Introduction to heart disease

The heart is like any other muscle, requiring blood to supply oxygen and nutrients for it
to function. The heart's needs are provided by the coronary arteries, which begin at the
base of the aorta and spread across the surface of the heart, branching out to all areas of
the heart muscle.

The coronary arteries are at risk for narrowing as cholesterol deposits, called plaques,
build up inside the artery. If the arteries narrow enough, blood supply to the heart muscle
may be compromised (slowed down), and this slowing of blood flow to the heart causes
pain, or angina.

A heart attack or myocardial infarction occurs when a plaque ruptures, allowing a blood
clot to form. This completely obstructs the artery, stopping blood flow to part of the heart
muscle, and that portion of muscle dies.

What are the risk factors for heart disease

Risk factors for heart disease include:

* Smoking

* High blood pressure (hypertension)

* High cholesterol

* Diabetes

* Family history

* Peripheral artery disease

* Obesity

What are the symptoms of heart disease?

The typical symptoms of coronary artery disease are associated chest pain with shortness
of breath. Classically, the pain of angina is described as a pressure or heaviness behind
the breast bone with radiation to the jaw and down the arm accompanied by shortness of
breath and sweating. Unfortunately, angina has a variety of presentations, and there may
not even be specific chest pain. There may be shoulder or back ache, nausea, indigestion
or upper abdominal pain.

Women, the elderly, and people with diabetes may have different perceptions of pain or
have no discomfort at all. Instead, they may complain of malaise or fatigue.
Healthcare providers and patients may have difficulty understanding each other when
symptoms of angina are described. Patients may experience pressure or tightness but may
deny any complaints of pain.

People with coronary artery disease usually have gradual progression of their symptoms
over time. As an artery narrows over time, the symptoms that it causes may increase in
frequency and/or severity. Healthcare providers may inquire about changes in exercise
tolerance (How far can you walk before getting symptoms? Is it to the mailbox? Up a
flight of stairs?) and whether there has been an acute change in the symptoms.

Once again, patients may be asymptomatic until a heart attack occurs. Of course, some
patients also may be in denial as to their symptoms and procrastinate in seeking care.

How is heart disease diagnosed?

The diagnosis of heart disease begins with obtaining a history that the potential for
coronary artery disease exists. Risk factors need to be assessed, and then testing may be
required to confirm the presence of heart disease.

Heart disease tests

Not every patient with chest pain needs heart catheterization (the most invasive test).
Instead, the healthcare provider will try to choose the testing modality that will best
provide the diagnosis, and if coronary artery disease is present, decide what impairment,
if any, is present.

Electrocardiogram (ECG or EKG)

The heart is an electrical pump, and the electrical impulses it generates can be detected on
the surface of the skin. Normal muscle conducts electricity in a reproducible fashion.
Muscle that has decreased blood supply conducts electricity poorly. Muscle that has lost
its blood supply and has been replaced with scar tissue cannot conduct electricity. The
electrocardiogram (EKG) is a noninvasive test used to reflect underlying heart conditions
by measuring the electrical activity of the heart.

Some people have "abnormal" EKGs at baseline but this may be normal for them. It is
important that an electrocardiogram be compared to previous tracings. If a patient has a
baseline abnormal EKG, they should carry a copy with them for reference if they ever
need another EKG.

Stress testing

If the baseline EKG is relatively normal, then monitoring the EKG tracing while the
patient exercises may uncover electrical changes that may indicate the presence of
coronary artery disease. There are a variety of testing protocols used to determine
whether the exercise intensity is high enough to prove that the heart is normal.
Some patients are unable to exercise on a treadmill test, but they can still undergo cardiac
stress testing by using intravenous medication that causes the heart to work harder.

Stress testing is done under the supervision of medical personnel because of the potential
of provoking angina, shortness of breath, abnormal heart rhythms, and heart attack.

Echocardiography

Used with or without exercise, echocardiography can assess how the heart works. Using
sound waves to generate an image, a cardiologist can evaluate many aspects of the heart.
Echocardiograms can examine the structure of the heart including the thickness of the
heart muscle, the septum (the tissues that separate the four heart chambers from each
other) and the pericardial sac (the outside lining of the heart).

The test can indirectly assess blood flow to parts of the heart muscle. If there is decreased
blood flow, then segments of the heart wall may not beat as strongly as adjacent heart
muscle. These wall motion abnormalities signal the potential for coronary artery disease.

The echocardiogram can also assess the efficiency of the heart by measuring ejection
fraction. Normally when the heart beats, it pushes more than 60% of the blood in the
ventricle out to the body. Many diseases of the heart, including coronary artery disease,
can decrease this percentage (the ejection fraction).

Perfusion studies

Radioactive chemicals like thallium or technetium can be injected into a vein and their
uptake measured in heart muscle cells. Abnormally decreased uptake can signify
decreased blood flow to parts of the heart because of coronary artery narrowing. This test
may be used when the patient's baseline EKG is not normal and is less reliable when used
to monitor a stress test.

Computerized tomography

The latest generation of CT scanners can take detailed images of blood vessels and may
be used as an adjunct to determine whether coronary artery disease is present. In some
institutions, the heart CT is used as a negative predictor. That means that the test is done
to prove that the coronary arteries are normal rather than to prove that the disease is
present.