Coronary Heart Disease

Plaque buildup in the arteries is called atherosclerosis. When this buildup happens in the heart's arteries over many years, the arteries become narrower and harden, reducing oxygen-rich blood flow to the heart. The result is coronary artery disease.

Obstructive coronary artery disease means the heart’s arteries are more than 50% blocked. The blood flow may eventually be completely blocked in one or more of the three large coronary arteries. In nonobstructive coronary artery disease, the large arteries may be narrowed by plaque, but not as much as they are in obstructive disease.

Small plaques can also develop in the small blood vessels in the heart, causing coronary microvascular disease.

Problems with how the heart’s blood vessels work can cause coronary heart disease. For example, the blood vessels may not respond to signals that the heart needs more oxygen-rich blood. Normally, the blood vessels widen to allow more blood flow when a person is physically active or under stress. But if you have coronary heart disease, the size of these blood vessels may not change, or the blood vessels may even narrow.

The cause of these problems is not fully clear. But it may involve:

• Damage or injury to the walls of the arteries or tiny blood vessels from chronic inflammation, high blood pressure, or diabetes.
• Molecular changes that are part of the normal aging process. Molecular changes affect the way genes and proteins are controlled inside cells.

In nonobstructive coronary artery disease, damage to the inner walls of the coronary arteries can cause them to spasm (suddenly tighten). This is called vasospasm. The spasm causes the arteries to narrow temporarily and blocks blood flow to the heart.

These problems can also happen in the tiny blood vessels in the heart, causing coronary microvascular disease (sometimes called coronary syndrome X). Coronary microvascular disease can happen with or without obstructive or nonobstructive coronary artery disease.

Learn more about the important role that inflammation, which is the body’s reaction to an injury, plays in the development of coronary heart disease.

Genetic or lifestyle factors cause plaque to build up in your arteries as you age. In men, the risk for coronary heart disease starts to increase around age 45. Before menopause, women have a lower risk of coronary heart disease than men. After around age 55, women’s risk goes up. This is likely because women make less estrogen (a female hormone) after menopause. Also, changes in the small blood vessels of the heart as you age raise the risk for coronary microvascular disease.

Air pollution in the environment can put you at higher risk of coronary heart disease. The increase in risk may be higher in older adults, women, and people who have diabetes or obesity. Air pollution may cause or worsen other conditions, such as atherosclerosis and high blood pressure, which are known to increase your risk for coronary heart disease.

Your work life can also raise your risk if you:

• Come into contact with toxins, radiation, or other hazards
• Have a lot of stress at work
• Sit for long periods
• Work more than 55 hours a week, or work long, irregular, or night shifts that affect your sleep

A family history of early heart disease is a risk factor for coronary heart disease. This is especially true if your father or brother was diagnosed before age 55, or if your mother or sister was diagnosed before age 65. Research shows that some genes are linked with a higher risk for coronary heart disease.

Over time, unhealthy lifestyle habits increase your risk of coronary heart disease because they can lead to plaque buildup in the heart’s blood vessels. Unhealthy lifestyle habits that are risk factors include the following:

• Being physically inactive, which can worsen other heart disease risk factors, such as high blood cholesterol and triglyceride levels, high blood pressure, diabetes and prediabetes, and overweight and obesity.
• Not getting enough good quality sleep, including waking up often throughout the night, which may raise your risk of coronary heart disease. While you sleep, your blood pressure and heart rate fall. Your heart does not work as hard as it does when you are awake. As you begin to wake up, your blood pressure and heart rate increase to the usual levels when you are awake and relaxed. Waking up suddenly can cause a sharp increase in blood pressure and heart rate, which has been linked to angina and heart attacks. Learn more in our How Sleep Works topic.
• Smoking tobacco or long-term exposure to secondhand smoke, which can damage the blood vessels.
• Stress, which can trigger the tightening of your arteries, which increases your risk of coronary heart disease, especially coronary microvascular disease. Stress may also indirectly raise your risk of coronary heart disease if it makes you more likely to smoke or overeat foods high in fat and added sugars.
• Unhealthy eating patterns, such as consuming high amounts of saturated fats or trans fats and refined carbohydrates (white bread, pasta, and white rice). This can lead to overweight and obesity, high blood cholesterol, atherosclerosis, and plaque buildup in the heart’s arteries.

