Dr. Amar Nath Ghosh

Coronary Artery Disease:

Coronary artery disease, also called coronary heart disease, or simply, heart disease, is the No. 1 killer in America, affecting more than 13 million Americans.

Heart disease is a result of plaque buildup in your arteries, which blocks blood flow and heightens the risk for heart attack and stroke.

What Is Coronary Artery Disease?

Heart disease is a result of plaque buildup in your coronary arteries -- a condition called atherosclerosis -- that leads to blockages. The arteries, which start out smooth and elastic, become narrow and rigid, restricting blood flow to the heart. The heart becomes starved of oxygen and the vital nutrients it needs to pump properly.

How Does Coronary Artery Disease Develop?

From a young age, cholesterol-laden plaque can start to deposit in the blood vessel walls. As you get older, the plaque burden builds up, inflaming the blood vessel walls and raising the risk of blood clots and heart attack. The plaques release chemicals that promote the process of healing but make the inner walls of the blood vessel sticky. Then, other substances, such as inflammatory cells, lipoproteins, and calcium that travel in your bloodstream start sticking to the inside of the vessel walls.

Eventually, a narrowed coronary artery may develop new blood vessels that go around the blockage to get blood to the heart. However, during times of increased exertion or stress, the new arteries may not be able to supply enough oxygen-rich blood to the heart muscle.

In some cases, a blood clot may totally block the blood supply to the heart muscle, causing heart attack. If a blood vessel to the brain is blocked, usually from a blood clot, an ischemic stroke can result. If a blood vessel within the brain bursts, most likely as a result of uncontrolled hypertension (high blood pressure), a hemorrhagic stroke can result.

What Is Ischemia?

Cardiac ischemia occurs when plaque and fatty matter narrow the inside of an artery to a point where it cannot supply enough oxygen-rich blood to meet your heart's needs. Heart attack can occur - with or without chest pain and other symptoms.

Ischemia is most commonly experienced during:

Exercise or exertion
Eating
Excitement or stress
Exposure to cold

Coronary artery disease can progress to a point where ischemia occurs even at rest. And ichemia can occur without any warning signs in anyone with heart disease, although it is more common in people with diabetes.

What Are the Symptoms of Coronary Artery Disease?

The most common symptom of coronary artery disease is angina, or chest pain. Angina can be described as a heaviness, pressure, aching, burning, numbness, fullness, squeezing or painful feeling. It can be mistaken for indigestion or heartburn. Angina is usually felt in the chest, but may also be felt in the left shoulder, arms, neck, back, or jaw.

Other symptoms that can occur with coronary artery disease include:

Shortness of breath
Palpitations (irregular heart beats, skipped beats, or a "flip-flop" feeling in your chest)
A faster heartbeat
Weakness or dizziness
Nausea
Sweating

How Is Coronary Artery Disease Diagnosed?

Your doctor can tell if you have coronary artery disease by:

Talking to you about your symptoms, medical history, and risk factors.
Performing a physical exam.
Performing diagnostic tests, including an electrocardiogram (ECG or EKG), exercisestress tests, electron beam (ultrafast) CT scans, cardiac catheterization, and others. These tests help your doctor evaluate the extent of your coronary heart disease, its effect on the function of your heart and the best form of treatment for you.

How Is Coronary Artery Disease Treated?

Treatment for coronary artery disease involves making lifestyle changes, taking medications, possibly undergoing invasive and/or surgical procedures, and seeing your cardiologist for regular checkups.

Reduce your risk factors. If you smoke, quit. Avoid high-cholesterol foods and adopt a low-fat, low-salt diet. Keep your blood sugar in control if you have diabetes. Exercise more to maintain a healthy weight (but talk to your doctor before you starting an exercise program).

Medications. If making lifestyle changes isn't enough to control your heart disease, medications may be needed to help your heart work more efficiently and receive more oxygen-rich blood. The drugs you are on depend on you and your specific heart problem.

Surgery and other procedures. Common procedures to treat coronary artery disease include balloon angioplasty (PTCA), stent placement, and coronary artery bypass surgery. All of these procedures increase blood supply to your heart, but they do not cure coronary heart disease. You will still need to decrease your risk factors to prevent future disease.

Doctors are also studying several innovative ways to treat heart disease. Here are a couple of the more promising ones:

Angiogenesis. This involves giving substances, such as stem cells and other genetic material, through the vein or directly into damaged heart tissue to trigger the growth of new blood vessels to bypass the clogged ones.

EECP (Enhanced External Counterpulsation). Patients who have chronic angina but are not helped by nitrate medications or who do not qualify for various surgeries and procedures may find relief with EECP. The outpatient procedure involves using treatment cuffs placed on the legs that inflate and deflate, increasing the blood supply that feeds coronary arteries.

What to Do If You Have a Coronary Emergency?

Learn to recognize your heart disease symptoms and the situations that cause them. Call your doctor if you begin to have new symptoms or if they become more frequent or severe. If you or someone you are with experiences chest discomfort, especially if there is shortness of breath, heart palpitations, dizziness, a fast heart beat, nausea or sweating, don't wait longer than a few minutes to call 911 for help.

