FitSugar

How Much Cheese Is Too Much?

FitSugar — Mon, 25 Feb 2008 09:30:00 -0800

I was talking to my grandmother the other day and she asked me what I was making for dinner. When I said, "homemade mac and cheese," she said, "You shouldn't eat cheese. It'll clog your arteries." While she's right that the cholesterol in cheese can be harmful to your heart, that doesn't mean you necessarily have to give it up entirely.

Eating foods high in cholesterol and saturated fats, mainly dairy products, meat, and eggs, can raise the total level of cholesterol in your body, which can lead to heart problems and stroke. When it comes to cholesterol, you want to shoot for:

Total cholesterol level	HDL level (good cholesterol)	LDL level (bad cholesterol)
Less than 200 mg/dL	60 mg/dL or higher	Less than 100 mg/dL

So what does this mean when it comes to your diet (and your cheese consumption)? I'll tell you if you read more

No matter what, after you hit 20 years old, you should get your cholesterol checked every five years. If your total cholesterol is over 200 mg/dL, your HDL level is less than 40 mg/dL, you have other risk factors associated with heart disease and stroke (such as high blood pressure), or you're a man over 45 or a woman over 50, your doctor will probably recommend you get it tested more often.

If you get your cholesterol checked, and everything seems healthy, then it's OK to consume about 300 mg of cholesterol a day. If your levels aren't looking too good, then my gram is right - you'll want to cut back on the cheese, meat, eggs, and other dairy products and consume less than 200mg of cholesterol a day. Look for low fat dairy products and lean cuts of meat.

Fit's Tips: Another great way to improve your cholesterol, is to get at least 30g of fiber a day, limit your sodium intake to less than 2,300 mg a day, and be sure to exercise regularly.

Source

Apple and Grape Juice Prevents Clogged Arteries

FitSugar — Thu, 22 May 2008 12:00:00 -0700

In general, I say it is better to eat fruit than to drink juice. Recent research, though, has found that some juices are better than actual fruit for preventing clogged arteries, which lead to heart disease. Well, at least this is true for hamsters.

Eating and drinking the juice of both grapes and apples can help prevent arteries from clogging. A team from The University of Montpellier tested these fruits and juices on hamsters while feeding them a high fat diet. They discovered that compared to those only given water, the hamsters that consumed fruit or fruit juice had lower levels of cholesterol and less fat accumulating in their arteries. To see which juice was most beneficial and in what quantity read more.

Purple grape juice was the most beneficial (it contains the highest amount of phenols, an antioxidant), followed by purple grapes, apple juice, and then apples. The only bad news is you'd have to eat three apples, three bunches of grapes, or four glasses of fruit juice a day to reap the benefits. Also, there was no info about whether or not these fruits and juices had any effect on existing clogged arteries.

Source

Spooky News on Smoke, Booze, Blood, and Bones

FitSugar — Thu, 30 Oct 2008 03:00:00 -0700

You all know that I am a firm believer in moderation, but I do also know that everyone occasionally takes moderation in moderation and has a wild night. Once again, I nominate myself to play the role of party-pooper and tell you social smoking and binge drinking are really bad for you, and not just for your brain cells and lungs. Partying too hard and smoking socially can harm your bones and your blood.

Simply put, binge drinking makes for brittle bones. Alcohol interferes with the body's calcium supply, and in cases of excessive drinking, can create alcohol-induced bone loss. Add to the brittle bones the higher incidence of falling when inebriated and your chances for breaking a bone increase. New research from Loyola's Alcohol Research Program shows the exposure to alcohol disrupts the way genes work to maintain "bone integrity." This happens with prolonged drinking, but also in shorter, three-day bouts of "binge drinking," which was defined as four drinks in two hours for women and five drinks in the same time period for men.

To see what smoking socially does to you, just read more.

Having just one or two cigarettes over the course of a weekend affects your arteries and they begin to function more slowly. A decline in arterial health is an early risk factor for heart disease. The decrease in function lasts for more than just a couple of days and may continue well on for a week. A recent study at the University of Georgia found that two cigarettes can reduce the rate that blood flows through the arteries by 24 percent in healthy, young adults. For me, the take-home message is don't light up at all, even with your friends.

Source

Coronary artery disease

FitSugar — Wed, 08 Oct 2008 17:35:07 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Angioplasty Versus Drugs

Angioplasty works no better than drug therapy (high blood pressure, cholesterol, anti-platelet, and other medication) in preventing heart attack and stroke in patients with stable coronary artery disease (CAD), according to an important New England Journal of Medicine study. Experts still recommend angioplasty for patients with unstable or severe CAD.

Stents

Stents coated with drugs may have a slightly higher risk of causing blood clots than bare metal stents, according to FDA meetings held in late 2006. Researchers still need to conduct more research before reaching final conclusions.
Drug-coated stents work well when they are used for patients with specific types of heart conditions, indicate several studies published in the New England Journal of Medicine. However, problems may develop when these stents are used for “off-label” purposes. Experts are also concerned that both bare metal and drug-coated stents may be used too frequently.
Patients who receive a drug-coated stent must take both aspirin and an anti-platelet thienopyridine drug (usually clopidogrel) for at least 1 year after the stent is inserted, advises an important statement from the American Heart Association. Patients who cannot take a thienopyridine drug should receive a bare metal stent instead of a drug-coated stent.

Anti-Bleeding Drugs for Coronary Artery Bypass Graft (CAGB)

Aprotinin (Trasylol), a drug used to control bleeding during CABG, is more dangerous than other types of anti-bleeding drugs, according to a 2007 study in the Journal of the American Medical Association. Many experts now recommend against its use.

Diagnosis

Blood tests for biomarkers do not provide much more predictive information than standard disease risk factors, suggest several recent studies. In a 2006 study published in the New England Journal of Medicine, researchers found that risk factors such as high blood pressure, high cholesterol, and diabetes are still the best methods for predicting the likelihood of heart disease and heart-related death.

Introduction

The heart is the human body's hardest working organ. Throughout life it continuously pumps blood enriched with oxygen and vital nutrients through a network of arteries to all parts of the body's tissues.

The external structures of the heart include the ventricles, atria, arteries, and veins. Arteries carry blood away from the heart while veins carry blood into the heart. The vessels colored blue indicate the transport of blood with relatively low content of oxygen and high content of carbon dioxide. The vessels colored red indicate the transport of blood with relatively high content of oxygen and low content of carbon dioxide.

In order to perform the difficult task of pumping blood to the rest of the body, the heart muscle itself needs a plentiful supply of oxygen-rich blood, which is provided through a network of coronary arteries. These arteries carry oxygen-rich blood to the heart's muscular walls (the myocardium).

Click the icon to see an image of the anterior heart arteries.

If blood flow to the myocardium is interrupted, an injury known as an infarct occurs. This is also known as myocardial infarction or, more commonly, a heart attack.

Click the icon to see an animation about coronary artery disease.

Coronary artery disease is the end result of a complex process called atherosclerosis (commonly called "hardening of the arteries"). This causes blockage of arteries (ischemia ) and prevents oxygen-rich blood from reaching the heart. There are many steps in the process leading to atherosclerosis, some not fully understood.

Click the icon to see an image of atherosclerosis.

Increasingly, however, researchers are studying the interactions between cholesterol and processes known as oxidation and the inflammatory response.

Cholesterol and Lipoproteins. The story begins with cholesterol and sphere-shaped bodies called lipoproteins that transport cholesterol.

Cholesterol is a white, crystalline substance that is found in all animal cells and in animal-based foods. It is critical for many functions, but under certain conditions cholesterol can have harmful effects.
The lipoproteins that transport cholesterol are referred to by their size. The most commonly known are low-density lipoproteins (LDL) and high density lipoproteins (HDL). LDL is often referred to as the "bad" cholesterol and HDL as the "good" cholesterol.

Click the icon to see an image of cholesterol inside an artery.

Oxidation. The damaging process called oxidation is an important trigger in the atherosclerosis story.

Oxidation is a chemical process in the body caused by the release of unstable particles known as oxygen-free radicals. It is one of the normal processes in the body, but under certain conditions (such as exposure to cigarette smoke or other environment stresses) these free radicals are overproduced.
In excess amounts, they can be very dangerous, causing damaging inflammation and even affecting genetic material in cells.
In heart disease, free radicals are released in artery linings and oxidize low-density lipoproteins (LDL). The oxidized LDL is the basis for cholesterol build-up on the artery walls and damage leading to heart disease.

Inflammatory Response. For the arteries to harden there must be a persistent reaction in the body that causes ongoing harm. Researchers now believe that this reaction is an immune process known as the inflammatory response. The following is one theory about how the inflammatory response contributes to heart disease:

The injuries to the arteries during oxidation signal the immune system to release white blood cells (particularly those called neutrophils and macrophages) at the site. These factors initiate the inflammatory response.
Macrophages literally "eat" foreign debris, in this case oxidized LDL cholesterol.
The process converts LDL cholesterol into foamy material that attaches to the smooth muscle cells of the arteries. The cholesterol becomes mushy and accumulates on artery walls.
Over time the cholesterol dries and forms a hard plaque, which causes further injury to the walls of the arteries.
In response to this additional harm, the immune system releases other factors called cytokines. These are powerful inflammatory molecules that attract more white blood cells and perpetuate the whole cycle, causing persistent injury to the arteries.

Click the icon to see an image of atherosclerosis.

Evidence is growing that the inflammatory response may be present not only in local plaques in single arteries but also throughout the arteries leading to the heart.

Blockage in the Arteries. Eventually these calcified (hardened) arteries become narrower (a condition known as stenosis).

As this narrowing and hardening process continues, blood flow slows and prevents sufficient oxygen-rich blood from reaching the heart.
Such oxygen deprivation in vital cells is called ischemia. When it affects the coronary arteries, it causes injury to the tissues of the heart.
Injured inner vessel walls also fail to produce enough nitric oxide, a substance critical for maintaining blood vessel elasticity. (Nitric oxide has complex effects and may increase inflammation in the arteries.)
These narrow and inelastic arteries not only slow down blood flow but also become vulnerable to injury and tears.

Click the icon to see an image of coronary artery blockage

The End Result: Heart Attack. Heart attack can occur as a result of one or two effects of atherosclerosis.

(1) If the artery becomes completely blocked and ischemia becomes so extensive that oxygen-bearing tissues around the heart die.

(2) If the plaque itself develops fissures or tears. Blood platelets adhere to the site to seal off the plaque, and a blood clot (thrombus) forms. A heart attack can then occur if the formed blood clot completely blocks the passage of oxygen-rich blood to the heart.

Click the icon to see an image of the developmental process of atherosclerosis.

Angina is the primary symptom of coronary artery disease and, in severe cases, of a heart attack. It is typically experienced as chest pain and occurs when the heart muscle does not get as much blood (hence as much oxygen) as it needs for a given level of work (ischemia). Angina is usually referred to as one of two states:

Click the icon to see an image about angina.

Stable Angina (which is predictable)
Unstable Angina (which is less predictable and a sign of a more serious situation)

Angina itself is not a disease. Much evidence indicates that onset of angina less than 48 hours before a heart attack may be protective, possibly by conditioning the heart to resist the damage resulting from the attack. Angina may be experienced in different ways and can be mild, moderate, or severe.

Click the icon to see an image of angina.

Specific factors are typically considered in determining whether symptoms indicate angina:

Quality of the pain. Angina pain is typically described by patients as squeezing, heavy, suffocating, or griplike. It is rarely described as stabbing or burning. Changing one's position or breathing in and out does not affect the pain. The intensity of the pain does not always relate to the severity of the medical problem. Some people may feel a crushing pain from mild ischemia, while others might experience only mild discomfort from severe ischemia. In some cases, the patient experiences shortness of breath, fatigue, or palpitations instead of pain. In others, the ischemia is entirely asymptomatic ("silent ischemia").
Duration. A typical angina attack lasts minutes. If it is more fleeting or lasts for hours, it is probably not angina.
Location. Pain is usually in the chest under the breast bone. It often radiates to the neck, jaw, or left shoulder and arm. Less commonly, patients report symptoms that radiate to the right arm or back.
Triggers of Angina. Angina is usually triggered by physical exertion, emotional stress, or exposure to cold.
Factors that Relieve Angina. Angina is usually relieved by rest or by taking nitroglycerine under the tongue.

Stable Angina. Stable angina is predictable chest pain. Although less serious than unstable angina, it can be extremely painful. It is usually relieved by rest and responds well to medical treatment (typically nitroglycerin). Any event that increases oxygen demand can cause an angina attack. Some typical triggers include:

Exercise
Cold weather
Emotional tension
Large meals

Angina attacks can occur at any time during the day, but most occur between 6 a.m. and noon.

Unstable Angina and Acute Coronary Syndrome. Unstable angina is a much more serious situation and is often an intermediate stage between stable angina and a heart attack, in which an artery leading to the heart (a coronary artery) becomes completely blocked. A patient is usually diagnosed with unstable angina under one or more of the following conditions:

Pain awakens a patient or occurs during rest.
A patient who has never experienced angina has severe or moderate pain during mild exertion (walking two level blocks or climbing one flight of stairs).
Stable angina has progressed in severity and frequency within a 2-month period, and medications are less effective in relieving its pain.

