Living with
Coronary Artery Disease

What is coronary artery disease?

Coronary artery disease (CAD), also called ischaemic heart disease, develops when the major blood vessels, known as the coronary arteries, that supply your heart with blood, oxygen and nutrients become damaged or diseased.
Cholesterol-containing deposits (plaques) in your arteries and subsequent arterial hardening (atherosclerosis) are usually to blame for the damage.

When plaque builds up, it narrows your coronary arteries, decreasing blood flow to your heart. Eventually, the decreased blood flow may cause chest pain (angina), shortness of breath or any of the other symptoms and signs of coronary artery disease.
A complete blockage can cause heart attack. Over time, CAD can also weaken the heart and contribute to heart failure and arrhythmias. Heart failure means that the heart can’t pump blood sufficiently to supply the rest of the body, while arrhythmias are irregular changes to the normal rhythm of the heartbeat.

CAD is the most common type of heart disease and is the leading cause of death in both men and women globally.

How could you know if you have CAD?

Because coronary artery disease often develops over decades, you might not notice a problem until you have a significant blockage or until you experience a heart attack.
However, early warning signs may include:

• Weakness or fatigue
• Chest pain known as angina
• Dizziness
• Shortness of breath.

Angina is a squeezing, suffocating or burning pain, discomfort or tightness in the centre of your chest that may radiate up your arm, neck, back, throat or jaw.

Women are more likely to experience non-traditional symptoms of CAD, such as:

• Vague chest discomfort
• Palpitations
• Sleep difficulties
• Indigestion or heartburn
• Anxiety.

What are the different types of coronary artery disease?

There are three different types of CAD:

1. Obstructive: With this type of CAD, the coronary arteries are significantly narrowed or blocked, preventing blood flow to the heart muscle.
2. Non-obstructive: This is a less common form of CAD that is not yet completely understood. It usually occurs when your coronary arteries inappropriately constrict after branching into tiny vessels or are squeezed by overlying heart muscle when the heart contracts during heartbeats.
3. SCAD: Spontaneous coronary artery dissection (SCAD) refers to the spontaneous tearing of the coronary arteries. Learn more about SCAD.

What causes coronary artery disease?

According to the Heart and Stroke Foundation of South Africa, cardiovascular disease is the leading cause of death worldwide, responsible for 17 million deaths annually. In South Africa, cardiovascular disease is the leading cause of death after HIV/AIDS, accounting for 17.3 % of deaths each year.

The risk factors for developing CAD are:

• Hypertension
• High blood cholesterol or high triglyceride levels
• Diabetes
• Overweight or obesity
• Unhealthy diet
• Over consumption of alcohol
• Lack of physical activity
• Smoking
• Stress
• Depression
• Age: The older you are, the higher your risk of heart disease. The risk of CAD increases for women post menopause.
• Family history: If you have a close relative who has experienced stroke or heart attack before, then you are at an increased risk of developing CAD.
  You are at particular risk of CAD if your father or brother has had a stroke or heart attack before 55 years of age, or your mother and sister before 65 years old.
• Excessive and frequent alcohol consumption
• Pre-eclampsia (high blood pressure first diagnosed during pregnancy).

Living and managing

Knowing your risk factors and reducing them can significantly reduce your risk of CAD or the risk of experiencing a heart attack or stroke if you have CAD.

By working closely with your doctor, you can reduce your risk of CAD by focusing on the following healthy lifestyle measures:

1. Manage your blood pressure
   As hypertension is the biggest cause of heart and blood vessel disease, keeping your blood pressure levels within healthy limits is very important in preventing and managing CAD.
   Click here to read more about how to better manage your blood pressure, including reducing your dietary salt intake.
   You can also access your own Cooking from the Heart Low Salt booklet, containing listed salt contents of South Africa’s most popular foods and nutrition brands. You’ll never be tricked again and might save yourself a headache trying to understand complicated, and often misleading, food labels. Download it now for healthier cooking, shopping and snacking!
2. Eat a healthy diet low in fat and cholesterol
   Click here to read about how to eat a heart-healthy, low-fat diet.
   If your cholesterol levels are high, even with a healthy diet, speak to doctor about medication to manage your cholesterol levels.
3. Exercise and try to maintain a healthy weight
   Try to keep as active as possible. You don’t have to join a gym do this; instead, just take regular walks, ride a bike or dance along to the music on your radio.
   Your goal should be 30 minutes of moderate activity (makes you sweat and your heart beat a little faster) most days of the week.
   Regular physical activity helps you manage your blood pressure and glucose levels, lose weight, and alleviates stress, thereby reducing the risk of heart disease.
4. Manage your diabetes
   Eating a healthy low-fat and low-sugar diet, exercising regularly and maintaining a healthy weight will all help you successfully manage your blood sugar levels.
   If your blood sugar levels are still above normal, even with healthy diet and exercise, then speak to your doctor as you may need to take medication to manage your blood sugar levels.
5. Manage stress
   When you’re stressed, your heart rate and blood pressure go up – this is not good for your heart or blood vessels. You may also not manage your blood pressure or other chronic conditions and forget to exercise, eat right or take your medicines when you are anxious.
   Find ways to relieve stress, like meditation, mindfulness or yoga.
6. Stop smoking
   Talk to your doctor about ways to quit smoking, as tobacco smoke significantly increases your risk of heart disease.
7. Limit your alcohol consumption
   As excess alcohol consumption damages the heart and blood vessels, you will need to speak to your doctor or healthcare provider about what amount of alcohol is appropriate for you to consume.
   Generally, to stay healthy, it is recommended that women not exceed one glass of alcohol per day, while men should have no more than two glasses per day.

What are the complications of CAD?

• Heart attack
• Stroke
• Heart failure
• Peripheral vascular disease (pain or numbness in legs, hands or feet, which could cause you to limp)
• Arrhythmia
• Sudden cardiac arrest.

What treatment is available for CAD?

There is no cure for CAD. However, along with healthy lifestyle behaviors, certain medications can be used to manage the underlying risk factors (like hypertension and high cholesterol) and to treat angina and other symptoms. Importantly, certain medications and surgical interventions can be used to significantly reduce your risk of heart attack or stroke.

Common medications prescribed to CAD patients include:

• ACE inhibitors
• Anti-platelets
• Beta-blockers
• Calcium channel blockers
• Statins
• Nitrates (nitroglycerine): This medication is used to relieve the symptom of angina. Nitrates are vasodilators; meaning that they cause blood vessels to widen, making it easier for blood to flow through and deliver oxygen to heart muscle cells.
  Nitrates are available as sublingual tablets or sprays (where absorption occurs through blood vessels beneath the tongue) and topical ointments or transdermal patches that allow delivery through the skin.
  Speak to your healthcare provider about how you should use this medication effectively.

For patients with severe atherosclerosis and angina, a doctor may recommend percutaneous coronary intervention (otherwise known as angioplasty with stent). This is a procedure that uses a catheter, or thin flexible tube, to insert a stent into narrowed blood vessels to keep them open, allowing blood to flow through.

However, in some cases of severe atherosclerosis, surgical intervention may be needed to bypass blocked coronary arteries to restore sufficient delivery of blood to the heart. This type of surgery is known as coronary artery bypass.

What should you know about heart attack?

A heart attack, medically known as a myocardial infarction, occurs when the heart muscle receives insufficient oxygen supply, resulting in the death of heart muscle cells. This occurs because blood flow to the heart is restricted or blocked, usually as a result of coronary artery disease.

Heart attack is a life-threatening medical emergency, and, as such, it is crucial that you seek help immediately if you think you or someone you know is experiencing a heart attack.

How do know you are having heart attack?

The symptoms of heart attack vary, but most commonly include:

• Pressure, tightness or pain in the centre of the chest that may radiate to up to the arms, neck or jaw
• Shortness of breath (even at rest)
• Sweating
• Palpitations
• Light-headedness, dizziness and fatigue
• Light-headedness, dizziness and fatigue
• Nausea or an upset stomach
• Cyanosis (a blue tinge to the tongue or other mucous membranes, representing reduced oxygenated blood flow).

Seek medical help immediately if you experience these symptoms, especially if you suffer from coronary artery disease.

What causes heart attack?