Learn about steps you can take to improve your heart health in our Heart-Healthy Living topic.

Other medical conditions that can raise your risk of developing coronary heart disease include:

• Atherosclerosis
• Autoimmune and inflammatory diseases such as Crohns disease, ulcerative colitis, psoriasis, lichen planus, pemphigus, histiocytosis, lupus erythematosus, and rheumatoid arthritis
• Chronic kidney disease
• Congenital coronary artery defects
• Diabetes
• High blood LDL cholesterol (sometimes called “bad cholesterol”)
• High blood pressure
• High blood triglycerides
• HIV/AIDS, especially among older adults. Part of the risk might be due to side effects of HIV treatments.
• Mental health conditions, including anxiety, depression, and posttraumatic stress disorder (PTSD)
• Metabolic syndrome
• Overweight and obesity
• Sleep disorders, such as sleep apnea or sleep deprivation and deficiency

Coronary heart disease is the leading cause of death for people of most racial and ethnic groups in the United States, including African Americans, Hispanics, and whites.

For Asian Americans or Pacific Islanders and American Indians or Alaska Natives, heart disease is second only to cancer. People of South Asian ancestry are at higher risk of developing coronary heart disease and serious complications than other Asian Americans.

Coronary heart disease affects men and women. Obstructive coronary artery disease is more common in men. However, nonobstructive coronary artery disease is more common in women. Since the nonobstructive type is harder to diagnose, women may not be diagnosed and treated as quickly as men.

If you are a woman having chest discomfort or shortness of breath during physical activity, ask your doctor about tests to check for nonobstructive coronary artery disease or coronary microvascular disease.

Women may have a higher than normal risk for developing coronary heart disease if they have one of the following conditions.

• Endometriosis, which raises the risk for heart disease in younger women
• Gestational diabetes, which can raise the risk for diabetes and metabolic syndrome even after pregnancy and the risk of developing coronary heart disease
• Polycystic ovary syndrome
• Preeclampsia, a condition that can happen during pregnancy and is linked to an increased lifetime risk for coronary heart disease
• Early menopause (before age 40)

To screen for coronary heart disease, your doctor will:

• Assess risk factors to help evaluate your risk of developing coronary heart disease
• Check blood pressure readings to see whether you have high blood pressure
• Calculate your body mass index and waist circumference to see whether you have an unhealthy weight
• Order blood tests to see whether you have high blood cholesterol, high blood triglycerides, or diabetes

Screening usually occurs in a doctor's office, but sometimes screenings are done at health fairs, drugstores, or other places. Blood samples might be collected at your doctor's office, a hospital, or a laboratory.

Ask your doctor or nurse whether you need to fast (not eat or drink anything besides water) before the blood tests.

Your doctor may use a risk calculator to estimate your risk of having a heart attack, having a stroke, or dying from a heart or blood vessel disease in the next 10 years or throughout your lifetime.

For example, the Atherosclerotic Cardiovascular Disease (ASCVD) Estimator considers your cholesterol levels, age, sex, race, and blood pressure. It also factors in whether you smoke or take medicines to manage your high blood pressure or cholesterol.

Ask about your risk during your annual check-up. Knowing your risk will help you and your doctor decide on healthy lifestyle changes and possibly medicines to lower your risk.

Risk assessments should be repeated every 4 to 6 years in adults 20 to 79 years of age who do not have heart or blood vessel disease.

No single risk calculator is appropriate for all people. Calculators can give you and your doctor a good idea about your risk, but your doctor might have to consider other factors to estimate your risk more accurately.