Unstable angina is now usually discussed as part of a condition called acute coronary syndrome (ACS). ACS also includes people with a condition called NSTEMI (non ST-segment elevation myocardial infarction) -- also referred to as non-Q wave heart attack. With NSTEMI, the blood tests suggest a developing heart attack. These conditions are less severe than heart attacks but may develop into full-blown attacks without aggressive treatment. [See In-Depth Report #12: Heart attack and acute coronary syndrome.]

Prinzmetal's Angina. A third type of angina, called variant or Prinzmetal's angina, is caused by a spasm of a coronary artery. It almost always occurs when the patient is at rest. About two-thirds of people with it have severe atherosclerosis in at least one major blood vessel. Irregular heartbeats are common, but the pain is generally relieved immediately with standard treatment.

Click the icon to see an image of a coronary artery spasm.

Silent Ischemia. Some people with severe coronary artery disease do not experience angina pain. This condition is known as silent ischemia, which some experts attribute to abnormal processing of heart pain by the brain. This is a dangerous condition because patients have no warning signs of heart disease. Some studies suggest that people with silent ischemia experience higher complication and mortality rates than those with angina pain. (Angina pain may actually protect the heart by conditioning it before a heart attack.)

Syndrome X. Syndrome X is a condition that occurs when patients have atypical angina chest pain. Their electrocardiograms are abnormal during a stress test, but they have no signs of blocked arteries. It is more likely to occur in women. Although it unclear what causes this condition, imaging tests suggest that Syndrome X may also be caused by ischemia, as is angina.

Prognosis

According to a 2007 report, nearly 16 million Americans have coronary artery disease. In the U.S., coronary artery disease is the leading killer of both men and women. In 2004, nearly 500,000 people died because of CAD. On the positive side, heart attack mortality rates have been declining. Half of men and 63% of women who die of heart disease do not have angina or other warning symptoms prior to their fatal attacks. Although at this time no tests can reliably predict whether a heart attack will occur, experts estimate that up to 30% of fatal attacks and many follow-up surgeries could be avoided with healthy lifestyle changes and by sticking to medical treatments. Two-thirds of patients who have suffered a first heart attack, however, do not take the necessary steps to prevent another.

The following syndromes suggest different degrees of severity among patients with heart disease.

Stable Angina. This condition can usually be managed with lifestyle measures and medications, such as low-dose aspirin. The more severe the angina, however, the greater the chance for progressing to a more serious condition.

Acute Coronary Syndromes (ACS). ACS includes severe and sudden heart conditions that require aggressive treatment but have not developed into a full-blown heart attack. ACS refers to either unstable angina or NSTEMI (non ST-segment elevation myocardial infarction). NSTEMI is also known as non Q-wave myocardial infarction.

Angina is a specific type of pain in the chest caused by inadequate blood flow through the blood vessels (coronary vessels) of the heart muscle (myocardium).

Unstable angina is potentially serious and chest pain is persistent, but blood tests do not show markers for heart attack.
With NSTEMI, the blood tests suggest a developing heart attack, but, most likely, injury in the arteries is less serious than with a full-blown heart attack.

Most discussions of the treatment of unstable angina now refer to acute coronary syndrome. Doctors use the presence of a number of factors to help predict which ACS patients are most at risk for developing a heart attack.

First, patients are categorized by whether they have a history of heart disease or risk factors for heart disease (such as diabetes, high blood pressure, peripheral artery disease) or other complicating conditions (such as lung disease, heart failure). The doctor also evaluates the severity of the angina. Other factors that pose a high risk for ACS include:

Age 65 years or older
Evidence of severe heart tissue injury
Having a lighter weight
Having a history of severe chronic angina
Having abnormal lung sounds called rales (a bubbling or crackling sound) on examination
ST-segment deviation
Having either very slow or very fast heat beats
Having very low blood pressure

Heart Attack. A full-blown heart attack occurs with severe damage to the heart, which blocks oxygen.

ANYONE WHO BELIEVES THEY ARE HAVING A HEART ATTACK SHOULD IMMEDIATELY CALL THE EMERGENCY MEDICAL SYSTEM (911 IN THE UNITED STATES).

People with known heart disease and any unusual chest pain or other symptoms of heart attack that do not clear up with medications should go to the hospital. The degree of pain and the specific symptoms before a heart attack vary greatly among individuals. Symptoms can be abrupt, gradual, or intermittent.

Chest Pain. People with heart disease or risk factors should be concerned about any chest pain, usually precipitated by exercise or stress, that interrupts normal activities and does not clear up after resting or taking angina medications. Chest symptoms might be experienced as follows:

Pain is typically felt as a crushing weight against the chest, accompanied by profuse sweating. The pain may radiate to the left shoulder and arm, the neck or jaw, and even infrequently to the right arm. The arm may be tingling or numb.
Some people may have only a tingling sensation or a sense of fullness, squeezing, or pressure in the chest.
In some patients with a history of heart disease, chest pain is mild. Such patients may have experienced unexplained fatigue, depression, and ill health within a month of a heart attack. Although chest pain is the classic symptom, it occurs in only about half of patients with a heart attack.

Other Common Symptoms.

Nausea, vomiting, and cold sweats
A feeling of indigestion or heartburn
Fainting
A great fear of impending death, a phenomena known as angor animi

Atypical Symptoms. Some studies suggest that nearly half of patients with heart attack do not have chest pain as the primary symptom. Common atypical symptoms of a heart attack include:

Shortness of breath
Cardiac arrest
Dizziness, weakness, and fainting
Abdominal pain

Patients most likely to have atypical symptoms are women and the very elderly (although they can certainly have classic heart attack symptoms as well).

In one study, 52% of elderly people with acute coronary syndrome had atypical symptoms that included shortness of breath, nausea, profuse sweating, pain in the arms, and fainting. Such symptoms were more likely to occur in people with personal or family history of heart disease.
Before a heart attack, women are more likely than men to be nauseous and experience pain high in the abdomen or chest. Their first symptom may be extreme fatigue after physical activity rather than chest pain. Chest pain in women is also more likely to be caused by non-heart problems than in men.

Symptoms That Are Less Likely to Indicate a Heart Attack. The following symptoms are less likely to be due to a heart attack:

Sharp pain brought on by lung movements or coughing
Pain that is mainly or only in the middle or lower abdomen
Pain that can be pinpointed with the top of one finger
Pain that can be reproduced by moving or pressing on the chest wall or arms
Pain that is constant and lasts for hours (although no one should wait hours if they suspect they are having a heart attack)
Pain that is very brief and lasts for a few seconds
Pain that spreads to the legs

However, the presence of these symptoms does not always rule out a serious heart event.

Chest pain is a very common symptom in the emergency room, but heart problems account for only 10 - 33% of all episodes.

The most common causes of chest pain are muscular and bone problems. Problems affecting the ribs and chest muscles include injured muscles, fractures, arthritis, spasms, and infections.

Other causes of chest pain include:

Anxiety attacks
Gastrointestinal disorders (gallstone attacks, peptic ulcer disease, hiatal hernia, heartburn)
Asthma
Spasm in the coronary artery
Abnormalities of the heart muscle
Rupture of the aorta
Collapsed lung
Acute inflammation of the heart
Blood clot in the lung
High thyroid levels (hyperthyroidism)
Anemia
Vasculitis (a group of disorders that cause inflammation of the blood vessels)
Exposure to high altitudes (rare)

Individuals who experience symptoms of a heart attack should take the following actions:

For angina patients, take one nitroglycerin dose either as an under-the-tongue tablet or in spray form at the onset of symptoms. Take another dose every 5 minutes up to three doses or when the pain is relieved, whichever comes first.
Call 911 or the local emergency number. This should be the first action taken if angina patients continue to experience chest pain after taking the full three doses of nitroglycerin. However, only 20% of heart attacks occur in patients with long-standing angina. Therefore, anyone who has heart disease or risk factors for it and experiences heart attack symptoms should contact emergency services.
The patient should chew an aspirin (250 - 500 mg) and be sure that emergency health providers are informed of this so an additional dose is not given.
Patients with chest pain should go immediately to the nearest emergency room, preferably traveling by ambulance. They should not drive themselves.

Click the icon to see an image about heart attack symptoms.

Click the icon to see another image about heart attack symptoms.

Risk Factors

Over 13 million Americans have had angina, a heart attack, or both. Each year, about 1.2 million people will experience a serious heart event. About 25% of all Americans have one or more risk factors for heart disease. Most risk factors for heart disease are related to lifestyle and environmental factors.

Over the past decades, heart disease rates declined in both men and women as they quit smoking and improved dietary habits. This rate, however, has stabilized in recent years, most likely because of the dramatic increase in obesity in the U.S. and other industrialized nations. There have also been minimal changes in other risk factors, including smoking, sedentary behavior, and blood pressure control. Some risk factors cannot be changed, including age, gender, and genetics. Nevertheless, their effects can still be modified with healthy lifestyle changes.

Heart disease may be prevented with a healthy diet and regular exercise, and by quitting smoking if you smoke. Follow your health care provider's recommendations for the treatment and prevention of heart disease.

The American Heart Association guidelines for preventing heart disease recommend:

Improve Cholesterol. People with at least two risk factors and a 10-year risk for heart disease or stroke of more than 20% should aim for LDL levels of less than 100 mg/dl. Statins are now used in more cases.

Keep Blood Pressure Low. People in normal health should have a blood pressure reading of 120/80 mm Hg or less. According to the latest guidelines, blood pressure readings of 120/80 are considered normal, readings of 140/90 or higher indicate hypertension, and readings in between the two are called pre-hypertension. Patients with diabetes or chronic kidney disease should maintain blood pressure readings of 130/80 mm Hg or less, while others should be no higher than 140/90 mm Hg.

Exercise. Everyone in normal health should engage in at least moderate physical activity for a minimum of 30 minutes on most, if not all, days of the week.

Healthy Diet. Everyone should aim for a diet that contains a healthy balance of fruits, vegetables, grains, fish, nuts, legumes, poultry, lean meat, and low-fat dairy items. Avoid saturated fats and trans-fatty acids.

Quit Smoking. Also avoid exposure to secondhand smoke.

Maintain Weight. People should aim for a BMI index of 18.5 - 24.9.

Taking Aspirin. People whose risk for heart disease within 10 years is 10% or more should take a low-dose aspirin every day, unless they have medical reasons to avoid aspirin.

Control Diabetes. People with diabetes should aim for fast blood glucose levels of less than 110 mg/dl and hemoglobin A1C or less than 7%.

Control Atrial Fibrillation. People with atrial fibrillation should use anticoagulants to reduce the risk for blood clots.

Age. About 85% of people who die from heart disease are over the age of 65.

Gender. Coronary artery disease and heart attacks are much more common in middle-aged men. Women have, on average, 10 - 15 more years of heart disease-free life than do men, but as women age, they catch up to men. Women, in fact, are more likely to have angina than men. Younger women with heart disease often do not have the same symptoms as their male counterparts and may be less likely to be diagnosed correctly. They are also more likely than men to die after a heart attack.

In 2007, the American Heart Association issued updated guidelines focusing on prevention of heart disease in women. The new guidelines recommend:

Healthy diet (fresh fruits and vegetables, low-fat dairy products, salt and saturated fat restrictions, alcohol moderation)
Eating oily fish (such as salmon) at least twice a week. Women with existing heart disease should consider taking fish oil supplements of 850 – 1,000 mg eicosapentaenoic acid (EPA) and docosahexaenoic acid (DPA).
Increased physical activity (60 – 90 minutes, preferably 7 days a week)
Quitting smoking
Low-dose aspirin therapy for all women age 65 years and older who can safely take aspirin. High-risk women may require 75 – 325 mg / day; lower-risk women may benefit from 81 mg a day or 100 mg every other day.

Genetic Factors. Genetics are involved in increasing the likelihood of developing important risk factors such as diabetes and high blood pressure. For example, one genetic variant called apolipoprotein E4 (ApoE4) affects cholesterol levels, particularly those associated with heart disease.

Ethnicity. African-American women face the highest risk for death from heart disease, and their rate of heart attacks is increasing. (Mortality rates in men do not differ much by race.) Native American men have a lower risk for heart disease than Caucasian men, and Hispanics have the lowest risk for heart disease of all major American population groups.

African-Americans face a number of biologic and social dangers to their hearts.

They have a higher prevalence of diabetes and hypertension than do Caucasians.
They tend to have poorer diets, higher stress levels, and less access to health care.
All African-Americans risk discrimination in obtaining optimal treatments, but women may be at particular risk for unequal treatment. In one study in which female actors portrayed heart patients, African-American women were 60% less likely to receive aggressive (and expensive) diagnostic tests than African-American men or any Caucasians, even though they presented with similar symptoms.
While African-Americans comprise 13% of the U.S. population, African-Americans have comprised only 2 - 9% of subjects in most major research trials, so knowledge about their specific risks is limited.
Some African-Americans with coronary artery disease appear to have a genetic trait that increases the danger of triglycerides, which may be particularly hazardous for women.

Click the icon to see an image about ethnicity and heart disease risks.

