Coronary Artery Disease

Cardiovascular Diseases (CVD) are the number 1 cause of death globally: more people die annually from CVDs than from any other cause. An estimated 17.9 million people died from CVDs in 2016, representing 31% of all global deaths. Of these deaths, 85% are due to heart attack and stroke.

In this article we will be talking about Coronary Artery Disease, its aetiology, symptoms, treatments, supportive treatments, prevention.

What is Coronary Artery Disease (CAD)?

Coronary artery disease develops when the major blood vessels that supply your heart with blood, oxygen and nutrients (coronary arteries) become damaged or diseased. Cholesterol-containing deposits (plaque) in your arteries and inflammation are usually to blame for coronary artery disease.

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 other coronary artery disease signs and symptoms. A complete blockage can cause a heart attack.

Because coronary artery disease often develops over decades, you might not notice a problem until you have a significant blockage or a heart attack. But there's plenty you can do to prevent and treat coronary artery disease. A healthy lifestyle can make a big impact.

Often, there are no symptoms of the underlying disease of the blood vessels. A heart attack or stroke may be the first warning of underlying disease. Symptoms of a heart attack include:

• pain or discomfort in the centre of the chest;
• pain or discomfort in the arms, the left shoulder, elbows, jaw, or back.

In addition the person may experience difficulty in breathing or shortness of breath; feeling sick or vomiting; feeling light-headed or faint; breaking into a cold sweat; and becoming pale. Women are more likely to have shortness of breath, nausea, vomiting, and back or jaw pain.

People experiencing these symptoms should seek medical care immediately.

Risk Factors for CAD

• high blood pressure
• high blood cholesterol levels
• tobacco smoking
• insulin resistance/hyperglycemia/diabetes mellitus
• obesity
• inactivity
• unhealthy eating habits
• emotional stress

The risk for CAD also increases with age. Based on age alone as a risk factor, men have a greater risk for the disease beginning at age 45 and women have a greater risk beginning at age 55. The risk for coronary artery disease is also higher if you have a family history of the disease.

Sometimes coronary artery disease develops without any classic risk factors. Other causes which can lead to CAD are:

• Sleep apnea. This disorder causes you to repeatedly stop and start breathing while you're sleeping. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system, possibly leading to coronary artery disease.
• High sensitivity C-reactive protein. High sensitivity C-reactive protein (hs-CRP) is a normal protein that appears in higher amounts when there's inflammation somewhere in your body. High hs-CRP levels may be a risk factor for heart disease. It's thought that as coronary arteries narrow, you'll have more hs-CRP in your blood.
• High triglycerides. This is a type of fat (lipid) in your blood. High levels may raise the risk of coronary artery disease, especially for women.
• Homocysteine. Homocysteine is an amino acid your body uses to make protein and to build and maintain tissue. But high levels of homocysteine may increase your risk of coronary artery disease.
• Preeclampsia. This condition that can develop in women during pregnancy causes high blood pressure and a higher amount of protein in urine. It can lead to a higher risk of heart disease later in life.
• Alcohol use. Heavy alcohol use can lead to heart muscle damage. It can also worsen other risk factors of coronary artery disease.
• Autoimmune diseases. Conditions such as rheumatoid arthritis and lupus (and other inflammatory rheumatologic conditions) have an increased risk of atherosclerosis.

The doctor will ask questions about your medical history, do a physical exam and order routine blood tests. He or she may suggest one or more diagnostic tests as well, including:

• Electrocardiogram (ECG). An electrocardiogram records electrical signals as they travel through your heart. An ECG can often reveal evidence of a previous heart attack or one that's in progress.
• In other cases, Holter monitoring may be recommended. With this type of ECG, you wear a portable monitor for 24 hours as you go about your normal activities. Certain abnormalities may indicate inadequate blood flow to your heart.
• Echo-cardiogram. An echo-cardiogram uses sound waves to produce images of your heart. During an echocardiogram, your doctor can determine whether all parts of the heart wall are contributing normally to your heart's pumping activity. Parts that move weakly may have been damaged during a heart attack or be receiving too little oxygen. This may indicate coronary artery disease or various other conditions.
• Stress test. Some stress tests are done using an echo-cardiogram. For example, your doctor may do an ultrasound before and after you exercise on a treadmill or bike.
• Another stress test known as a nuclear stress test helps measure blood flow to your heart muscle at rest and during stress. It's similar to a routine exercise stress test but with images in addition to an ECG. A tracer is injected into your bloodstream, and special cameras can detect areas in your heart that receive less blood flow.
• Cardiac catheterization and angiogram. To view blood flow through your heart, your doctor may inject a special dye into your coronary arteries. This is known as an angiogram.
• Heart scan. Computerized tomography (CT) technologies can help your doctor see calcium deposits in your arteries that can narrow the arteries. If a substantial amount of calcium is discovered, coronary artery disease may be likely.
• A CT coronary angiogram, in which you receive a contrast dye injected intravenously during a CT scan, also can generate images of your heart arteries.

Treatment for coronary artery disease usually involves lifestyle changes and, if necessary, drugs and certain medical procedures.

