who already have CAD. It should be noted, however, that the results of the HERS trial only apply to women who have known CAD prior to starting hormone therapy and not to women without known coronary artery disease.

WHI trial results

The Women’s Health Initiative (WHI) was the first randomized controlled trial designed to determine the long-term benefits and risks of treatment with estrogens plus medroxyprogesterone (progestin) in healthy menopausal women (women without CAD). The results were reported in a series of articles in 2002, 2003, and 2004. The estrogen + progestin portion of the WHI study had to be stopped earlier than planned, after just 5.2 years, because of the increase in coronary heart disease, stroke, and pulmonary embolism among women who use estrogen + progesterone outweighed the benefits of reduced bone fractures and colon cancer. The estrogen-alone portion of the WHI was stopped because women who took estrogen alone had no reduction in heart attack risk, yet there was a significant increase in stroke risk.

An increase in breast cancer became apparent after three to five years, but the increase in heart disease and pulmonary emboli occurred early on, in the first year.

Recommendations for the use of estrogens plus medroxyprogesterone (progestin) in women

MedicineNet Medical Editors believe that:

Decisions regarding the use of hormone therapy have to be individualized, and all women should discuss with their physicians what is best for them.
Estrogens plus medroxyprogesterone (progestin) is still the best therapy for hot flashes. Despite the WHI study, many women remain good candidates for estrogens plus medroxyprogesterone (progestin) therapy (or estrogen alone if they have had a hysterectomy). This is especially true if hormone therapy is limited to the shortest duration, optimally less than five years.
Estrogens with or without medroxyprogesterone (progestin) should not be used to prevent or treat either Alzheimer’s disease, heart disease, or stroke.
While estrogens plus medroxyprogesterone (progestin) are effective in preventing osteoporosis and related bone fractures, women concerned about the risk of hormone therapy should discuss their concerns with their doctors, the use of other non-hormonal alternatives to prevent and treat osteoporosis.

What Is Heart Disease?

Heart disease refers to conditions that involve the heart, its vessels, muscles, valves, or internal electric pathways responsible for muscular contraction. Common heart disease conditions include:

Coronary artery disease
Heart failure
Cardiomyopathy
Heart valve disease
Arrhythmias

Coronary artery disease, the most common type of heart disease in the U.S., is the main cause of heart attacks.

What Is a Heart Attack?

Do you know the stages of a heart attack? When a coronary artery becomes blocked (usually by a blood clot), an area of heart tissue loses its blood supply. This reduction of blood can quickly damage and/or kill heart tissue, so quick treatments in an emergency department and/or catheterization suite are necessary to reduce the loss of heart tissue. Loss of heart tissue due to a blockage can cause symptoms such as chest pain, shortness of breath, weakness, and even death. Quick treatments have reduced the number of deaths from heart attacks in recent years. About 790,000 people suffer from heart attacks in the U.S. each year.

Heart Attack Symptoms

The following are possible symptoms of a heart attack:

Chest pain (may spread to the back, neck, arms and/or jaw)
Dizziness
Nausea, vomiting
Rapid or irregular heartbeats
Shortness of breath
Some people may exhibit anxiety, indigestion and/or heartburn (some women may present with these as their predominant symptoms instead of chest pain)
Weakness
Lightheadedness
Breaking out in a cold sweat

Women may experience different heart attack signs and symptoms than men. Jaw pain, shortness of breath, and nausea and vomiting may be more common in women who have heart attacks than men.

Heart Attack Symptoms in Women

Although some women present with symptoms of chest pain, a large number of women will not present with chest pain. Instead, women commonly have a different set of heart attack symptoms.

Know These Heart Attack Symptoms in Women

Arrhythmias
Cough
Heartburn
Loss of appetite
Malaise

Such symptoms in women can cause delays in diagnosis if the symptoms are not considered as possible signs of heart disease. Delays in diagnosis can cause further damage to heart tissue or even death. Women should exercise, quit smoking, and see their doctors for regular check-ups to monitor heart disease risk factors.

Coronary Artery Disease Symptoms

Coronary artery disease (CAD) occurs when plaque, a sticky substance, narrows or partially obstructs coronary arteries (like sticky material stopping up a straw) and can result in reduced blood flow. This reduced blood flow may cause chest pain (angina), a warning sign of potential heart problems such as a heart attack. Plaque may also trap small blood clots, completely blocking a coronary artery suddenly, resulting in a heart attack.

How Plaque, Blood Clots can Cause Heart Attack

Plaque can occur in coronary and other arteries (for example, carotid arteries). Some plaque may be hard or firm on the outside, but soft and mushy or sticky on the inside. If the hard, shell-like area cracks open, blood components like platelets and small blood clots can form a large clot and effectively block blood flow through the artery. The heart tissue downstream from the clot then suffers from lack of blood and can become damaged or die.