Studies show that heart-healthy living—never smoking, eating healthy, and being physically active—throughout life can prevent coronary heart disease and its complications.

Work with your doctor to set up a plan that works for you based on your lifestyle, your home and neighborhood environments, and your culture. Working with a team of healthcare providers may help with making changes in your diet, being physically active, managing other medical conditions, and helping you quit smoking.

An acute coronary event, such as a heart attack, may cause the following symptoms:

• Angina, which can feel like pressure, squeezing, burning, or tightness during physical activity. The pain or discomfort usually starts behind the breastbone, but it can also occur in the arms, shoulders, jaw, throat, or back. The pain may feel like indigestion.
• Cold sweats
• Dizziness
• Light-headedness
• Nausea or a feeling of indigestion
• Neck pain
• Shortness of breath, especially with activity
• Sleep disturbances
• Weakness

Women are somewhat less likely than men to experience chest pain. Instead, they are more likely to experience:

• Dizziness
• Fatigue
• Nausea
• Pressure or tightness in the chest
• Stomach pain

Women are also more likely than men to have no symptoms of coronary heart disease.

Chronic (long-term) coronary heart disease can cause symptoms such as the following:

• Angina
• Shortness of breath with physical activity
• Fatigue
• Neck pain

The symptoms may get worse as the buildup of plaque continues to narrow the coronary arteries. Chest pain or discomfort that does not go away or happens more often or while you are resting might be a sign of a heart attack. If you do not know whether your chest pain is angina or a heart attack, call 9-1-1 right away. All chest pain should be checked by a doctor.

Coronary heart disease can cause serious complications, including the following:

• Acute coronary syndrome, including angina or heart attack
• Arrhythmia
• Heart failure
• Cardiogenic shock
• Sudden cardiac arrest

Complications of coronary heart disease can be life-threatening and may lead to disability.

Your doctor will ask about your eating and physical activity habits, your medical history, your family history, and risk factors for coronary heart disease. Your doctor may ask whether you have any other signs or symptoms. This information can help your doctor determine whether you have complications or other conditions that may cause coronary heart disease.

To diagnose coronary heart disease, your doctor may order some of the following tests.

• Blood tests to check the levels of cholesterol, triglycerides, sugar, lipoproteins, or proteins, such as C-reactive protein, that are a sign of inflammation.
• Electrocardiogram (EKG or ECG) to determine whether the heart’s rhythm is steady or irregular. An EKG also records the strength and timing of electrical signals as they pass through the heart.
• Coronary calcium scan to measure the amount of calcium in the walls of your coronary arteries. Buildup of calcium can be a sign of atherosclerosis, coronary artery disease, or coronary microvascular disease. This test is a type of cardiac CT scan. Coronary calcium scans can also help assess coronary heart disease risk for people who smoke or for people who do not have heart symptoms.
• Stress tests to check how your heart works during physical stress. During stress testing, you walk or run on a treadmill or pedal a stationary bike to make your heart work hard and beat fast. If you have a medical problem that prevents you from exercising, your doctor may give you medicine to make your heart work hard, as it would during exercise. To detect reduced blood flow to your heart muscle, while you exercise you will be monitored by ECG and possibly echocardiogram or a CT scan.
• Cardiac MRI (magnetic resonance imaging) to detect tissue damage or problems with blood flow in the heart or coronary arteries. It can help your doctor diagnose coronary microvascular disease or nonobstructive or obstructive coronary artery disease. Cardiac MRI can help explain results from other imaging tests such as chest X-rays and CT scans.
• Cardiac positron emission tomography (PET) scanning to assess blood flow through the small coronary blood vessels and into the heart tissues. This is a type of nuclear heart scan that can diagnose coronary microvascular disease.
• Coronary angiography to show the insides of your coronary arteries. To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization. This procedure is often used if other tests show that you are likely to have coronary artery disease. To diagnose coronary microvascular disease, your doctor will use coronary angiography with guidewire technology. A guidewire with sensors is inserted into the heart’s arteries. The sensors measure how easily blood flows through the small vessels. Usually, measurements are done before and after giving you medicine to enhance blood flow in your heart.
• Coronary computed tomographic angiography to show the insides of your coronary arteries rather than an invasive cardiac catheterization. It is a noninvasive imaging test using CT scanning.