Cholesterol. In spite of its bad press, cholesterol is an essential nutrient necessary for many cellular functions. However, when certain cholesterol levels rise in the blood, they can have dangerous consequences, depending on the type of cholesterol. Low-density lipoprotein (LDL) cholesterol is the "bad" cholesterol responsible for many heart problems. Triglycerides are another type of lipid (fat molecule) that can be bad for the heart. High-density lipoprotein (HDL) cholesterol is the "good" cholesterol that helps protect against heart disease. Doctors test for a "total cholesterol" profile that includes measurements for LDL, HDL, and triglycerides. The ratio of these lipids can affect heart disease risk.

For example, according to one study, men with total cholesterol levels over 240 mg/dl have a risk that is two to four times higher than men whose cholesterol is below 200. A number of studies have demonstrated that reducing LDL and total cholesterol levels and boosting high-density lipoprotein (HDL) levels can improve survival and prevent heart attacks in people with and without heart disease.

It is very difficult to measure LDL levels by themselves, but LDL levels can be reliably calculated by the Friedewald formula: LDL=TC-HDL-TG/5. (LDL=low-density lipoprotein; TC= total cholesterol; HDL=high-density lipoprotein; TG=triglycerides.)

Click the icon to see an image about serum cholesterol.

Cholesterol Goals. In 2004, the National Cholesterol Education Program updated its clinical practice guidelines. The new recommendations set lower treatment goals for LDL levels based on a patient's risk factors for heart disease.

These risk factors include:

Having a first-degree female relative diagnosed with heart disease before age 65 or a first-degree male relative diagnosed before age 55
Being male and over age 45 or female and over age 55
Cigarette smoking
Diabetes
High blood pressure
Metabolic syndrome (risk factors associated with obesity such as low HDL levels and high triglycerides

Having two or more of these risk factors indicates a greater than 20% chance of having a heart attack within 10 years.


Risk Level	Goal (d/L)	Optimal Goal(d/L)
Very High Risk	70	70
High Risk	100	70
Moderate Risk	130	100
Low Risk	160	130

LDL cholesterol, together with other risk factors for heart disease, is the best determinant for whether cholesterol therapy is needed and whether it is working properly. In particular, the new guidelines emphasize lower LDL levels and earlier treatment for people with coronary artery disease, or other forms of atherosclerosis, and diabetes.


Total Cholesterol Goals	LDL Goals	HDL Goals	Triglyceride Goals
Less than 200 mg/dL is desirable. Between 200 and 239 is borderline. Over 240 is high.	70 mg/dL or less is the new goal for very high-risk patients (recent heart attack; current active or unstable cardiovascular or cerebrovascular disease; or two multiple risk factors as defined above.) Below 100 mg/dl is optimal for everyone. It should be the goal for high-risk people including those with existing heart disease, diabetes, or two or more risk factors for heart disease; 70 mg/dL is an optimal goal for these individuals. 130 mg/dl or below for people with two or more risk factors; 100 mg/dL is the optimal goal. 160 mg/dl or less for people at less risk (one or zero risk factors); 130 mg/dL is the optimal goal. Anything over 160 is high with levels over 190 being very high. LDL levels over 190 require medication even with no other cardiac risk factors present.	Levels above 40 mg/dL are desirable; levels above 60 mg/DL are optimal.	Below 150 mg/dL is normal. 150-199 is borderline high. 200-499 is high. Over 500 is very high.
*Risk factors for heart disease include a family history of early heart problems before age 55 for men, before age 65 for women, smoking, high blood pressure, diabetes, being older (over 45 for men and 55 for women), and having HDL levels below 35 mg/dl. People with two or more of these risk factors may have a 10-year risk of heart attack that exceeds 20%, and may therefore need to aim for LDL levels of 100 mg/dL or below.

Other Lipids. Elevated levels of other fatty molecules (lipids) are also now thought to be important indicators of heart disease risk. Studies are finding an elevated risk for angina and first heart attacks in people with elevated levels of lipoprotein(a), or lp(a). This lipoprotein falls somewhere in density between HDL and LDL and may have some properties that increase the risk for blood clots. Some experts suggest, however, that high levels of lp(a) may merely be markers of late-stage atherosclerosis, not a cause.

[See In-Depth Report #23: Cholesterol; and In-Depth Report #43: Heart-healthy diet.]

High blood pressure, or hypertension, has long been a proven cause of coronary artery disease. Blood pressure is categorized as normal, prehypertensive, and hypertensive (which is further divided as Stage 1 or 2 according to severity). High blood pressure is generally considered to be a blood pressure reading greater than or equal to 140 mm Hg (systolic) or greater than or equal to 90 mm Hg (diastolic). Blood pressure readings in the prehypertension category (120 - 139 systolic or 80 - 89 diastolic) indicate an increased risk for developing hypertension. [See Table Blood Pressure Ranges.]

A normal blood pressure reading is 120/80 mm Hg or lower. Most people with high blood pressure should aim for a goal of below 140/90 mm Hg. Patients with certain health problems should aim lower (blood pressure in patients with kidney disease, heart failure, or diabetes should be equal to or lower than 130/80 mm Hg.)

Click the icon to see an image about hypertension.


Blood Pressure Category	Ranges for Most Adults (systolic/diastolic)
Normal Blood Pressure (systolic/diastolic)	Systolic below 120 mm Hg Diastolic below 80 mm Hg
Prehypertension (Formerly Classified as Normal to High-Normal Blood Pressure)	Systolic 120 to 139 mm Hg Diastolic 80 to 89 mm Hg (NOTE: 139/89 or below should be the minimum goal for everyone. People with diabetes or chronic kidney disease should strive for 130/80 or less.)
Mild Hypertension (Stage 1)	Systolic 140 to 159 mm Hg Diastolic 90 to 99 mm Hg
Moderate-to-Severe Hypertension (Stage 2)	Systolic over 160 mm Hg and/or Diastolic over 100 mm Hg
Note: If one of the measurements is in a higher category than the other, the higher measurement is usually used to determine the stage. For example, if systolic pressure is 165 (Stage 2) and diastolic is 92 (Stage 1), the patient would still be diagnosed with Stage 2 hypertension. A high systolic pressure should be a major focus of concern in most adults.

American obesity is at epidemic levels in all age groups. The effect of obesity on cholesterol levels is complex. Although obesity does not appear to be strongly associated with overall cholesterol levels, among obese individuals triglyceride levels are usually high while HDL (beneficial cholesterol) levels tend to be low, both risk factors for heart disease. Obesity has other effects (hypertension, increase in inflammation) that pose major risks to the heart.

Click the icon to see an image of childhood obesity.

Obesity is particularly hazardous when it is one of the components of the metabolic syndrome. This syndrome is diagnosed when three of the following are present: abdominal obesity, low HDL cholesterol, high triglyceride levels, high blood pressure, and insulin resistance. Metabolic syndrome is a pre-diabetic condition that is significantly associated with heart disease and higher mortality rates from all causes. A 2002 study estimated that 24% of the population now has this condition. Obesity is highly linked with type 2 diabetes, and diabetes itself poses a significant risk for high cholesterol levels and heart disease.

Some obese patients with coronary artery disease may consider having bariatric surgery (stomach bypass) to lose excess weight. The weight lost after surgery can help improve blood pressure, cholesterol, blood sugar and other factors associated with CAD. A 2005 study reported that bariatric surgery is safe for patients with CAD who cannot lose weight with diet and exercise, which should always be tried first.

[See In-Depth Report #53: Weight control and diet.]

People who are sedentary are almost twice as likely to suffer heart attacks as are people who exercise regularly. Exercise has a number of effects that benefit the heart and circulation, including:

Improving cholesterol and lipid levels
Reducing inflammation in the arteries
Assisting weight loss programs
Helping to keep blood vessels flexible and open

Studies continue to show that physical activity and avoiding high-fat foods are the two most successful means of reaching and maintaining heart healthy levels of fitness and weight.

Experts have been attempting to define how much exercise is needed to produce heart benefits. In 2002, a well-conducted study on overweight adults confirmed previous research that reported beneficial changes in cholesterol and lipid levels even when people performed low amounts of moderate or high intensity exercise (walking or jogging 12 miles a week). However, more intense exercise is required to significantly change cholesterol levels, notably by increasing HDL (the so-called good cholesterol). Overweight people who have trouble losing pounds can still achieve considerable heart benefits by exercising. Resistance (weight) training has also been associated with heart protection. Exercises that train and strengthen the chest muscles may prove to be very important for patients with angina.

Click the icon to see an image about exercise.

Click the icon to see an image about hypertension and lifestyle changes.

Some studies suggest that for the greatest heart protection, it is not the duration of a single exercise session that counts but the total daily amount of energy expended. Therefore, the best way to exercise may be in multiple short bouts of intense exercise, which can be particularly helpful for older people.

Sudden strenuous exercise (such as snow shoveling and mowing lawns) puts many people at risk for angina and heart attack. Activities that involve raising the arms above the head may also be risky. Patients with angina should never exercise shortly after eating. People with risk factors for heart disease should seek medical clearance and a detailed exercise prescription. And all people, including healthy individuals, should listen carefully to their bodies for signs of distress as they exercise. [See In-Depth Report #29: Exercise.]

Heart disease and stroke are the leading causes of death in people with diabetes. People with diabetes are at risk for the following heart-risk conditions, and the more of these conditions they have, the worse the outlook.

High blood pressure (hypertension). Up to 75% of cardiovascular problems in people with diabetes may be due to hypertension.
Very unhealthy cholesterol and lipid balances (high triglyceride levels and lower HDL).
Blood clotting problems.
Impaired nerve function (neuropathy), which can also damage the heart. Some experts estimate that the mortality rates from neuropathy-related heart conditions range from 15 - 53%.

People with both diabetes and heart disease may have a higher risk for silent ischemia, a condition in which people have blocked arteries but do not experience the angina, the chest pain that signals heart disease. [See In-Depth Report #9: Diabetes - type 1; or In-Depth Report #60: Diabetes - type 2.]

Peripheral artery disease (PAD) occurs when atherosclerosis affects the extremities, particularly the feet and legs. The major risk factors for heart disease and stroke are also the most important risk factors for PAD. (The combination of such conditions with PAD also produces more severe forms of heart or circulatory disease.) Although signs of heart disease are detected in only 20 - 40% of patients with PAD after an initial diagnosis, studies suggest that when intense heart-diagnostics tests are performed, such as angiography or thallium stress tests, co-existing heart disease is detected in up to 90% of all PAD patients. [See In-Depth Report #102: Peripheral artery disease.]

Smokers in their 30s and 40s have a heart-attack rate that is five times higher than their nonsmoking peers. Cigarette smoking may be directly responsible for at least 20% of all deaths from heart disease, or about 120,000 deaths annually. Smoking cigars may increase the risk of early death from heart disease, although evidence is much stronger for cigarette smoking. Although heavy cigarette smokers are at greatest risk, a 2002 study suggested that people who smoke as few as three cigarettes a day are at higher risk for blood vessel abnormalities that endanger the heart. Regular exposure to passive smoke also increases the risk of heart disease in nonsmokers. [See In-Depth Report #41: Smoking.]

Eating habits can be protective or dangerous to the heart. Avoiding saturated fats and trans-fatty acids is particularly important for controlling cholesterol.

Diet plays an important role in the health of the heart. In 2006, the American Heart Association (AHA) issued revised diet and lifestyle recommendations. The current guidelines recommend:

Balance calorie intake and physical activity to achieve or maintain a healthy body weight. (Controlling weight, quitting smoking, and exercising regularly are essential companions of any diet program. Try to get at least 30 minutes, and preferably 60 – 90 minutes, of daily exercise.)
Consume a diet rich in a variety of vegetables and fruits. Vegetables and fruits that are deeply colored (spinach, carrots, peaches, berries) are especially recommended as they have the highest micronutrient content.
Choose whole-grain, high-fiber foods. These include fruits, vegetables, and legumes (beans). Good whole grain choices include whole wheat, oats/oatmeal, rye, barley, brown rice, buckwheat, bulgur, millet, and quinoa.
Consume fish, especially oily fish, at least twice a week (about 8 ounces/week). Oily fish such as salmon, mackerel, and sardines are rich in the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Consumption of these fatty acids is linked to reduced risk of sudden death and death from coronary artery disease.
Limit daily intake of saturated fat (found mostly in animal products) to less than 7% of total calories, trans fat (found in hydrogenated fats, commercially baked products, and many fast foods) to less than 1% of total calories, and cholesterol (found in eggs, dairy products, meat, poultry, fish, shellfish) to less than 300 mg per day. Choose lean meats and vegetable alternatives (such as soy). Select fat-free and low-fat dairy products. Grill, bake, or broil fish, meat, and skinless poultry.
Use little or no salt in your foods. Reducing salt can lower blood pressure and decrease the risk of heart disease and heart failure.
Cut down on beverages and foods that contain added sugars (corn syrups, sucrose, glucose, fructose, maltrose, dextrose, concentrated fruit juice, honey.)
If you consume alcohol, do so in moderation. The AHA recommends limiting alcohol to no more than 2 drinks per day for men and 1 drink per day for women.

[See In-Depth Report #43: Heart-healthy diet.]

Stress. The effects of mental stress on heart disease are controversial. Stress can affect the heart when it activates the sympathetic nervous system (the automatic part of the nervous system that affects many organs, including the heart). Some studies suggest an association between acute stress and a higher risk for serious cardiac events, such as heart rhythm abnormalities and heart attacks, in people with heart disease. However, not all studies report strong evidence that stress has any effect on the heart, particularly in people without any history of heart disease. [See In-Depth Report #31: Stress.]