Heart Attack Symptoms? Call 9-1-1

If you or an individual develop symptoms of a heart attack, do not delay getting medical help. Call 911 or have someone call for you. Do not drive yourself or others to a hospital as 911 emergency medical services (EMS) personnel can begin basic treatment immediately. Delaying care can result in increased heart damage or death. The sooner heart attack symptoms are identified, the sooner the patient can be treated, maximizing the chance of a good outcome.

Sudden Cardiac Arrest

A heart attack can cause other abnormalities besides blocking blood flow. For example, sudden cardiac death may occur when the heart’s electrical signals become erratic (arrhythmias). When the heart tissue that is responsible for regular electrical stimulus of heart muscle contractions is damaged, the heart stops effectively pumping blood. Death usually occurs in a few minutes after the heart stops pumping blood. Consequently, rapid coronary pulmonary resuscitation (CPR) and a restoration of the organized electrical activity (usually done by electric shock with a defibrillator) may restore effective pumping of blood. This action can be lifesaving for some individuals.

Erratic Heart Beat (Arrhythmia)

People who notice that their heartbeats are abnormally fast, slow, or irregular may be experiencing irregular electrical impulses known as arrhythmias. They may also have symptoms of weakness, shortness of breath, and anxiety. Arrhythmias can alter, slow or even stop the heart’s ability to pump blood. Consequently, individuals with arrhythmias should seek emergency medical care especially if the arrhythmia is persistent or causes any symptoms related to heart attack symptoms, such as chest pain. Ventricular fibrillation and atrial fibrillation are two examples of arrhythmias. Atrial fibrillation may increase the risk of a stroke.

Cardiomyopathy

Cardiomyopathy is a condition indicated by abnormal heart muscle. Abnormal muscles make it harder for your heart to pump blood to the rest of the body.

Main Types of Cardiomyopathy

Dilated (stretched and thinned muscle)
Hypertrophic (thickened heart muscle)
Restrictive (rare problem where the heart muscle does not stretch normally so the chambers in the heart do not fill with blood properly)

Signs and Symptoms of Cardiomyopathy

Shortness of breath
Fatigue
Swelling of the feet, ankles and/or legs
Coughing when lying down
Dizziness
Chest pain
Irregular heartbeats

Heart Failure

Heart failure (also termed congestive heart failure) means the pumping action of the heart cannot meet the body’s demand for blood; it does not mean that the heart fails to pump – it does mean a failure in an aspect of the heart’s ability to complete an otherwise normal function. The symptoms and signs are almost identical to those seen with cardiomyopathy. Most cases of heart failure are chronic, long-term heart failure.

Congenital Heart Defect

A congenital heart defect is a defect in the development of the heart as an organ that is usually first noticed at birth, although some are not found until adulthood. There are many types of congenital heart defects and a few need no treatment, but others may need surgical repair. The American Heart Association lists at least 18 distinct types of congenital heart defects – many of them have additional anatomical variations.

Congenital heart defects put those patients at higher risk to develop arrhythmias, heart failure, heart valve infections, and other problems. A cardiologist (often a pediatric cardiologist) needs to be consulted on how to treat these defects. Recent advances have allowed surgeons to repair many of these defects so that the patient can go on to develop normally.

The most common congenital heart defects are problems with the heart valves and holes in the walls of the heart.

Heart Disease Testing: EKG (Electrocardiogram)

Your heart’s electrical activity can be seen with an EKG (also termed ECG or electrocardiogram). EKGs are tests that provide important information to the physician about the heart rhythm, damage to the heart, or a heart attack, and may provide several other important pieces of information or clues to the patient’s condition. In addition, EKGs can be compared to past and future EKGs to see changes in the heart’s electrical activity over time or after treatments.

Heart Disease Testing: Stress Test

A stress test measures the ability of your heart to respond to your body’s demand for more blood during stress (exercise or work). A continual measurement of the heart’s electrical activity (a continual EKG or rhythm strip) is recorded along with the heart rate and blood pressure as a person’s stress (exercise) is gradually increased on a treadmill. The information helps to show how well the heart responds to the body’s demands and may provide information to help diagnose and treat problems. It can also be used to see the effects of treatment on the heart.

Heart Disease Testing: Holter Monitor

Many people have intermittent symptoms such as intermittent chest pain or occasional feelings of their heart beating faster or irregularly. However, their EKG does not show any changes. To detect these intermittent changes, a device called a Holter monitor can be worn for several days to record the hearts’ electrical function.