If you have coronary heart disease risk factors, your doctor may recommend diagnostic tests even if you do not have symptoms.

Nonobstructive coronary artery disease and coronary microvascular disease can be missed because patients or doctors may not recognize the warning signs. Diagnosing these types often requires more invasive tests or specialized tests, such as cardiac PET scans, that are not widely available.

Your doctor may recommend that you adopt lifelong heart-healthy lifestyle changes, including:

• Aiming for a healthy weight. Losing just 3% to 5% of your current weight can help you manage some coronary heart disease risk factors, such as high blood cholesterol and diabetes. Greater amounts of weight loss can also improve blood pressure readings.
• Being physically active. Routine physical activity can help manage coronary heart disease risk factors such as high blood cholesterol, high blood pressure, or overweight and obesity. Before starting any exercise program, ask your doctor what level of physical activity is right for you.
• Heart-healthy eating, such as the DASH (Dietary Approaches to Stop Hypertension) eating plan. A heart-healthy eating plan includes fruits, vegetables, and whole grains and limits saturated fats, trans fats, sodium (salt), added sugars, and alcohol.
• Managing stress. Learning how to manage stress, relax, and cope with problems can improve your emotional and physical health.
• Quitting smoking. Visit Smoking and Your Heart and the National Heart, Lung, and Blood Institute's Your Guide to a Healthy Heart. Although these resources focus on heart health, they include basic information about how to quit smoking. For free help and support to quit smoking, you can call the National Cancer Institute's Smoking Quitline at 1-877-44U-QUIT (1-877-448-7848). Talk to your doctor if you vape. There is scientific evidence that nicotine and flavorings found in vaping products may damage your heart and lungs.
• Get enough good-quality sleep. The recommended amount for adults is 7 to 9 hours of sleep a day.

Learn more about heart-healthy living.

Your doctor may recommend medicines to manage your risk factors or treat underlying causes of coronary heart disease. Some medicines can reduce or prevent chest pain and manage other medical conditions that may be contributing to your coronary heart disease.

• ACE inhibitors and beta blockers to help lower blood pressure and decrease the heart's workload.
• Calcium channel blockers to lower blood pressure by allowing blood vessels to relax.
• Medicines to control blood sugar, such as empagliflozin, canagliflozin, and liraglutide, to help lower your risk for complications if you have coronary heart disease and diabetes.
• Metformin to control plaque buildup if you have diabetes.
• Nitrates, such as nitroglycerin, to dilate your coronary arteries and relieve or prevent chest pain from angina.
• Ranolazine to treat coronary microvascular disease and the chest pain it may cause.
• Statins and/or non-statin therapies to control high blood cholesterol. Your doctor may recommend statin therapy if you have a higher risk for coronary heart disease or stroke or if you have diabetes and are between ages 40 and 75. Non-statin therapies may be used to reduce cholesterol when statins do not lower cholesterol enough or cause side effects. Your doctor may prescribe non-statin drugs, such as, ezetimibe, bile acid sequestrants, alirocumab, or evolocumab to lower cholesterol or omega-3 fatty acids, gemfibrozil, or fenofibrate to reduce triglycerides.

You may need a procedure or heart surgery to treat more advanced coronary heart disease.

• Percutaneous coronary intervention (PCI) to open coronary arteries that are narrowed or blocked by the buildup of atherosclerotic plaque. A small mesh tube called a stent is usually implanted after PCI to prevent the artery from narrowing again.
• Coronary artery bypass grafting (CABG) to improve blood flow to the heart by using normal arteries from the chest wall and veins from the legs to bypass the blocked arteries. Surgeons typically use CABG to treat people who have severe obstructive coronary artery disease in multiple coronary arteries.
• Transmyocardial laser revascularization or coronary endarterectomy to treat severe angina associated with coronary heart disease when other treatments are too risky or did not work.