Depression. Depression increases the severity of heart attack and may even worsen a patient's response to medication for heart disease. Although people with heart disease may become depressed, this does not explain entirely the link between the two problems. Data suggest that depression itself may be a risk factor for heart disease as well as its increased severity.

A number of studies indicate that depression has biologic effects on the heart, including blood clotting and heart rate. One study, for example, reported an association between depression and a greater risk for death from heart problems even in people without a history of heart disease. Even mild depression, which includes feelings of hopelessness experienced over many years, may harm the heart. A 2007 study suggested that depressive symptoms (fatigue, loss of appetite) may be a sign of thickening arteries, the early stage of coronary artery disease. [See In-Depth Report #8: Depression.]

Benefits of Moderate Drinking. Several studies have found heart protection from moderate intake of alcohol (one or two glasses a day). Moderate alcohol consumption can help boost HDL levels. Alcohol may also prevent blood clots and inflammation. Although red wine is most often cited for healthful properties, any type of alcoholic beverage appears to have similar benefit.

Adverse Effects of Heavy Drinking. By contrast, heavy drinking harms the heart. In fact, heart disease is the leading cause of death in alcoholics. Evidence suggests that people who consume more than three drinks a day have abnormal blood clotting factors. Heavy alcohol consumption can raise blood pressure, and binge drinking may increase the risk for hemorrhagic stroke (caused by bleeding in the brain). Large doses of alcohol can trigger irregular heartbeats, which can be dangerous in people with existing heart disease.

Pregnant women and people who can't drink moderately should not drink at all.

Homocysteine and Vitamin B Deficiencies. Deficiencies in the B vitamins folate (known also as folic acid), B6, and B12 have been associated with a higher risk for heart disease in some studies. Such deficiencies produce higher blood levels of homocysteine, an amino acid that has been associated with a higher risk for heart disease, stroke, and heart failure. Researchers have been studying whether vitamin B supplements can reduce homocysteine levels and, consequently, heart disease risks.

Several major 2006 studies indicated that while B vitamin supplements do help lower homocysteine levels, they have no effect on heart disease outcomes. The studies, published in the New England Journal of Medicine, examined patients who had either recently had a heart attack or suffered from diabetes or heart disease. Results showed a similar number of heart attacks and strokes among patients who took B vitamins and those who received placebo. Some experts think that homocysteine may be a marker for heart disease rather than a cause of it.

Click the icon to see the benefits of vitamin B.

Click the icon to see the food sources of vitamin B.

C-Reactive Protein. C-reactive protein is a product of the inflammatory process. Evidence increasingly suggests that high levels may predict future heart disease. It is not known if the protein plays any causal role or whether it is simply a marker for other factors in the disease process.

C. pneumoniae and Other Infectious Organisms. Some microorganisms and viruses have been under suspicion for triggering the inflammation and damage in the arteries that contribute to heart disease. The strongest evidence to date supports a possible role from Chlamydia (C.) pneumoniae (a non-bacterial organism that causes mild pneumonia in young adults). C. pneumoniae has been detected in plaques in the arteries of patients with heart disease. In some studies, evidence of previous infection has been associated with a higher risk for heart events.

Other studies also suggest that cytomegalovirus (CMV), a common virus, may have similar effects. Many people, however, have been infected with these organisms, and no clear association has been found with any of these infections.(H. pylori, the bacteria that causes peptic ulcers, has also been studied for heart effects, but evidence is very weak on any link.)

Erectile Dysfunction. Recent research suggests that erectile dysfunction may be a warning sign of coronary artery disease, even in men who are not considered at risk for the condition. Some studies indicate that men with erectile dysfunction have higher levels of C-reactive protein and more symptoms of atherosclerosis than men without erectile problems.

Periodontal Disease. A number of studies support an association between periodontal disease and cardiovascular disorders. According to a 2003 major analysis, periodontal (gum) disease is associated with a 20% higher risk for ischemic stroke and heart disease. (The added risk may be even higher in adults under 65.) Recent evidence is pointing to the inflammatory response as the common element.

Click the icon to see an image of gum disease.

Anemia. Anemia has adverse effects on the heart and increases the severity of cardiac conditions, including heart failure and heart attacks. A 2002 study suggested that anemia may even be a risk factor for heart disease itself. Blood transfusions after a heart attack improve survival rates in elderly patients who are anemic.

Iron Overload. An inherited disease called hemochromatosis, in which the intestinal tract absorbs too much iron from food, has been associated with atherosclerosis and heart attack. About 10% of Caucasians carry the gene for this condition. There is no strong evidence that excess iron levels in people without hemochromatosis can contribute to heart disease.

Sleep Apnea. Obstructive sleep apnea is a condition in which tissues in the upper throat collapse at intervals during sleep, thereby blocking the passage of air. It has been strongly associated with high blood pressure and obesity, but is also associated with heart disease and heart attacks, regardless of these risk factors. Some evidence suggests that obstructive apneas cause an increase in stiffness and inflammation in the arteries.

Some inborn or natural conditions are not risk factors themselves but have been associated with a higher incidence of heart disease or its consequences:

Factors Before Birth and In Infancy. Low weight at birth and in the womb has been associated with later heart disease in a few studies. Some suggest, however, that this may just reflect poor nutrition in the mother, which appears to affect life-long risk.

Seasonal Differences. More deaths from heart disease occur in December and January, and the fewest in the summertime. Although lower temperatures and snow shoveling may play a role in some cases, more winter deaths have been reported even in warm regions. Holiday stress or fewer daylight hours have been suggested as other reasons for these higher winter rates.

Physical Characteristics. Male pattern baldness, hair in the ear canals, and creased earlobes are associated with a higher risk for heart disease in Caucasian males.

Click the icon to see an image of an ear lobe crease.

Diagnosis

Many tests can diagnose possible heart disease. The choice of which (and how many) tests to perform depends on the patient's risk factors, history of heart problems, and current symptoms. Usually the tests begin with the simplest and may progress to more complicated ones.

Doctors routinely check for high blood pressure and unhealthy cholesterol levels in all older adults. Specific tests are also important in people who may have risk factors or symptoms of diabetes. Doctors may also test for homocysteine, the protein albumin, and blood clotting factors, especially fibrinogen.

An electrocardiogram (ECG) measures and records the electrical activity of the heart. Between 25 - 50% of people who suffer from angina or have silent ischemia, however, have normal ECG readings. The waves measured by the ECG correspond to the contraction and relaxation pattern of the different parts of the heart. Specific waves seen on an ECG are named with letters:

The electrocardiogram (ECG, EKG) is used extensively in the diagnosis of heart disease, from congenital heart disease in infants to myocardial infarction and myocarditis in adults. Several different types of electrocardiogram exist.

P. The P wave is associated with the contractions of the atria (the two chambers in the heart that receive blood from outside).
QRS. The QRS is a series of waves associated with ventricular contractions. (The ventricles are the two major pumping chambers in the heart.)
T and U. These waves follow the ventricular contractions.

The most important wave patterns in diagnosing and determining treatment for heart disease and heart attack are called ST elevations and Q waves.

A depressed or horizontal ST wave suggests some blockage and the presence of a heart disease, even if there is no angina present. (This finding, however, is not very accurate, particularly in women, and can occur without heart problems).
ST elevations and Q waves are the most important wave patterns in diagnosing and determining treatment for a heart attack. They suggest that an artery to the heart is blocked, and that the full thickness of the heart muscle is damaged. ST segment elevations do not always mean the patient has a heart attack. And, some heart attack patients do not have elevated ST segments. Other factors are important in making a diagnosis.

The primary value of exercise stress tests is not to detect coronary artery disease but to help determine the severity and predict the outcome of an existing heart condition. It is considered for the following people:

Patients with possible or probable angina and low or intermediate risk for adverse heart events.
Selected adults who do not have symptoms of heart disease but are at moderate risk to high risk for developing heart disease (a 10 - 20% chance within 10 years). Moreover, heart blockage without angina (silent ischemia) may suggest a more severe condition, at least in men.

Basic Procedure. A stress test (exercise tolerance test) monitors the patient's heart rhythms, blood pressure, and clinical status. It can tell how well the heart handles work and if parts of the heart have decreased blood supply. A typical stress test involves:

The patient walks on a treadmill or rides a stationary bicycle. Exercise continues until the heart is beating at least 85% of its maximum rate, until symptoms of heart trouble occur (changes in blood pressure, heart rhythm abnormalities, angina, fatigue), or the patient simply wants to stop.
For patients who cannot exercise, the doctor may administer dobutamine or arbutamine, which are drugs that simulate the stress of exercise.
An ECG is used to monitor heart rhythms during a stress test. (An echocardiogram or more advanced imaging technique may also be used to visualize the actions of the heart and blood flow.)

More than 25% of patients stop exercising before they reach their own maximum limits because of fear of a heart event. Patients should be reassured that the activities performed in the test under the guidance of a professional are safe.

Interpreting Results. To accurately assess heart problems, experts look at a number of findings derived from the ECG and other tools during exercise. They include:

Exercise capacity. This is a measure of a person's capacity to reach certain metabolic rates.
Heart rate and ST waves. On ECGs, doctors specifically look for abnormalities in part of the wave tracing called an ST segment. A certain type of ST segment depression may suggest the presence of heart disease. However, gender, drugs and other medical conditions can affect the ST segment. Using a measurement that adjusts the ST segment to heart rate improves accuracy.
Dukes Treadmill Score. This important score uses the number of minutes a patient can exercise and other factors that are present in patients with exercise-limiting angina.
Heart rate recovery.
Chronotropic index. This is the percentage of the heart-rate reserve that is used during the exercise. A result of 80% or less suggests a significant risk for serious heart problems in most patients.
Changes in systolic blood pressure.

Using these and other measures, doctors can determine risk fairly accurately, particularly for men of any age with chronic stable angina. The test has limitations, however, and some are significant. For example, a 2002 study indicated that in patients with suspected unstable angina the chances for a future adverse heart event remain high even if the exercise test shows low risk. In addition, for many reasons, the test is less accurate in women, and an echocardiogram may be a more accurate procedure for them. About 10% of patients, particularly younger people, will have false positive test results. In such cases, test results indicate abnormalities when there are no heart problems.

An echocardiogram is a noninvasive test that uses ultrasound images of the heart. This test is more expensive than an ECG, but it can be very valuable, particularly when used with a stress test, to detect the location and extent of heart muscle damage. It appears to be more accurate for women than ECG stress tests, but at this time it is not routinely recommended as a replacement for most women.

Computed tomography (CT) scans used alone or with ECG may be used to detect calcium deposits on the arterial walls, which are strong indicators of current and future coronary artery disease. The presence of calcium does not always signify narrowing of the arteries. But, the absence of calcification in the arteries indicates the patient has no risk for heart disease.

Advanced CT techniques are improving accuracy:

Click the icon to see an image of a CT scan.

Electron Beam Computed Tomography. Electron beam computed tomography (EBCT) is a CT technique that scans the heart so quickly that the motion of the heart appears frozen. This procedure identifies calcification and stratifies cardiac risk accurately.
Multidetector Computed Tomography. Another CT technique called multidetector computed tomography (MDCT) is able to take pictures of the entire heart in 1 millimeter slices in the time it takes for a patient to hold one breath. A 2006 study indicated that MDCT tends to have a high “false-positive” rate (indicating disease when it is not actually there), but for some patients the test may be helpful in ruling out coronary artery disease.

Some expert groups recommend CT scans in selected patients who have an intermediate risk (10 - 20% chance of heart disease within 10 years). For some of these patients, EBCT may be preferred over exercise stress testing, but most experts recommend a stress test as the main diagnostic tool. In general, the use of these expensive imaging tests is probably not very helpful for people at low or high risk. (For people with high risk, the additional information from these tests would not add much value.) More research is needed to determine the benefits of CT scanning in specific individuals.

Radionuclide procedures use imaging techniques and computer analyses to plot and detect the passage of radioactive tracers through the region of the heart. Such tracing elements are typically given intravenously. Radionuclide imaging is useful for diagnosing and determining:

Severity of unstable angina when less expensive diagnostic approaches are unavailable or unreliable
Severity of chronic coronary artery disease
Success of surgeries for coronary artery disease.
Whether a heart attack has occurred

Various imaging techniques may be used with radionuclide procedures, including:

Planar scintigraphy uses a special overhead camera and is the oldest scanning technique.
Single-photon emission computed tomography (SPECT) uses a camera that rotates around the patient and takes pictures of "slices" of the heart. It is more accurate than planar imaging in precisely locating problems in the arteries.
Positron-emission tomographic (PET) scanners employ multiple rings that surround the patients, which detect and record atomic particles (photons) that are emitted by the tracer elements (such as radioactive oxygen, nitrogen, or carbon). It is more expensive and less widely available than SPECT.

Myocardial Perfusion (Blood Flow) Imaging Test (also called the Thallium Stress Test). This radionuclide test is typically used with an exercise stress test to determine blood flow to the heart muscles. It is a reliable measure of severe heart events. It may be useful in determining the need for angiography if CT scans have detected calcification in the arteries. About a minute before the patient is ready to stop exercising, the doctor administers a radioactive tracer into the intravenous line. (Tracers include thallium, technetium, or sestamibi.) Immediately afterwards, the patient lies down for a heart scan, usually with a planar scintigraphy or with SPECT. If the scan detects damage, more images are taken 3 or 4 hours later. Damage due to a prior heart attack will persist when the heart scan is repeated. Injury caused by angina, however, will have resolved by that time.