A Holter monitor is similar to a stress test, but it is worn for 1 or 2 days and provides a continual EKG-like recording of the heart’s electrical activity during those days. Most doctors will ask the patient to keep a logbook of the time they do certain activities (for example, walking a mile starting at 7:20 AM and ending at 7:40 AM) and list any symptoms (for example, “experienced shortness of breath or rapid irregular heartbeats at 7:35 AM”). The Holter monitor’s recordings can then be examined based on when certain symptoms occurred.

Heart Disease Testing: Chest X-ray

Chest x-rays can provide limited information about your heart’s condition. Chest X-rays are used to provide the doctor with a view of both your heart and lungs to help determine if any abnormalities are present. These two X-rays show a relatively normal heart on the left. In the right X-ray, an enlarged heart (mainly the left ventricle) is easily seen and suggests the heart’s main pumping chamber is not functioning normally. In addition, x-rays may show fluid accumulation in the lungs, possibly from heart failure.

Heart Disease Testing: Echocardiogram

An echocardiogram is a real-time moving picture of a functioning heart made by using sound waves (ultrasound) to generate images. Echocardiograms use the same noninvasive technology used to examine the fetus during pregnancy. It can show how well heart chambers and heart valves are functioning (for example, effective or poor pumping action, blood flow through the valves), before and after treatments, as well as other features.

Heart Disease Testing: Cardiac CT Scan

Specialized cardiac computerized tomography (CT) scans or “cardiac CTs” can provide detailed 3-D images of the heart. The images can be manipulated to look for calcium buildup (plaque) in coronary arteries or provide images of such internal structures of the heart like valves or wall thickness. CTs can also be used to examine normal heart anatomy or congenital defects. The information from a CT can provide insight into several heart disease problems.

Heart Disease Testing: Cardiac Catheterization

Plaque in cardiac arteries can be a severe problem, even life-threatening, in some patients. Diagnosing plaque blockage of coronary arteries and treatments for blockages has improved the lives of many patients with coronary artery disease. Cardiac catheterization is a technique that may provide both diagnostic information and therapeutic methodology in one procedure. The technique is invasive and can be used to detect blockages in your heart that trigger heart attacks.

How Cardiac Catheterization Works

A thin tube is placed in a blood vessel in the leg or arm and threaded into the heart and into the opening of a coronary artery.
Dye is put into the tube and goes into the artery.
A special X-ray machine images the dye, showing narrowing or blockage of the artery.
The same tube may be used with special tips to open the coronary artery by angioplasty (small balloon is inflated) or used to place a wire mesh (stent) that expands to hold the artery open.

Living With Heart Disease

Most types of heart disease are chronic but slowly progressive like heart failure or cardiomyopathy. They begin with minor symptoms that often slowly worsen and require long-term medical treatment.

Symptoms That May Resist Treatment

Ankle swelling
Fatigue
Fluid retention
Shortness of breath

Lifestyle changes may become necessary (for example, home oxygen, limited activity.)

Take medications as prescribed by your doctor. Follow the doctor’s diet and exercise plan for you. If you experience new or worsening symptoms, see your doctor right away.

Heart Disease Treatment: Medicines

Advances in medicines that can help reduce the symptoms and slow the damage of heart disease have helped the majority of heart disease patients. Drugs are available to do the following:

Lower blood pressure (anti-hypertensives)
Lower heartbeat rates (beta blockers)
Lower cholesterol levels to reduce plaque (diet, statins)
Help stabilize abnormal heart rhythms (ablation, cardiac pacers)
Reduce or prevent clotting in coronary arteries (blood thinners)
Improve the pumping ability of a person’s heart with heart disease (inotropic agents)
Remove excess fluid from the system and decrease blood volume (diuretic)

Take cardiac medications as prescribed by your doctor to control your condition. Never skip doses of your medications or stop taking them without speaking with your doctor first.

Heart Disease Treatment: Angioplasty

Other treatments for heart disease involve special techniques like angioplasty and stent placement.

Angioplasty Step by Step

A thin catheter or tube (stent) is placed in a coronary artery and is threaded through an obstruction like a clot.
A balloon is inflated and pushes aside the obstruction.
The balloon is then deflated leaving the artery unblocked, thus allowing good blood flow.
Often, after angioplasty, an expandable mesh tube is then inserted and expanded, reinforcing the artery to keep it from collapsing.

The nurses will apply pressure to the area where the catheter was inserted for at least 15 minutes. The patient has to lie flat on his or her back for several hours to minimize the risk of bleeding. The doctor will order the patient to avoid lifting heavy objects and avoid engaging in strenuous physical activity for a certain amount of time after the procedure, usually 1 to 2 days.