Lifestyle changes

Making a commitment to the following healthy lifestyle changes can go a long way toward promoting healthier arteries:

• Quit smoking.
• Eat healthy foods.
• Exercise regularly.
• Lose excess weight.
• Reduce stress.

Drugs

Various drugs can be used to treat coronary artery disease, including:

• Calcium channel blockers.
• Beta blockers.
• Aspirin.
• Cholesterol-modifying medications.
• Other drugs, sprays or patches that help people with chest pain, decrease blood pressure and as complementary to beta blockers.

Medical Procedures and Surgery

In the event of severe atherosclerosis, your doctor may recommend one of several procedures or surgeries.

• Coronary artery bypass grafting (CABG) is a type of surgery that uses arteries or veins from other areas in your body to bypass your narrowed coronary arteries. CABG can improve blood flow to your heart, relieve chest pain, and possibly prevent heart attack.
• Angioplasty is a procedure to open blocked or narrowed coronary (heart) arteries. It can improve blood flow, relieve chest pain, and possibly prevent a heart attack.

Research on the influence of diet

A systemic review was done to study the relationship between balanced Mediterranean diet on the phenomenon of “cardiodiabecity”. Here, “Cardio Diabesity” is a combination of obesity, diabetes, and heart disease. (Ref:Garcia-Fernandez E, et al. Mediterranean Diet and Cardiodiabesity: A Review. Nutrients 2014; Vol. 6, pg. 3474-3500.)

This diet pattern included 

• moderate consumption of dairy products (mainly cheese and yogurt); low to moderate amounts of fish, poultry and eggs;”
• the presence of fruit as the main daily dessert and olive oil as the main source of dietary lipids;
• the seasonal choice of fresh and locally grown produce as far as possible;
• high consumption of plant foods (such as fruit, vegetables, legumes, nuts and seeds and cereals, preferably wholegrain)

In this review, 33 of 37 studies demonstrated a significant reduction in the risk of “cardio diabesity”  with adherence to Mediterranean diet pattern. 

Cardio-protective nutrients

Antioxidants

Vitamin E - It is the most powerful antioxidant when it comes to hindering the process of hardening of the arteries.  

Vitamin E is found in the following foods:

• Vegetable oils (such as wheat germ, sunflower, safflower, corn, and soybean oils)
• Nuts (such as almonds, peanuts, and hazelnuts/filberts)
• Seeds (such as sunflower seeds)
• Green leafy vegetables (such as spinach and broccoli)
• Fortified breakfast cereals, fruit juices, margarine, and spreads. Fortified means that vitamins have been added to the food. Check the Nutrition Fact Panel on the food label.

Vitamin C - helps in preserving and protecting the function of the endothelium i.e the thin lining of arteries.  It is also has the ability to regenerate Vitamin E and Intracellular glutathione so they can be used again and again.  Its sources include:

• Fruits and Vegetables like bell pepper, tomatoes, lemon, broccoli, greens, oranges, sweet lime, gooseberry and so on
• It is also available in commercially available juice and cereals which are fortified with Vitamin C

Glutathione - It is the most potent intracellular antioxidant present within every cell.  Patients with known CAD have low levels of glutathione within their cells.  Nutrients like selenium, Vitamin B2, niacin and N-acetyl-l-cysteine are used to generate glutathione.

Bioflavanoids - These extremely potent antioxidants have anti allergen and anti-inflammatory properties thereby preventing the CAD.  The more varied the color of the fruits and vegetables, the greater variety of bioflavonoids is present.

Folic acid, Vitamin B6 and Vitamin B12 - are the important components that help to break down homocysteine levels thereby protecting against heart disease.  They also help to generate glutathione.

These nutrients are present in colourful fruits and vegetables, whole grains, nuts and seeds. In severe cases, nutritional supplements can be recommended by the doctor if the needs are not met with diet alone.

A study was done to examine the feasibility and effectiveness of comprehensive ayurvedic therapy-incorporating diet, meditation, breathing exercises, yoga, and herbs-for patients with established coronary heart disease.  The study's results suggest a favourable effect for ayurveda on arterial function and multiple risk factors in patients with established coronary heart disease.

Ayurveda promotes a healthy diet, good quality sleep, preventive medication, meditation and deep breathing techniques or yoga to prevent or manage coronary artery disease.

1. Avoid sleeping immediately after meals and eating the right food at the right time in limited quantities.
2. Drinking 1 cup warm water with Ajwain at night , avoiding late night dinners, heavy to digest dinners
3. Engaging in hobbies to enhance mental health
4. Panchakarma like Vaman, virechana help in detoxification. It reduces the presence of free radicals in the body, improves fat metabolism and also destresses the body.
5. Medicinal herbs like Arjun, Giloy, Ashwagandha, amalaki, kanchnar guggulu , Tapyadi Loha can be taken on a regular basis with doctors advice.
6. Pranayama daily for 30 minutes including anuloma viloma
7. Diet rich in vegetables, fruits, diet devoid of non - veg especially egg yolk, red meat.
8. If a person has a strong family history or any precursors one must do serum homocysteine and troponin t test
9. Diet, proper sleep, preventive medication and deep breathing techniques / yoga help in the management of coronary artery disease.