Radionuclide Angiography. This is a technique for visualizing the chambers and major blood vessels of the heart. It uses an injected radioactive tracer and can be performed during exercise, at rest, or with use of stress-inducing drugs. It is an excellent test for assessing the heart's pumping action and for determining the severity of coronary artery disease. It is an alternative to echocardiograms in certain situations.

Click the icon to see an internal view of the heart.

Magnetic Resonance Angiography (MRA). MRA is a very promising noninvasive imaging technique that can provide three-dimensional images of the major arteries to the heart and identify disease with high accuracy. Experts believe this approach will eventually be a good alternative to angiography.

Click the icon to see an image of a MRI.

Angiography is an invasive test. It is used for patients who show strong evidence for severe obstruction on stress and other tests, and for patients with acute coronary syndrome.

A narrow tube is inserted into an artery, usually in the leg or arm, and then threaded up through the body to the coronary arteries.
A dye is injected into the tube, and an x-ray records the flow of dye through the arteries.
This process provides a map of the coronary circulation, revealing any blocked areas.

Click the icon to see an image of dye in the coronary artery.

Major complications include stroke, heart attacks, and kidney damage. These risks are very low (about 0.1%), however, if the procedure is done in an experienced medical center (one that performs at least 300 of these operations every year). Allergic reactions can also occur. The procedure is expensive, and between 10 - 30% of patients who have this procedure have normal results.

When heart cells become damaged, they release different enzymes and other molecules into the bloodstream. Elevated levels of such markers of heart damage in the blood or urine may help predict a heart attack in patients with severe chest pain and help determine treatment. Some of these factors include:

Troponins. The proteins cardiac troponin T and I are released when the heart muscle is damaged. Both are proving to be among the best diagnostic indications of heart attacks. They help to identify many individuals with ACS who might otherwise be misdiagnosed.
Creatine kinase myocardial band (CK-MB). CK-MB has been a standard marker, but the MB fraction is not as accurate as troponin levels, since elevated levels can appear in people without heart injury.
Myoglobin. Myoglobin is a protein found in heart muscles. It is released early in the injured heart, and it may be useful in combination with CK-MB and the troponins.
Newer biomarkers, including C-reactive protein (CRP), homocysteine, B-type natriuretic peptide (BNP), urinary albumin, and fibrinogen.

Several 2006 studies that evaluated how well biomarkers predict risk of heart events concluded that they do not provide much more useful information than standard risk factors (high blood pressure, unhealthy cholesterol levels, diabetes). At this time, most experts feel that these standard disease risk factors provide the best predictors of the likelihood of developing coronary artery disease, heart attack, or stroke.

Managing Heart Disease

The approach for managing any degree of coronary artery disease involves lifestyle changes. Depending on severity and individual conditions, patients may need one or more medications, surgery, or both.

Healthy diet, regular exercise and quitting smoking if you are a smoker may prevent heart disease. Follow your health care provider's recommendations for treatment and prevention of heart disease.

Experts have come up with a mnemonic device (ABCDE) for remembering 10 factors that are fundamental for management of stable angina and coronary artery disease:

A. Aspirin and anti-angina drugs

B. Blood pressure and beta-blockers

C. Cholesterol-lowering drugs (typically statins) and cigarettes (stopping)

D. Diet and diabetes control

E. Exercise and education

Unstable angina is now usually classified with non-Q myocardial infarction as acute coronary syndrome (ACS) in professional discussions of treatments. ACS usually requires more aggressive treatments, including surgery. [ACS is more fully discussed in In-Depth Report #12: Heart attack and acute coronary syndrome.]

Click the icon to see an image about angina.

Anti-Clotting Medications

Anti-clotting drugs that inhibit or break up blood clots are used at every stage of heart disease. They are generally classified as either antiplatelets or anticoagulants. All anti-clotting therapies carry the risk of bleeding, which can lead to dangerous situations, including stroke.

A thrombus is a blood clot that forms in a vessel and remains there. An embolism is a clot that travels from the site where it formed to another location in the body. Thrombi or emboli can lodge in a blood vessel and block the flow of blood in that location depriving tissues of normal blood flow and oxygen. This can result in damage, destruction (infarction), or even death of the tissues (necrosis) in that area.

Antiplatelet Drugs. These drugs prevent formation of blood platelets. Platelets are very small disc-shaped blood cells that are important for blood clotting.

Aspirin. Aspirin is an antiplatelet. It is the most common anti-clotting drug. Nearly anyone with existing heart disease or at risk for it is advised to take a low-dose aspirin every day.
Thienopyridines. Clopidogrel (Plavix) and ticlopidine (Ticlid) are thienopyridines, another type of anti-platelet drug.
Glycoprotein IIb/IIIa Inhibitors. These powerful blood-thinning drugs include abciximab (ReoPro, Centocor), eptifibatide (Integrilin), tirofiban (Aggrastat), and lamifiban. They are administered intravenously in the hospital and are used after angioplasty surgery and stent placement.

Click the icon to see an image about blood.

Anticoagulants. Anticoagulants help thin blood and include:

Heparin
Warfarin (Coumadin)
Direct thrombin inhibitors

Aspirin. Aspirin is known as a nonsteroidal anti-inflammatory drug (NSAID). It stops blood platelets, which are major clotting factors, from sticking together to form a blood clot. A daily low-dose aspirin (75 - 325 mg) is usually the first choice for preventing heart disease in high-risk individuals. Aspirin can prevent by 25 – 50% the risk of heart attacks and death in people with existing heart disease and a history of heart attack. It also reduces the risk for stroke. According to a 2006 review, aspirin works equally well for both men and women.

Click the icon to see an image about stomach ulcers.

Side effects from prolonged use of aspirin may include stomach ulcers and bleeding. (There may be a slight increased risk for bleeding-related strokes, which are very uncommon, however. Furthermore, this risk may be outweighed by protection against the more common type of stroke, which is caused by artery blockage.)

Clopidogreland Ticlopidine. Clopidogrel (Plavix) and ticlopidine (Ticlide) are anti-platelet drugs known as thienopyridines. When taken with aspirin, these drugs can significantly reduce the risk for heart attack and stroke in patients with acute coronary syndrome (unstable angina or early signs of heart attack). The combination of aspirin and a thienopyridine is essential for patients who have a drug-eluting stent. According to a 2007 American Heart Association advisory, patients who have a drug-eluting stent must take both aspirin and a thienopyridine for at least 1 year after the stent is inserted. Many experts recommend clopidogrel instead of ticlopidine because ticlopidine has been associated with dangerous blood disorders, particularly thrombocytopenia.

Clopidogrel is also recommended for patients who are undergoing angioplasty. For patients having coronary bypass surgery, it should be withheld for at least 5 -7 days prior to surgery because of a significant bleeding risk. Researchers are investigating whether clopidogrel and aspirin together are better than aspirin alone in reducing the risks following coronary bypass surgery. A 2006 study suggested that for some patients with heart disease, clopidogrel plus aspirin does not work better than aspirin alone for preventing a first heart attack or stroke.

Click the icon to see an image of the developmental process of atherosclerosis.

Click the icon to see an image about atherosclerosis.

Anticoagulants are drugs that prevent or delay blood coagulation and the formation of blood clots. Heparin has been the standard anticoagulant, but a number of drugs are now available that are proving to be better choices in many cases.

Standard (Unfractionated) Heparin. The heparin referred to as unfractionated heparin has been the standard for years and is used alone or in combination with aspirin for managing unstable angina. It is no longer the recommended first choice, however, for this patient group. It must be intravenously administered and monitored with frequent blood tests. The major complication is thrombocytopenia (a severe drop in platelets). This condition is extremely serious and can become life-threatening, particularly with bleeding in various body tissues. Alternatives include low-molecular weight heparin and direct thrombin inhibitors.

Low-Molecular Weight Heparin. Enoxaparin (Lovenox), dalteparin (Fragmin), tinzaparin (Innohep) are drugs known as low-molecular weight heparins (LMWHs). Many doctors now recommend these drugs over standard heparin for patients with unstable angina (unless bypass surgery is being planned). They have similar rates of survival, recurring angina, and bleeding as standard heparin. However, they pose lower risks for heart attack, repeat angioplasties, and thrombocytopenia. They require injections but do not require the ongoing monitoring that standard heparin does. Patients may even be able to self-administer LMWHs as people with diabetes do insulin.

Warfarin. Warfarin (Coumadin) is an oral anticoagulant. It prevents clots by inhibiting vitamin K. Warfarin is used with aspirin after a heart attack to prevent another one and to prevent blood clots in patients with atrial fibrillation. Warfarin is also proving to be more effective than aspirin for preventing heart attacks in patients with acute coronary syndromes. Warfarin therapy poses a dangerous risk for bleeding and blood coagulation must be monitored with frequent blood tests.

Direct Thrombin Inhibitors (DTIs). Direct thrombin inhibitors are a more recent group of anti-coagulants. The first DTI was hirudin, a natural substance derived from the saliva of leeches. New forms include argatroban (Novastan), bivalirudin (Angiomax), danaparoid (Orgaran), lepirudin (Refludan), desirudin (Revasc), and ximelagatran (Exanta). Many of these drugs are used along with warfarin and may be good options for patients who develop thrombocytopenia with heparin use. DTIs may prove to be superior to standard heparin for patients with acute coronary syndrome.

Other Medications

Nitrates have been used in the treatment of angina for over 100 years. These drugs release nitric oxide, thereby relaxing the smooth muscles in blood vessels. Many nitrate preparations are available. The most commonly used are nitroglycerin, isosorbide dinitrate, and isosorbide mononitrate. Nitrates can be absorbed from the gastrointestinal tract (oral tablet), skin (ointment or patch), or from under the tongue (sublingual tablet or spray).

Rapid Acting Nitrates. Rapid-acting nitrates are used to treat acute attacks. Nitroglycerin is the most widely used drug for this purpose. It can be administered under the tongue (sublingually or as a spray) or pocketed between the upper lip and gum (buccally) and can relieve angina within minutes. The procedure for taking nitroglycerin during an attack is as follows:

At the onset of an angina attack, the patient administers one sublingual or buccal tablet or one metered dose of the spray.
If the pain is not relieved within 5 minutes the patient takes a second dose; a third can be taken after another 5 minutes if symptoms persist.
If pain continues after a total of three doses in 15 minutes, the patient should go immediately to the nearest emergency room.

Nitroglycerin is very volatile so its potency can be easily lost. Patients should take the following precautions:

Keep no more than 100 tablets on hand, stored in their original container.
When first opened, the cotton filler should be discarded, and the cap screwed on tightly immediately after each use.
A supply should always be kept close at hand in case of an attack, with the rest kept in a cool dry place.

Intermediate to Long-Term Nitrates. Sublingual tablets of isosorbide dinitrate have a somewhat slower onset of action than nitroglycerin and are useful for preventing exercise angina. Ointments, patches, and oral tablets are used for longer-term prevention of angina attacks:

Transdermal patches are applied in the morning to any hair- or injury-free area on the chest, back, stomach, thigh, or upper arm. Hands should be washed after each patch or ointment application, and sites of application should be rotated to avoid skin irritation.
Nitroglycerin ointment is applied by measuring out an even amount on an applicator paper and then placing, not rubbing or massaging, it on the chest, stomach, or thigh. Any ointment that remains from the previous application should be removed.

Long-acting forms may lose their effectiveness over time, so doctors generally schedule nitrate-free breaks to prevent tolerance. Some concern exists that nitrate-free periods might increase the risk for angina and adverse heart events. One large study, however, found no increased danger when patients used a nitroglycerine patch with scheduled breaks. The use of high blood pressure drugs known as ACE inhibitors may help prevent tolerance to nitrates.

Side Effects. Nitrates have many side effects, some of which can be serious.

Common side effects of nitrates include headaches, dizziness, nausea and vomiting, blurred vision, fast heartbeat, sweating, and flushing on the face and neck. Low blood pressure and dizziness can be relieved by lying down with the legs elevated. These effects are significantly worsened by alcohol, beta-blockers, calcium channel blockers, sildenafil (Viagra), and certain antidepressants. The doctor may prescribe medicines to lessen these side effects. Patients should contact their doctor if these side effects are persistent or severe.

Serious side effects requiring immediate medical help include fever, joint or chest pain, sore throat, skin rash (especially on the face), unusual bleeding or bruising, weight gain, and swelling of the ankles.

Withdrawal. Withdrawal from nitrates should be gradual. Abrupt termination may cause angina attacks.

Beta-blockers are useful for preventing angina attacks and reducing high blood pressure. They reduce the heart's oxygen demand by slowing the heart rate and lowering blood pressure. They are recognized for reducing deaths from heart disease and from heart surgeries, including angiography and coronary bypass. Beta-blockers are the drugs of choice for older patients with stable angina and may also be beneficial for people with silent ischemia. They are, however, less useful for the treatment of Prinzmetal’s angina. Beta-blockers are often prescribed along with other drugs such as nitrates, calcium channel blockers, or statins. A 2006 study suggested that beta-blockers and statins may help stabilize coronary artery disease and prevent the development of heart attacks.