Heart Disease Treatment: Bypass Surgery

Some patient’s coronary arteries are not good candidates for angioplasty and/or stents. Such patients may benefit from another treatment technique termed bypass surgery. Bypass surgery occurs when a surgeon removes a blood vessel from one part of the body (chest, legs, or arms) and uses it to connect one open part of a coronary artery to another open part, thus bypassing the area that has blocked blood flow. Often the surgeon may need to bypass more than one artery.

The decision to try and stent a coronary artery versus doing bypass surgery is usually recommended to the patient by their cardiologist and a heart surgeon. Bypass surgery is usually done if coronary arteries are narrowed or blocked in multiple places.

The procedure is known as coronary artery bypass graft (CABG). The doctor will take blood vessel from another part of the body and graft them onto the heart to bypass one, two, three, or more blocked coronary arteries. The procedure requires a stay in the hospital afterwards to recover.

Who Is at Risk for Heart Disease?

Health conditions, lifestyle, age, and family history may increase your risk for heart disease. Although men, even at a younger age, have a higher risk for heart disease than women, heart disease is still the number one killer of both sexes (about 611,000 total deaths/year). Approximately 735,000 people in the U.S. suffer a heart attack every year. People with a family history of heart disease, who smoke, and who are obese have a higher risk of developing heart disease. About half of all Americans (47%) have at least one of three key risk factors for heart disease including high blood pressure, high cholesterol, or smoking. Approximately 80 million people in the U.S. have some form of heart disease. It is the leading cause of death in men and women in the U.S.

Controllable Heart Disease Risks

Often, risk factors for heart disease can be managed or reduced through simple methods. Common risk factors for heart disease include the following:

Heart Diseases Risks You Can Control or Modify

Diabetes
Elevated cholesterol
High blood pressure
Lack of physical activity
Stop smoking

These risk factors can be reduced simply by making healthy lifestyle choices and taking medications. Your primary care doctor can help you with your choices and medications. Stress, being overweight or obese, and alcohol consumption are contributing risk factors for heart disease. Talk to your doctor about how to decrease your risk.

Smoking Increases Heart Disease Risk

Many researchers suggest one of the best things a person can do to decrease the risk of heart disease is to stop smoking cigarettes. Smoking increases a person’s risk for heart disease from 2 to about 4 times greater than nonsmokers. Smoking can damage the heart muscle, its blood vessels, can raise blood pressure, increase carbon monoxide levels, and reduce oxygen available to heart tissue.

People who do not smoke but are exposed to second-hand smoke are at greater risk for heart disease than those not exposed to second-hand smoke. Although over 135,000 people die each year from heart disease related to smoking, it is never too late to quit smoking because once you quit, your risk of heart disease begins to drop almost immediately. According to the American Heart Association, there are 480,000 deaths due to smoking-related illnesses in the U.S. every year.

Life After a Heart Attack

Don’t give up activities if you have a heart attack. If a person suffers a heart attack, it is still possible to develop a healthy lifestyle. Many doctors recommend that their patients participate in a cardiac rehab program and learn how to avoid cigarettes, develop a healthy diet, and become more active. All of these changes may help a person’s heart recover and function better and to reduce the chance of additional heart problems.

Approximately 20 percent of people over 45 years of age will suffer another heart attack within 5 years of suffering a first heart attack. Reduce your risk of future cardiac problems by going to follow-up appointments with your doctor and taking medications as prescribed. Participate in cardiac rehabilitation and seek support from loved ones and outside help if you need it. Manage the heart disease risk factors you can control to reduce your risk of future heart problems.

Preventing Heart Disease

Heart disease prevention and risk reduction is possible by living a healthy lifestyle. Basic components of a heart-healthy lifestyle include:

Never smoke or stop smoking cigarettes (and using other tobacco products)
Eat a nutritious diet (many vegetables and fruits, less fats, sugars, and meats)
Get at least 30 minutes of exercise almost every day
Avoid alcohol or consume no more than 1 drink per day for women and no more than 2 drinks per day for men
If needed, achieve medical control of diabetes, high blood pressure, and cholesterol
Encourage friends and family to help you. Maybe they could benefit from your good example!

Know your family history of heart disease. Manage your stress levels. Know the warning signs of heart attack and stroke and act fast if you notice signs and symptoms in yourself or others. Monitor your blood sugar and watch for signs and symptoms of diabetes. Be mindful of snoring; it may indicate you have sleep apnea, which increases the risk of heart disease, high blood pressure, and stroke.

Heart Disease and Diet

A major key to preventing, recovering from, and slowing heart disease is a heart-healthy diet. Most heart doctors recommend the following foods.