If you have angina and have been prescribed nitroglycerin, call your doctor or have someone take you to the nearest emergency room if pain persists after taking two doses (taken at five-minute intervals) or after 15 minutes.

Emergency personnel may tell you to chew an aspirin to help break up a possible blood clot, if there is not a medical reason for you to avoid aspirin.

Coronary Artery Bypass Surgery:

When your coronary arteries are blocked, your doctor may treat the problem by giving the blood a new pathway to the heart muscle.

During coronary artery bypass graft surgery (also called CABG) a blood vessel is removed or redirected from one area of the body and placed around the area or areas of narrowing to "bypass" the blockages and restore blood flow to the heart muscle. This vessel is called a graft.

These substitute blood vessels can come from your chest, legs, or arms. They're safe to use because there are other pathways that take blood to and from those tissues. The surgeon will decide which graft(s) to use depending on the location of your blockage, the amount of blockage, and the size of your coronary arteries.
Heart bypass surgery is among the most common operations performed in the U.S., with more than 500,000 performed each year.

Which Arteries Are Used for Coronary Grafts?
There are several types of heart bypass grafts. The surgeon decides which graft(s) to use, based on the location of the blockage, the amount of blockage, and the size of the patient's coronary arteries.

Internal mammary arteries: These are the most common bypass grafts used, as they have been shown to have the best long-term results. In most cases, these arteries can be kept intact at their origin since they have their own oxygen-rich blood supply. During the procedure, the arteries are sewn to the coronary artery below the site of blockage. This artery is located in the chest and can be accessed through the primary incision for the heart bypass surgery.

Saphenous veins: These veins are removed from your leg, and then sewn from your aorta to the coronary artery below the site of blockage. Minimally invasive saphenous vein removal may be performed and results in less scarring and a faster recovery.

Radial artery: There are two arteries in the lower part of the arm, the ulnar and radial arteries. Most people receive adequate blood flow to their arm from the ulnar artery alone and will not have any side effects if the radial artery is removed and used as a graft. Careful preoperative and intraoperative tests determine if the radial artery can be used. If you have certain conditions (such as Raynaud's, carpal tunnel syndrome, or painful fingers in cold air) you may not be a candidate for this type of bypass graft. The radial artery incision is in your forearm, about 2 inches from your elbow and ending about 1 inch from your wrist. If you have this type of bypass, you will probably be prescribed a medication called a calcium channel blocker for about six months after surgery to help keep the radial artery open. Some people report numbness in the wrist after surgery. However, long-term sensory loss or numbness is uncommon.

The gastroepiploic artery to the stomach and the inferior epigastric artery to the abdominal wall are less commonly used for grafting.

It is common for three or four coronary arteries to be bypassed during surgery. A coronary artery bypass can be performed with traditional surgery (see below) or with minimally invasive surgery (see below). Your surgeon will review your diagnostic tests prior to your surgery to see if you are a candidate for minimally invasive bypass surgery.

How Is Traditional Heart Bypass Surgery Performed?
During traditional heart bypass surgery, a surgeon makes an incision (about 6 to 8 inches) down the center of your sternum (breastbone) to get direct access to your heart. You are connected to a heart-lung bypass machine (called "on-pump" surgery), which allows for circulation of blood throughout your body during surgery. The heart is stopped and the surgeon then performs the bypass procedure described above.

After surgery, the surgeon closes the breastbone with special sternal wires and the chest with special internal or traditional external stitches.

What Is Off-Pump Heart Bypass Surgery?

"Off-pump" or beating heart bypass surgery allows surgeons to perform surgery while the heart is still beating. The heart-lung machine is not used. The surgeon uses advanced operating equipment to stabilize (hold) portions of the heart and bypass the blocked artery. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body.

With present technology, all coronary arteries can be bypassed off-pump. The off-pump technique may be ideal for certain patients who have an increased risk of complications from being placed on the heart-lung machine, such as those who have vascular disease, heavy plaque buildup in the aorta (aortic calcification), carotid artery stenosis (narrowing or blockage in the arteries leading to the brain), prior stroke or transient ischemic attacks (TIAs), or breathing or kidney function problems.

Not all patients are candidates for off-pump surgery. According to the American Heart Association, about 20% of heart bypass surgeries are performed off-pump. The decision to use off-pump surgery is made at the time of surgery when the patient's heart and arteries can be evaluated more closely.

What Is Minimally Invasive Heart Bypass Surgery?

During minimally invasive heart bypass surgery, the surgeon performs the surgery through a small incision (about 3 inches) in the chest. It may be an option for some patients who require a left internal mammary artery graft to the left anterior descending artery.

Some patients are also candidates for surgery using robotic-assisted techniques, allowing surgeons to perform bypass surgery in a closed chest, beating-heart environment through even smaller keyhole incisions.

The benefits of minimally invasive bypass surgery include:

A smaller incision, thus a smaller scar.
A shorter hospital stay. In some cases, only three days are needed (instead of the average five to six days for traditional surgery).
Shorter recovery time.

Other benefits may include:

Less bleeding.
Less potential for infection.
Less pain and trauma.
Talk to your doctor to see if minimally invasive bypass surgery is right for you.