Specific Beta-blockers. Beta-blockers include propranolol (Inderal), carvedilol (Coreg), bisoprolol (Zebeta), acebutolol (Sectral), atenolol (Tenormin), labetalol (Normodyne, Trandate), metoprolol (Lopressor, Toprol-XL), and esmolol (Brevibloc). A nasal spray form of propranolol appears to be very helpful in reducing exercise-induced angina attacks.

Side Effects. Beta-blocker side effects include fatigue, lethargy, vivid dreams and nightmares, depression, memory loss, and dizziness. They can lower HDL (“good”) cholesterol. Beta blockers are categorized as non-selective or selective. Non-selective beta blockers such as carvedilol and propranolol can narrow bronchial airways. These beta-blockers should not be used by patients with asthma, emphysema, or chronic bronchitis.

Patients should never abruptly stop taking these drugs. The sudden withdrawal of beta-blockers can rapidly increase heart rate and blood pressure. The doctor may advise a patient to slowly decrease the dose before stopping completely.

Calcium channel blockers reduce heart rate and slightly dilate the blood vessels of the heart, thereby decreasing oxygen demand and increasing oxygen supply. They also reduce blood pressure. CCBs vary chemically, however, and although some are helpful, others may even be dangerous for certain patients with angina.

Click the icon to see an image of the anterior heart arteries.

Long-acting nifedipine (Adalat, Procardia) and nisoldipine (Sular) and newer CCBs, such as amlodipine (Norvasc) and nicardipine (Cardene), may be beneficial for some patients with angina. They can be considered alone for patients who cannot tolerate beta-blockers, but may provide the best results when used in combination with a beta-blocker. Studies suggest that they reduce the need for repeat angioplasties. Their effects on other outcomes, including mortality rates and heart attack, are less clear.
Short-acting CCBs, including short-acting forms of verapamil, diltiazem, nifedipine, and nicardipine, are helpful for many patients with Prinzmetal's angina. However, short-acting forms of certain CCBs, such as nifedipine and nisoldipine, have been associated with severe and even dangerous side effects, including an increase in heart attacks and sudden death in some patients with unstable angina. They also increase the risk for adverse effects in patients with stable angina. Short-acting CCBs are, therefore, not used for stable or unstable angina.

There is no strong evidence that any calcium channel blockers improve survival rates. Overdose can cause dangerously low blood pressure and slow heart beats. Patients with heart failure have a higher risk for death with these drugs and should not take them. No one taking any calcium channel blocker should withdraw abruptly because such action could dangerously increase the risk of high blood pressure. Note: Grapefruit and Seville oranges boost the effects of CCBs, sometimes to toxic levels. (Regular oranges do not appear to pose any hazard.)

Angiotensin converting enzyme (ACE) inhibitors are important heart-protective drugs, particularly for people with diabetes and high blood pressure. They reduce the production of angiotensin, a chemical that causes arteries to narrow, and so are commonly used to lower blood pressure. They may also reduce risk for heart attack, stroke, complications of diabetes, and death in patients at high risk for heart disease.

ACE inhibitors include captopril (Capoten), ramipril (Altace), enalapril (Vasotec), quinapril (Accupril), benazepril (Lotensin), perindopril (Aceon), and lisinopril (Prinivil, Zestril).

Side Effects. Side effects of ACE inhibitors are uncommon but may include an irritating cough, excessive drops in blood pressure, and allergic reactions. In the past, doctors sometimes avoided giving aspirin to patients who were taking ACE inhibitors because the combination was believed to cause kidney problems. But, a 2005 study of patients with both coronary artery disease and heart failure found that taking aspirin and ACE inhibitord together is safe. The researchers also noted that taking aspirin with an ACE inhibitor can significantly reduce the risk of death for older patients with CAD and heart failure. [See In-Depth Report #14: High blood pressure.]

In 2004, the National Cholesterol Education Program issued updated recommendations on how to control cholesterol levels. These guidelines emphasize that patients should lower their LDL (“bad”) cholesterol and recommend that more people take LDL-lowering medication. Lowering LDL cholesterol and raising HDL (“good”) cholesterol can significantly reduce the risks of heart disease. Several different types of drugs (statins, bile-acid binding resins, niacin, and fibrates) are used to treat cholesterol. [See In-Depth Report #23: Cholesterol.]

Statins are the most important of these drugs. Brands include lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor), fluvastatin (Lescol), atorvastatin (Lipitor), and rosuvastatin (Crestor). A major analysis of over 200 studies found that statins reduced the risk for heart problems by 60% and stroke by 17%. A 2005 review found that the more that statins lower LDL, the more they reduce CAD and other heart disease risks.

An important 2006 study found that aggressive treatment with statins may have the potential to reverse coronary artery disease. In the study, rosuvastatin reduced fatty plaque in the arteries in addition to improving LDL and HDL cholesterol levels. However, a follow-up 2007 study of rosuvastatin indicated that while the drug slowed the rate of atherosclerotic progression, it did not reverse heart disease. Future studies will continue to investigate this issue.

Side effects of statins may include stomach upset, headaches, skin rashes, muscle aches, sexual dysfunction, drowsiness, dizziness, nausea, constipation, and peripheral neuropathy (numbness or tingling in the hands and feet).

The main safety concern with statins is an uncommon condition called myopathy, which can cause muscle and joint pain and possible muscle damage. Doctors will immediately stop statin therapy if myopathy occurs. Patients should talk to their doctor about any unusual muscle discomfort or weakness, or if their urine becomes brown-colored. Statins can also affect the liver, particularly at higher doses, so patients taking these drugs should receive regular liver function tests.

Click the icon to see an image of cholesterol.

Influenza Vaccinations (Flu Shots). Evidence suggests influenza vaccinations help protect against adverse heart events (including after heart surgeries), stroke, and death from all causes in the elderly. Still, studies suggest that only two-thirds of at risk people are vaccinated, mostly because of unwarranted fears of ineffectiveness or adverse effects.

Antibiotics. Researchers have investigated antibiotics for treating patients with heart disease and past infection of the bacteria Chlamydia pneumoniae. Results from several recent large-scale clinical trials suggest that antibiotic treatment provides no benefit in preventing heart attack or other cardiac events in patients with coronary artery disease. In addition, a 2006 study indicated that short-term treatment with the antibiotic clarithromycin may increase the risk for death in patients with coronary artery disease. While it is still possible that C. pneumoniae may play a role in triggering inflammatory responses associated with ACS, antibiotic therapy is no longer considered appropriate for treatment or prevention of heart disease.

Ranolazine (Ranexa) was approved in 2006 for treatment of chronic angina. It is recommended for patients who have not responded to other angina drugs. Ranolazine is taken in combination with amlodipine, beta blockers, or nitrates. The drug appears to work better in men than in women

Gene Therapy and Angiogenesis. Proteins known as growth factors are being investigated for their ability to grow new blood vessels for supplying oxygen to the heart. After promising small trials, two large studies of genetically engineered forms of vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF [GenerX]) failed to detect any benefits. Studies on therapies that actually genetically encode these proteins are underway.

Testosterone Supplements. Some trials using testosterone supplements or patches have reported improved exercise-induced blood flow in the coronary arteries and improvement in angina in some cases. Supplements of this male hormone, however, may increase the risk for prostate cancer. Experts suggest that testosterone be used only in older men with significant deficiencies in testosterone.

Selective Estrogen-Receptor Modulators (SERMs). Selective estrogen-receptor modulators (SERMs), including raloxifene (Evista), have been designed to produce the benefits of estrogen without its risks. They are thought to act like estrogen in some tissues but behave like estrogen blockers (antiestrogens) in others. Raloxifene may have some heart benefits, although it poses a risk for deep vein blood clots, which may have long-term implications for patients with heart problems. A major study is underway to determine its effects on the heart.

Surgery

Surgery is usually recommended for patients who have:

Unstable angina that does not respond promptly to medical treatment
Severe recurrent episodes of angina that last more than 20 minutes
Acute coronary syndrome
Severe coronary artery disease (severe angina, multi-artery involvement, evidence of ischemia), particularly if abnormalities are evident in the left ventricle of the heart, the main pumping chamber

Atherosclerosis is a disease of the arteries in which fatty material is deposited in the vessel wall, resulting in narrowing and eventual impairment of blood flow. Severely restricted blood flow in the arteries to the heart muscle leads to symptoms such as chest pain. Atherosclerosis shows no symptoms until a complication occurs.

Researchers have been investigating whether surgery offers any advantages if used as an early treatment for mild angina. A major analysis in 2003 reported that the use of angioplasty in patients with mild heart blockage did not reduce the risk for heart attack or death over the long term. A landmark 2007 study found that angioplasty was no better than drug therapy for preventing heart attack and stroke in patients with stable coronary artery disease. (For more information, see Angioplasty and Stents.)

Two effective surgical procedures for heart patients are:

Coronary artery bypass grafting (commonly called bypass or CABG)
Percutaneous coronary intervention (commonly called angioplasty or PCI), usually with coronary artery stent placement

Click the icon to see an image about bypass grafting.

Each of these procedures is described below.

Studies have generally reported similar survival rates with either procedure. There are some differences, however, and decision often depends on individual conditions. Patients considering surgery should discuss all options and risks with their doctor. No surgical procedure cures coronary artery disease, and patients must continue to rigorously maintain a healthy lifestyle and any necessary medications. For some patients, lifestyle changes and medications may be able to control the disease without surgery or angioplasty.

Considerations for Choosing Angioplasty with Stent Placement. Angioplasty has the following advantages for most patients. It is:

Less invasive than bypass. (Although a minimally invasive variation of bypass surgery may reduce this distinction.)
Less expensive than bypass. (Although the postoperative need for more medications and the high risk for repeat procedures to reopen the artery may reduce the long-term difference in cost between the two procedures.)
Life-saving emergency procedure for many patients with heart attacks. (The use of bypass after a heart attack has much higher mortality rates than when it is used electively and its use is controversial in heart attack patients.)

It has the following disadvantages:

The blood vessels can close up again (restenosis) so that patients require additional procedures. (New blood thinning drugs, coronary stent coatings, and radiation treatments may help to significantly reduce restenosis rates. However, there is also some indication that stents, especially drug-eluting stents, may increase the risk for blood clots.)
It is not as appropriate as bypass for many patients with angina (people with diabetes, elderly patients, or those with multi-vessel blockage). Increasingly, however, angioplasty is proving to be as safe and as effective as bypass in many high-risk patients. Patients should be sure to discuss with their doctors the relevant risks and benefits of angioplasty and bypass.

Considerations for Choosing Bypass. Bypass is usually the appropriate procedure in patients with high-risk conditions, such as:

Multi-vessel blockage. (In one report comparing surgery to angioplasty in patients with two or three blocked vessels, the mortality rate 1 year after bypass was 0.8% and after angioplasty was 2.5%. About 80% of patients in the study were men.)
Diabetes. (Bypass produces significantly higher survival rates in these patients. Some experts believe angioplasty should rarely, if ever, be used in this population.)
Being elderly.
Certain structural features, such as a left main artery narrowed by 50% or more or a very long diseased portion of the artery.

Considerations for Women. Studies have reported higher mortality rates in women than in men after any heart surgery. Some experts theorize that on average women may be older and sicker when they have a heart operation. A 2002 study, however, suggested that when women with acute coronary syndromes are given the same aggressive and early treatment as men are, their survival rates are equal or even better.

In addition to angioplasty and bypass procedures, a number of other procedures are available or under investigation for coronary artery disease. They include:

Atherectomy
Myocardial Laser Revascularization
Enhanced External Counterpulsation (EECP)

Coronary Artery Bypass Graft Surgery

Coronary artery bypass graft surgery (CABG) is a good alternative to angioplasty for many patients, but it is very invasive. The surgery involves the following processes:

Click the icon to see an animation about CABG.

The chest is opened, and the blood is rerouted through a lung-heart machine.
The heart is stopped during the procedure.
Large blood vessels supply the grafts, which are used to reroute the blood. The blood vessel grafts are transplanted in front of and beyond the blocked arteries, so the blood flows through the new vessels around the blockage.
The standard grafts now use arteries taken from the chest wall. Studies are reporting that with such grafts arteries remain open in 90% of cases after 15 years.
In general, patients with triple bypass procedures stay in the hospital for 5 days. Those with one-vessel bypass may be able to go home in 3 days.

Click the icon to see an illustrated series detailing a heart bypass surgery.

In spite of the invasive nature of this procedure, elective bypass procedures produce better long-term survival rates than angioplasty, particularly in patients with diabetes and multi-vessel blockage. Overall mortality rates after this procedure range from 1% to slightly over 2%. The risk for stroke or heart attack after a bypass operation ranges from 1.3 - 5%. Finding a surgeon who performs at least 100 of the procedures a year helps reduce the risk for complications.

Blood clots may form in the new graft, closing it up or narrowing the treated vessel over time. Therapy with aspirin and other anti-clotting drugs help keep the graft open and working properly. For long-term prevention of closure, as well as for slowing progression of atherosclerosis, aggressive treatment with cholesterol-lowering drugs may be more beneficial than standard anti-clotting drugs.