It is important to get routine medical care and to take all medicines regularly, as your doctor prescribes. Do not change the amount of your medicine or skip a dose unless your doctor tells you to. Talk with your doctor about how often you should schedule office visits and blood tests.

Between visits, call your doctor if you have any new symptoms, if your symptoms worsen, or if you have problems with your blood pressure or blood sugar.

Return to Treatment to review possible treatment options for coronary heart disease.

You may be referred for exercise-based cardiac rehabilitation, also called cardiac rehab, to manage symptoms and reduce the chances of future problems such as heart attack. Studies have shown that cardiac rehabilitation lowers the risk of hospitalization and death. It can also improve your quality of life.

Your doctor will work with you to manage medical conditions that can raise your risk of heart problems and complications.

Your doctor will likely suggest heart-healthy lifestyle changes, such as eating heart-healthy foods, being physically active, and quitting smoking. Your doctor may refer you to other professionals, such as a registered dietitian or exercise physiologist. Your healthcare team can help you set up a personal plan to meet your health goals.

There are benefits to quitting smoking no matter how long or how much you have smoked. Coronary heart disease risk associated with smoking begins to decrease soon after you quit, and it generally continues to decrease over time. In addition:

• You will likely be given a statin to lower your LDL cholesterol, especially after a heart attack.
• Your doctor may recommend aspirin to prevent a heart attack or stroke. Low-dose aspirin may help prevent blood clots and lower the risk for heart attacks and other complications of coronary heart disease for some people, particularly those with microvascular disease or who have diabetes. Talk to your doctor before taking aspirin, because it raises the risk of serious bleeding.
• If you have diabetes, you will need to check your blood sugar regularly and keep taking any prescribed medicines.
• If your coronary heart disease becomes unstable or has led to a heart attack or sudden cardiac arrest, your doctor may recommend a pacemaker or defibrillator to detect and treat certain types of serious arrhythmias.

Living with heart disease may cause fear, anxiety, depression, and stress. You may worry about having heart problems or making lifestyle changes that are necessary for your health. Talk with your healthcare team about how you feel. Your doctor may talk to you about:

• Talking to a professional counselor. If you have depression or anxiety, your doctor also may recommend medicines or other treatments that can improve your quality of life.
• Joining a patient support group. This may help you adjust to living with heart disease. You can find out how other people manage similar symptoms. Your doctor may be able to recommend local support groups, or you can check with an area medical center.
• Seeking support from family and friends. Letting your loved ones know how you feel and what they can do to help you can help relieve stress and anxiety.

Coronary heart disease can lead to heart attack or stroke. If you think that you are or someone else is having the following symptoms, call 9-1-1 right away. Every minute matters.

Heart attack

The signs and symptoms of a heart attack include:

• Prolonged or severe chest pain or discomfort not relieved by rest or nitroglycerin. This involves uncomfortable pressure, squeezing, fullness, or pain in the center or left side of the chest that can be mild or strong. This pain or discomfort often lasts more than a few minutes or goes away and comes back.
• Nausea, vomiting, light-headedness or fainting, or breaking out in a cold sweat. These symptoms of a heart attack are more common in women.
• Shortness of breath. This may accompany chest discomfort or happen before it.
• Upper body discomfort. This can be felt in one or both arms, the back, neck, jaw, or upper part of the stomach.

Coronary heart disease is different for women than men because of hormonal and anatomical differences.