The Heart and Stroke Foundation of South Africa estimate that as many as five South Africans suffer a heart attack every hour. You are at risk of heart attack if you have coronary artery disease.

What is the treatment when someone has a heart attack?

It is essential that you contact emergency services or medical services if you suspect that you or someone you know may be having a heart attack. CPR must be administered if cardiac arrest occurs (if the person appears not to be breathing or doesn’t have a pulse and is non-responsive) and must continue until emergency services arrive.

Medical treatment for heart attack may include:

• Anti-platelets, particularly aspirin
• Anticoagulants
• ACE inhibitors
• Beta-blockers
• Statins
• Nitrates

How do you avoid having a heart attack?

Because heart attack is caused by coronary artery disease, lifestyle management, such as healthy diet and exercise, is crucial for preventing heart attack.

What is the difference between heart attack and angina?

Angina is the medical term for a symptom of coronary artery disease that occurs when blood flow and oxygen to the heart is restricted. It is typified by a chest pain or discomfort that is:

• Usually described as a squeezing, burning or suffocating feeling, typically felt in the centre of the chest or behind the breastbone.
• More commonly occurs during exertion or periods of physical activity and worsens with an increase in duration and level of activity. It will usually improve or resolve at rest.
• Can also occur when exposed to very cold temperatures that cause blood vessels to constrict, or after a very large meal.
• Usually only experienced for a short period of time, maybe lasting for a few minutes.
• May be accompanied by shortness of breath and/or fatigue.

Angina is a sign that you are at risk of heart attack. However, while angina indicates that there is reduced blood flow and oxygen to the heart, heart attack occurs because there is complete blockage of blood flow to the heart and heart damage is occurring.
The chest pain experienced during heart attack is usually described as more severe than angina and unlike angina, the pain can occur at rest and does not ease after taking nitrates. The person experiencing a heart attack may also appear to be in a more serious condition than if they were just experiencing angina, with palpitations or more serious symptoms such as cyanosis (blue tinge to the tongue or other mucous membranes).

There are two types of angina that may indicate different risks of heart attack:

• Stable angina is usually only short-lived (5-15 minutes) and typically occurs during physical exertion and is relieved by rest or nitrate administration.
• Unstable angina represents a high risk of heart attack and should be reported to your healthcare professional immediately for medical treatment to avoid heart attack. It usually occurs very suddenly, even at rest, lasting and worsening over a longer period (more than 20 minutes) and is often not relieved by nitrates.

How do you treat angina?

Because angina is caused by coronary artery disease, lifestyle management, such as healthy diet and regular physical exercise, can help manage angina and reduce the risk of heart attack.
Additionally, nitrates can be used to relieve angina.

What is cardiac arrest?

Cardiac arrest is a medical emergency that indicates a person is at high risk of dying. It can be caused by heart attack.

It is characterised by:

• A lack of heartbeat, meaning blood is not flowing through the body
• The affected person having stopped breathing
• The affected person being non-responsive / unconscious.

If this occurs, contact emergency services immediately and start CPR and continue until emergency services arrive.

What is Spontaneous Coronary Artery Dissection (SCAD)?

Coronary artery dissection (SCAD) occurs when there is a tear in the wall of the coronary arteries that supply blood and oxygen to the heart, meaning that blood flow to the heart is reduced.
This condition can result in arrhythmias, heart attack and cardiac arrest.

SCAD is classified as a type of coronary artery disease and, as such, has the same symptoms of this condition. However, while CAD is mostly caused by atherosclerosis resulting from certain conditions – like high cholesterol and hypertension – and unhealthy lifestyle habits (such as a high-fat diet and lack of physical activity), SCAD is usually caused by a genetic predisposition mostly found in woman aged between 30-60 years old.

Women are at increased risk of SCAD if they have had multiple pregnancies, have certain underlying connective tissue or inflammatory conditions (like Crohn’s disease), are post-menopausal and using hormone-replacement therapy (HRT) or have a history of cocaine use.

As a type of CAD, SCAD can be prevented by certain lifestyle management measures, such as healthy diet and exercise; however, if a large tear occurs it might require emergency medical and surgical treatment to stabilise and repair.