Bleeding is also a potential complication of CABG. Anti-bleeding (also called hemorrhage-sparing) drugs are sometimes used to limit blood loss in patients who undergo this surgery. In 2006, concerns were raised about one of these drugs, aprotinin (Trasylol). Data suggested that aprotinin seriously increased the risks for kidney failure, heart failure, and stroke.

An important study, published in 2007 in the Journal of the American Medical Association, compared aprotinin with two anti-fibrinolytic drugs, aminocaproic acid (Amicar) and tranexamic acid (Cyklokapron), which are also used to control blood loss. The study of nearly 4,000 patients who had CABG found that over a 5-year period, the death rate for patients who took aprotinin was 21%, and patients had a 48% increased risk of dying. By comparison, the death rate was 16% for aminocaproic acid, 15% for tranexamic acid, and 13% for no anti-bleeding drug. Because aprotinin is more expensive as well as potentially more dangerous than other anti-bleeding drugs, experts are now recommending against its use in CABG.

Minimally invasive bypass (also called buttonhole or keyhole bypass) surgeries are exciting advances in basic bypass surgery. Studies indicate good success of these procedures for patients with disease in single vessels. They are also being investigated for multiple vessels.

One variation of minimally invasive bypass uses a four-inch incision. The surgeon works on the front of the heart while it is beating slowly. To date, there have been no differences in cardiac events or later mental complications between this so-called off-pump procedure and the standard bypass procedure.
In another variation, the heart is stopped, and the patient is put on a machine that reroutes the blood through a device that keeps it oxygenated. Fiberoptic scopes and instruments are passed through a number of finger-sized incisions. The surgeon works on all sides of the heart, guided by a video image from a tiny camera inserted through a 4-inch incision.
Some advanced heart centers now use robotic systems, which allow the surgeon to perform extremely delicate maneuvers on tiny vessels through pencil-size incisions. They are not yet used for the whole bypass process.

Eventually, minimally invasive bypass procedures may prove to be less expensive, require a shorter hospital stay, and have fewer complications than conventional coronary artery bypass surgery -- or even angioplasty. At this time, however, they are experimental procedures, performed in only a few medical centers for select candidates. Long term-success rates are unknown.

Angioplasty and Stents

Percutaneous coronary intervention (PCI), also called angioplasty, involves procedures such as percutaneous transluminal coronary angioplasty (PTCA) that help open the blocked artery.

Click the icon to see an animation about percutaneous transluminal coronary angioplasty.

A typical angioplasty procedure follows these steps:

The cardiologist threads a narrow catheter (a tube) containing a catheter into the blocked vessel.
The doctor opens the blocked vessel using balloon angioplasty, in which the surgeon passes a tiny deflated balloon through the catheter to the vessel.
The balloon is inflated to compress the plaque against the walls of the artery, flattening it out so that blood can once again flow through the blood vessel freely.
In order to keep the artery open afterwards, surgeons use a device called a coronary stent, an expandable metal mesh tube that is implanted during angioplasty at the site of the blockage. (In some cases, a stent may be used as the initial opening device instead of balloon angioplasty.)
Once in place, the stent pushes against the wall of the artery to keep it open.

Click the icon to see an animation about percutaneous transluminal coronary angioplasty.

Complications occur in about 10% of patients (about 80% within the first day). Outcomes are better in hospital settings with experienced teams and backup.

Click the icon to see an illustrated series detailing coronary artery balloon angioplasty surgery.

The most important long-term complication is reclosure (restenosis), which can lead to heart attack if not treated with a repeat procedure. Stenting and other advances have helped significantly in preventing reclosure and reducing heart attack rates. Nevertheless, a repeat procedure is still needed to restore the opening in 10 - 15% of procedures that use stents.

PCI (angioplasty) has been proven to help reduce the frequency of angina attacks. It is commonly recommended for patients who have critically blocked arteries or have already had a recent, acute heart attack. PCI can also help improve survival and prevent heart attacks in patients with acute coronary syndrome (ACS). However, doctors have been uncertain about angioplasty’s benefits for survival and heart attack prevention in lower-risk patients with stable coronary artery disease.

In 2007, a landmark study was published in the New England Journal of Medicine and presented at the 2007 meeting of the American College of Cardiology. The COURAGE study found that PCI works no better than standard heart medication (drugs to control blood pressure, lower cholesterol, and prevent blood clots) in preventing heart attack, stroke, and hospitalization in patients with stable coronary artery disease. Based on this study’s findings, experts are now recommending angioplasty only for patients who have severe heart disease. For patients with stable heart disease, drug therapy may be sufficient enough treatment and allow them to safely defer having surgery.

Angioplasty is less invasive than bypass surgery, requiring only one night in the hospital. Recuperation takes about a week. Chest pain after the procedure is very common and usually due to problems other than ischemia. Mild chest pain is even more common when a stent is used, possibly because the artery is stretched.

Reclosure of the artery during or shortly after angioplasty often occurs. A number of anti-clotting drugs are used to help prevent this.

Aspirin and the anti-platelet drug clopidogrel (Plavix) are often used to prevent reclosure during the procedure.
A high dose of the anticoagulant heparin is typically given before the operation.
Intravenous glycoprotein IIb/IIIa inhibitors, powerful drugs that block platelets, also prevent reclosure after stenting in many high-risk patients, and evidence now strongly suggests that they reduce rates of heart attack and death. Eptifibatide (Integrilin) and tirofiban (Aggrastat) are the standard drugs used during angioplasty. They may be most effective if administered during angioplasty, rather than beforehand.

All of these drugs pose a risk for bleeding complications.

Narrowing or reclosing of the artery (restenosis) can occur within a year of angioplasty or even longer in 15 - 60% of angioplasty patients. Coronary stents, anti-clotting drugs, and other advances have reduced these events significantly, but have not eliminated the problem. Theories for the cause of restenosis include:

The release of oxidants (damaging unstable particles) at the surgical site may cause injury and activate immune factors that produce cellular overgrowth in smooth muscles of the blood vessels.
Other activities, including scarring, may remodel and narrow the blood vessels. (This is most likely the reason for restenosis in patients with stents.)

Symptoms of restenosis include chest pain on exertion. (Heart attacks, however, do not usually occur with such events.) The narrowing of the artery in this case is not due to blood clots, so anti-clotting drugs are not useful. Restenosis usually requires a repeat operation. A number of approaches, mostly investigative, have been developed to prevent restenosis after angioplasty.

Drug-Coated Stents. Stents coated with the drugs sirolimus (Rapamune) or paclitaxel (Taxol) have been increasingly used in the last several years. Drug-eluting stents (as they are also called) can help prevent restenosis. However, because drug-eluting stents reduce arterial tissue growth, they can increase the risks of blood clots. In late 2006, the FDA held several meetings to discuss the increased risks of blood clots associated with drug-eluting stents. The committees found that drug-eluting stents do appear to have a small increased risk of blood clots compared to bare metal stents, but not enough research has been conducted to fully determine their risks for heart attack and death.

Five studies published in the New England Journal of Medicine in March 2007 indicated that drug-eluting stents are safe and effective for patients with coronary artery disease when they are used for FDA-approved indications. Problems have arisen when these stents are used for “off-label” purposes in patients with more complicated health problems. There is still some concern as to whether all stents (both bare metal and drug eluting) are used too frequently for patients who may be better served by drugs or bypass surgery.

In February 2007, the American Heart Association and other professional organization issued an extremely important joint advisory statement. The statement advises that all patients who have drug-eluting stents must continue to take aspirin and clopidogrel (or, rarely, ticlopidine) for at least 1 year after the stent is inserted to reduce the risk of blood clots. Clopidogrel and ticlopidine are thienopyridine drugs that, like aspirin, help prevent blood platelets from clumping together. It is very important that patients who have drug-eluting stents take both aspirin and a thienopyridine drug. If for some reason patients cannot take a thienopyridine drug, they should receive a bare metal stent instead of a drug-eluting stent.

Coronary Artery Brachytherapy. Radiation treatment called coronary artery brachytherapy (Gamma One, Beta-Cath) can slow the cell growth in the arteries that causes restenosis. With this approach, any blockage in the stent is first removed, and a tube with an inflatable balloon is inserted. The surgeon then implants a temporary device that delivers radiation. Brachytherapy has shown excellent results in preventing restenosis and significantly reducing heart events and improving survival. Brachytherapy is also showing promise in preventing restenosis in stented artery grafts that were put in place after bypass surgery and later failed. However, several 2006 studies in the Journal of the American Medical Association indicated that drug-coated stents may work better than brachytherapy in preventing restenosis in failed stents. In these studies, the drug-coated stents were inserted inside the original bare metal stents.

Medications. A number of medications are being studied for prevention of restenosis, although benefits to date have been modest. Other drugs under investigation include statins, various anti-clotting drugs, and B vitamins.

Other Procedures. Other procedures under investigation to keep the arteries open use ultrasound, "soft" x-rays, and cryotherapy (very low temperatures).

Other Treatments

Transmyocardial laser revascularization (TMLR) applies laser energy directly to areas in the heart where blockage has occurred, creating 10 - 50 tiny channels. TMLR is recommended for patients with severe angina who have not responded to surgical bypass or angioplasty procedures. TMLR is not suitable for patients who have severely damaged heart muscles. A variant called percutaneous transmyocardial laser revascularization uses a small laser (a holmium YAG laser), which is smaller than the device used in TMLR and does not require open chest surgery and a general anesthetic.

Patients report improved symptoms and exercise tolerance. Both procedures carry risks for serious complications, however, including some that can be life-threatening. It is not clear if either TMLR procedure improves survival, and, in one study, the quality of life afterwards was less than with standard heart surgeries.

A noninvasive technique called enhanced external counterpulsation (EECP) has been used successfully by over a million people in China. The technique uses an air pump that inflates and deflates pressurized cuffs around the legs, causing blood to be pushed into the heart.

EECP may help patients with angina who have not had pain relief from nitrate drugs and who do not qualify as candidates for bypass or angioplasty. In different studies, it has relieved angina in over 75% of patients who used it and reduced the need for medication. The benefits persist, and there is some evidence that it produces actual cellular changes that benefit the heart. In 2002, the FDA approved EECP for the treatment of heart failure but some insurance companies still consider its use “experimental” and will not pay for it. EECP is not recommended for patients with arrhythmia, serious heart valve problems, or peripheral artery disease.

Atherectomy procedures clear the narrowed arteries by using an approach called debulking. All of these procedures use a catheter (a thin tube) that is inserted into an artery (usually in the groin) and threaded up to the blockage. Devices are inserted through the tube to remove the plaque. They include:

Rotational atherectomy, which uses a tiny cutter spinning at 2,500 rpm
Extractional atherectomy, which "shaves" the plaque
Directional atherectomy, which slices the plaques

Although they are successful in opening arteries, they offer no advantages over standard angioplasty and are used only for special cases.

Resources

www.nhlbi.nih.gov -- National Heart, Lung, and Blood Institute
www.americanheart.org -- American Heart Association
www.acc.org -- American College of Cardiology

References

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Crouse JR 3rd, Raichlen JS, Riley WA, Evans GW, Palmer MK, O'Leary DH, et al. Effect of rosuvastatin on progression of carotid intima-media thickness in low-risk individuals with subclinical atherosclerosis: the METEOR Trial. JAMA. 2007 Mar 28;297(12):1344-53. Epub 2007 Mar 25.

Eisenstein EL, Anstrom KJ, Kong DF, Shaw LK, Tuttle RH, Mark DB, et al. Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA. 2007 Jan 10;297(2):159-68. Epub 2006 Dec 5.

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Lagerqvist B, James SK, Stenestrand U, Lindback J, Nilsson T, Wallentin L; SCAAR Study Group. Long-term outcomes with drug-eluting stents versus bare-metal stents in Sweden. N Engl J Med. 2007 Mar 8;356(10):1009-19. Epub 2007 Feb 12.

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Review Date:
4/16/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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Peripheral artery disease and intermittent claudication

FitSugar — Wed, 08 Oct 2008 17:35:09 -0700

In This Report

Highlights
Introduction
Symptoms
Risk Factors
Diagnosis
Complications
Lifestyle Changes
Medications
Reducing Heart Risks
Surgery
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Peripheral Artery Disease (PAD) Risks

Smoking, unhealthy cholesterol levels, and diabetes are the main risk factors for PAD. According to a 2006 study in Circulation, they affect PAD in different ways:

Smoking and high cholesterol are more likely to cause PAD progression in the large vessels of the legs. Painful cramps in the hips, thighs, and calves -- especially those that occur during exercise -- are the tell-tale symptoms.
Diabetes is more likely to cause PAD progression in the small vessels of the feet. Symptoms include foot ulcers that are slow to heal.

According to the American Heart Association, quitting smoking is the best way to prevent PAD and slow its progression. Patients should also control cholesterol through exercise, diet, and medications.

PAD and Heart Disease

Patients with PAD have a 1 in 5 chance of having a heart attack or stroke, or dying from a heart-related event, within the course of a year, indicates a 2007 study in the Journal of the American Medical Association (JAMA). Blood clots in other arteries (brain, heart) further double this risk.
PAD also increases the risk of dying from heart surgery or other interventional heart procedures, suggests a 2006 Journal of the American College of Cardiology study. Surgeons should take extra care when treating patients with PAD.