• Hormonal changes affect a woman’s risk for coronary heart disease. Before menopause, the hormone estrogen provides women with some protection against coronary artery disease. Estrogen raises levels of HDL cholesterol (sometimes called “good” cholesterol) and helps keep the arteries flexible so they can widen to deliver more oxygen to the tissues of the heart in response to chemical and electrical signals. After menopause, estrogen levels drop, increasing a woman’s risk for coronary heart disease.
• The size and structure of the heart is different for women and men. A woman’s heart and blood vessels are smaller, and the muscular walls of women’s hearts are thinner.
• Women are more likely to have nonobstructive coronary heart disease or coronary microvascular disease. These types are harder to diagnose than obstructive coronary artery disease, which can be harder to diagnose. This can cause delays in getting diagnosed and treated.

Women are more likely than men to have medical conditions or life issues that raise their risk for coronary heart disease.

• Anemia, especially during pregnancy
• Early menopause (before age 40)
• Endometriosis
• High blood pressure after age 65
• History of problems during pregnancy, including gestational diabetes, preeclampsia, eclampsia (high blood pressure during pregnancy), and giving birth to a baby who is premature or smaller than average.
• Hormonal birth control
• Inflammatory and autoimmune diseases
• Lack of physical activity
• Mental health issues, such as stress, marital stress, anxiety, depression, or low social support
• Metabolic syndrome, a group of risk factors that raises your risk of heart disease and other health problems
• Overweight and obesity

Some factors raise women’s risk for coronary heart disease more than they increase risk in men.

• Diabetes
• Low levels of HDL cholesterol
• Mild to moderate high blood pressure
• Smoking

Visit The Heart Truth® to learn more about coronary heart disease risk factors for women and how to lower them.

Although men and women can experience the same symptoms of coronary heart disease, women often experience no symptoms or have different symptoms than men do.

• Activity that brings on chest pain. In men, angina tends to worsen with physical activity and go away with rest. Women are more likely than men to have angina while they are resting. In women who have coronary microvascular disease, angina often happens during routine daily activities, such as shopping or cooking, rather than during exercise. Microvascular angina events may last longer and be more painful than other types of angina.
• Location and type of pain. Pain symptoms are different for each person. Women having angina or a heart attack often describe their chest pain as crushing, or they say it feels like pressure, squeezing, or tightness. Women may have pain in the chest or the neck and throat.
• Mental stress. Mental stress is more likely to trigger angina pain in women than in men.
• Other symptoms. Common signs and symptoms for women include nausea, vomiting, shortness of breath, abdominal pain, sleep problems, fatigue, and lack of energy.

Tests and procedures for diagnosing coronary heart disease are very similar for women and men. But women may experience delays in diagnosis or treatment. Learn about important diagnostic tests and treatment options.

• Ask about important diagnostic tests. Doctors are less likely to refer women for diagnostic tests for coronary heart disease. When women go to the hospital for heart symptoms, they are more likely than men to experience delays receiving an initial EKG, are less likely to receive care from a heart specialist during hospitalization, and are less likely to receive certain types of therapy and medicines. Younger women are more likely than men to be misdiagnosed and sent home from the emergency department after cardiac events that occur from undiagnosed and untreated vascular heart disease.
• Ask about treatment options that are effective for men and women. Women may be less likely than men to receive aspirin, statins, and beta blockers for treating their heart disease. Although women may be as likely as men to benefit from a pacemaker or a defibrillator, women are less likely to receive these treatments for complications of coronary heart disease. Women are often less likely to receive percutaneous coronary intervention or coronary artery bypass grafting than men are, even though research shows that both men and women can benefit from these procedures.
• Know and share your risk factors. Doctors may not recognize women’s risk for coronary heart disease. Commonly used risk-scoring systems may not accurately predict risk in women. Also, in one survey, fewer than one in four women reported that their doctors had ever discussed their risk for heart disease.
• Learn the symptoms and seek medical care right away. Being familiar with the symptoms of coronary heart disease and how they may differ in women may help you recognize when to talk to your doctor or when to seek medical care. Immediate care may help prevent complications such as heart attack or sudden cardiac arrest.