Heart-Healthy Foods

Fruits
Legumes
Vegetables
Whole grains

Foods That May Help Reduce Cholesterol Levels

Nuts
Plant oils
Seeds

Eating fish about twice a week is a good source of protein without the fats found in red meat. Some researchers have suggested that a more vegetarian-like diet may actually reverse some aspects of coronary artery disease like plaque size. Limit your intake of saturated fat, trans fat, red meat, sugar, sugar-sweetened beverages, and sodium to protect your heart and blood vessels.

While heart disease is treatable by many methods, prevention or healing by living a reasonable lifestyle seems to be one of the best ways to reduce this widespread health problem.

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Atrial Fibrillation: How to Treat Atrial Fibrillation

Determining Treatment for Afib

Your irregular heartbeat means blood doesn’t flow as well as it should, and clots may form inside your heart. If one of those travels to your brain, it can cause a stroke. Your doctor may recommend medications but your course of treatment depends on your age, your symptoms and how often they occur, how long you have been in AFib, any other health problems you have, and if you have already had a stroke.

Blood Thinners

To help lower the chances of clots, your doctor may prescribe a more powerful blood thinner called an anticoagulant, especially if you have high blood pressure, diabetes, or heart failure. The most common is warfarin (Coumadin). It can cut your risk of stroke, but you’ll have to get your blood tested often, and you’ll have to be careful to avoid cuts or other injuries. Some foods can make warfarin less effective, too. If you need a procedure, dental work, or surgery, it might be necessary to stop the blood thinner. It’s important to let all your doctors know you are taking a blood thinner just in case.

Other Blood Thinners

Newer anticoagulants including apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Lixiana, Savaysa), and rivaroxaban (Xarelto) also reduce the risk of stroke. You don’t have to have regular blood tests when you take them. Plus, food doesn’t affect how well they work. But you still could have problems with bleeding.

Slow Down Your Racing Heart

When your heart is beating too fast, medicine can slow it down and lessen the strain on your heart muscle. Getting the rate below 100 beats per minute can help you feel stronger. To do that, doctors often prescribe either beta-blockers or calcium channel blockers, depending on your health.

Reset an Irregular Heart Rhythm

Some people with AFib need electrical cardioversion to “reset” their heart’s rhythm. While you’re under mild anesthesia, a doctor uses patches or paddles to gently shock your heart.

Your doctor might want to do an ultrasound first to check for clots in your heart. If you have one, you may need to take blood thinners for a few weeks both before and after your procedure.

Heart Reset With Anti-arrhythmics

About half of people who have electrical cardioversion get AFib again. So doctors sometimes prescribe medications called anti-arrhythmics to help keep your heartbeat regular. You’ll need to check in with your doctor often, because they can cause side effects including heart rhythm problems.

Ablation

When drugs and electrical treatments aren’t working, your doctor may suggest a procedure called ablation. While you’re sedated, a cardiologist will insert a thin, flexible tube into a large blood vessel and guide it to the spot in your heart that’s misfiring. They’ll destroy the tissue there by heating or freezing it. Depending on what kind of ablation you have, you may need a pacemaker, too. Sometimes it takes more than one ablation for it to work, but it can get rid of the atrial fibrillation when it is a success.

Pacemaker for a Steady Beat

This small, battery-powered device goes under your skin near your collarbone. It has wires that attach to your heart to keep it going when it gets too slow.

After surgery, you’ll need to avoid pulling on the area, but you’ll soon be able to get back to your usual activities. Most electronics like microwaves or phones won’t bother your pacemaker, but some security systems and headphones can. You’ll learn what to avoid and how to check your own pulse.

Heart Surgery

If medication and simpler procedures haven’t helped, or if you have certain other heart problems, your doctor may recommend an operation called a Maze procedure. The surgeon makes precise cuts to scar the surface of the heart’s upper chambers and interrupt the electrical signals that throw off your heart rhythm. Sometimes it can be done with only a tiny “keyhole” incision. If the surgery works, you should have fewer symptoms and be able to live normally. This surgery is often the last option for people whose atrial fibrillation is causing severe heart problems.

Lifestyle Changes

No matter how you treat your AFib, your daily habits can help your heart. Eat a heart-healthy diet. Cut back on the caffeine you drink. (Some people find that coffee, sodas, and tea make their symptoms worse.) Read medicine labels to check for decongestants — especially in cold and cough medicines. Limit alcohol to no more than 1 drink a day if you’re a woman and 2 if you’re a man. Get regular exercise. And if you smoke, quit.

Talk to your doctor if your symptoms get worse.