Exercise is Essential

Exercise is important for preventing PAD, and essential for those with the disease. According to a 2006 Circulation study, patients with PAD who are the most physically active have a third of the chance of dying than those who are inactive.
For patients who have difficulty walking, arm aerobics may be a helpful alternative and can actually help improve walking ability, suggests research presented at the 2006 American Heart Association Scientific Sessions.

Introduction

Peripheral artery disease (PAD) occurs when the arteries in the extremities (feet, legs, hands, and arms) become clogged with a fatty substance called plaque. It most often occurs in the legs. The build up of plaque causes the arteries to become narrow and hard, which obstructs blood flow. This hardening of the arteries is called atherosclerosis. (Atherosclerosis that affects arteries to the heart and brain is the major process leading to heart disease and stroke.)

PAD is also called peripheral arterial disease and peripheral vascular disease.

Atherosclerosis of the extremities is a disease of the peripheral blood vessels. It is characterized by narrowing and hardening of the arteries that supply the legs and feet. The narrowing causes a decrease in blood flow. Symptoms include leg pain, numbness, cold legs or feet, and muscle pain in the thighs, calves or feet.

Symptoms

People with peripheral artery disease (PAD) may or may not have symptoms. Because of silent symptoms, many cases of PAD go undiagnosed.

Claudication comes from the Latin word "to limp." Claudication is crampy leg pain that occurs during exercise, especially walking. The pain is due to insufficient blood flow in the legs (caused by blocked arteries). Intermittent means the pain comes and goes. Intermittent claudication is the most prominent symptom of PAD. About a third to a half of patients with PAD have this symptom.

The most frequently affected artery in intermittent claudication is the popliteal artery. This artery leads off from the femoral artery (the major artery in the thigh). It continues below the knee where it branches off and carries blood to the muscles in the calf and foot. You should be sure to talk to your doctor about any leg or thigh pain you are experiencing.

PAD-related leg pain is relieved only by rest. Leg pain occurs in one leg in 40% of patients and in both legs in 60% of patients. Patients may also experience fatigue or pain in the thighs and buttocks.

There is also some evidence that people with PAD have blood cells that are prone to forming clots.

In advanced cases, the arteries are so blocked that even rest does not help. Leg pain that continues when lying down is called ischemic rest pain. Ischemia is the medical term for insufficient blood flow to tissues.

People with ischemic rest pain are at risk for ulcers and gangrene. In severe cases, amputation may be required.

Symptoms of advanced PAD can include:

Calf muscles that shrink (wither)
Hair loss over the toes and feet
Thick toenails
Shiny, tight skin
Painful non-bleeding ulcers on the feet or toes (usually black) that are slow to heal

In some cases, blood clots form in the arteries in the legs, producing abrupt symptoms.

Risk Factors

About 10 million American adults have peripheral artery disease (PAD). Although it was once believed that PAD occurs more often in men than women, current research now indicates that both genders are equally susceptible. African-Americans have twice the risk for PAD as Caucasians.

The most important risk factors for PAD and intermittent claudication are the same as the major risk factors for heart disease and stroke. People with a combination of these conditions (including PAD) are at increased risk of a more severe form of the heart or circulatory disease. Smoking and high cholesterol levels may increase the risk for PAD progression in large blood vessels (such as the legs), while diabetes increases the risk for PAD in small blood vessels (such as the feet). Quitting smoking and controlling cholesterol are the two best ways to slow PAD progression.

The most important risk factors for PAD include:

Smoking. Experts believe that smoking is the number one risk factor for PAD and that smoking even a few cigarettes a day can interfere with PAD treatment. Smoking increases the risk for PAD by 2 - 25 times, with the danger being higher when other risk factors are present. One study reported that 90% of patients with PAD were current or former smokers. [See In-Depth Report #41: Smoking.]
Diabetes. People with type 2 diabetes have 3 – 4 times the normal risk for PAD and intermittent claudication. In fact, their risk for PAD is higher than their risk for heart disease. People with type 2 diabetes also tend to develop PAD at an earlier age and have more severe cases. Patients with both diabetes and PAD are at high risk for complications in the feet and ankles. In one study, people with diabetes and intermittent claudication had a 30% chance of developing skin ulcers on their legs. [See In-Depth Report #60: Diabetes - type 2.]
Unhealthy cholesterol and lipid levels. The risk for PAD increases by 10% with every 10 mg/dL increase in total cholesterol levels. Low levels of high-density lipoprotein (HDL, the so-called good cholesterol) and high triglyceride levels also increase the risk for PAD. [See In-Depth Report #23: Cholesterol.]
Hypertension. High blood pressure doubles the chances for PAD. [See In-Depth Report #14: High blood pressure.]

Blood pressure is the force applied against the walls of the arteries as the heart pumps blood through the body. The pressure is determined by the force and amount of blood pumped and the size and flexibility of the arteries.

Family history of heart and artery disease. Genetic factors that cause specific lipid and cholesterol abnormalities may increase the risk for PAD.
Artery inflammation and damage. High levels of C-reactive protein can indicate persistent inflammation in the arteries. Such inflammation can cause significant damage in blood vessels, and is highly associated with PAD
Age. PAD occurs more frequently in people over age 50 and affects 12 – 20% of Americans age 65 years and older.
Ethnicity. African-Americans are at highest risk for PAD. They are twice as likely to develop PAD as Caucasians.

Homocysteine. Abnormally high blood levels of the amino acid homocysteine have been linked to an increased risk of heart disease, stroke, and PAD. Excessive levels occur with deficiencies of vitamins B6, B12, and folic acid. Scientists are continuing to research connections between homocysteine and heart and vascular disease. Some experts believe that high levels of homocysteine are only indicators, not causes, of heart disease.

Click the icon to see an image of vitamin B12 sources.

Click the icon to see an image of sources of folate.

Infectious Organisms. Some microorganisms and viruses may be able to trigger the inflammation and damage in the arteries that contribute to heart disease and peripheral artery disease.

The primary suspect has been Chlamydia pneumoniae, a non-bacterial organism that causes mild pneumonia in young adults. In one study, treatment with antibiotics in patients with evidence of a previous C. pneumoniae infection appeared to reduce PAD-related plaque build up. However, until better studies are conducted, experts do not recommend antibiotics to treat heart disease or PAD even in patients with evidence of C. pneumoniae.

It should be noted that many people have been infected with C. pneumoniae, and some studies have found no evidence that it increases the risk for heart disease.

Diagnosis

PAD is greatly under diagnosed. Many patients do not report symptoms, or may not even have symptoms. People should be checked for peripheral artery disease if they have risk factors for heart disease, leg pain during walking, or ulcers on their legs.

The doctor should perform a number of physical examinations to check for high blood pressure, heart abnormalities, blockage(s) in the artery in the neck, and abdominal aneurysms. The doctor should also examine the skin of the legs and feet for color changes, ulcers, infection, or injuries, and check the pulse of the arteries in the leg.

Intermittent claudication caused by peripheral artery disease is typically diagnosed using a procedure called Doppler ultrasound and a calculation called the ankle-brachial index. This method is also proving to be a helpful way to diagnose PAD in patients without symptoms of intermittent claudication.

The procedure is done as follows:

The doctor measures the systolic blood pressure of both arms while the patient is lying down. (The systolic pressure is the "top" number in a blood pressure measurement. It is the force that blood exerts on the artery walls as the heart contracts to pump out the blood. For example, in a blood pressure reading of 120/80, 120 is the systolic number.)
The doctor then puts blood pressure cuffs on four different locations on each leg. An ultrasound probe is passed over arteries in the foot. The signal emitted from the strongest artery is recorded as the cuffs are inflated and deflated. This is the ankle's systolic pressure.

The doctor divides the systolic pressure in the ankle by the systolic pressure in the arm. The result is called the ankle-brachial index (ABI), also called ankle-arm pressure index (API).

What the results mean:

ABI over 0.90. This result often rules out PAD, but if the patient has specific risk factors for artery disease, the doctor may still suspect PAD. In such cases, the patient takes a treadmill test and another ABI measurement. If the API index drops, then the doctor makes a diagnosis of peripheral artery disease.
ABI below 0.90. This is usually sufficient information to diagnose PAD. The lower the index the greater the risk for heart attack, stroke, or other serious circulatory or heart events. (In patients with diabetes, the doctor may perform additional tests, which may include ultrasound, pressure measurement in the first toe, or others that might confirm or dismiss a diagnosis of PAD.)
ABI less than 0.50. These measurements are highly associated with impaired leg function.
ABI less than 0.40. These measurements indicate very severe blockage in the leg arteries and a risk for gangrene.

MRA is a type of magnetic resonance imaging (MRI). It provides a non-invasive alternative to a traditional angiogram. The MRA uses a magnetic field and radiofrequency waves to provide pictures of arteries and blood vessels. An angiogram uses dye, which is injected through a catheter that is inserted in the groin. MRA patients are given gadolinium (a contrast material) through an IV to improve the image quality.

A new technology called computed tomography angiography (CTA) uses x-rays to visualize blood flow in arteries throughout the body. This technique is highly effective in diagnosing PAD.

A patient is often given a treadmill test if the ankle-brachial index is questionable. Patients with claudication have a 50 - 60% reduction in peak performance, which is comparable to that in patients with congestive heart failure. The treadmill test is also useful for determining the severity of the pain while walking and for assessing the effectiveness of treatments.

A test called a wave form analysis may be used to confirm an abnormal API or pressure reading. The patient lies on their back for at least 10 minutes in a warm room (so that the blood vessels will not narrow). The leg is turned outward, and the knee is slightly bent. The doctor passes a handheld scanner over the leg, which picks up sound waves coming from the arteries. These signals are recorded, and the wave forms are traced to detect abnormal blood flow.

Patients with suspected PAD should have an electrocardiogram (ECG) and other tests that would detect heart problems. Evidence suggests that heart disease may be under diagnosed in patients with PAD. In one study, a third of patients had silent ischemia, which is heart disease without angina, the chest pain that indicates blockage of blood flow to the heart.

The electrocardiogram (ECG, EKG) is used extensively in the diagnosis of heart disease, from congenital heart disease in infants to myocardial infarction and myocarditis in adults. There are several different types of electrocardiograms.

A number of other tests may be ordered to rule out disorders with similar symptoms. Such disorders include:

Arthritis
Anemia
Spinal stenosis -- narrowing of the spinal canal causing leg or lower back pain

Click the icon to see an image of spinal stenosis.

Thrombophlebitis -- blood clots in the deep veins of the legs

Click the icon to see an image of thrombophlebitis.

Peripheral neuropathy -- nerve damage in the legs and feet, usually in people with diabetes
Night cramps in older people that are not due to problems in blood vessels
Muscle entrapment of the arteries or kinks in the arteries in the leg -- typically occur in young athletes
Adventitial cystic disease -- a rare disorder that produces cysts that block the popliteal and other arteries and typically occurs in young people

Complications

Patients with peripheral artery disease (PAD) have the same risk of death from heart events or stroke as people with heart disease. The risk increases as PAD gets worse. The worse the leg condition, the poorer the overall health of the patient.

According to a 2007 Journal of the American Medical Association study, patients with PAD have a 21% chance of having a heart attack or stroke, or dying from a heart event, within 1 year. If patients have blood clots and blockages in other arteries (brain, heart) as well as the legs, this risk doubles. Another 2007 study indicated that patients with PAD also have an increased risk of dying shortly after heart surgery or other interventional procedures, such as heart catheterizations.

Although signs of heart disease are detected in only 20 - 40% of patients with PAD after an initial diagnosis, studies suggest that when intense heart-diagnostic tests are performed (such as angiography or thallium stress tests) co-existing heart disease is detected in up to 90% of all patients with PAD.

The pain from intermittent claudication in the legs itself clears up in 40% of patients (although this does not eliminate any accompanying heart risks). Damage in the leg from oxygen loss progresses in about 35% of patients. Ischemic rest pain develops in about 10% of patients. This condition can lead to ulcers, gangrene, and, in extreme cases, amputation. People with diabetes are at highest risk for these complications.

In rare cases, blood clots can develop suddenly in a major artery in the leg -- a condition called acute occlusion. Symptoms include numbness, pain, coolness, pale color, lack of pulse in the artery, and weakness. This is a very serious event, which can lead to amputation or even loss of life. Treatment options include clot-busting drugs delivered to the blockage or surgery to remove the clot.

Peripheral artery disease can significantly impair daily physical functioning. Claudication pain severely limits physical activity. Even worse, intermittent claudication increases the risk for falling, usually because of unsteadiness, regardless of the severity of PAD. Intermittent claudication and PAD are also associated with mental decline.

Lifestyle Changes

There are two treatment goals for PAD and claudication:

Manage the pain of intermittent claudication, improve functioning, and prevent PAD from getting worse, so that gangrene does not occur
Reduce the risk for cardiovascular disease (heart attack and stroke)

Evidence indicates that even when patients are treated for PAD, they are frequently not given information or therapies to reduce the risk for heart disease.

Lifestyle changes are critical for every patient with PAD. Medication is often required to improve function and protect the heart. In very severe cases, surgery may be needed to improve blood flow.

People with type 2 diabetes have three to four times the risk for PAD and intermittent claudication. They also tend to develop PAD at earlier ages and to have a significant risk for heart disease. Patients with both diabetes and PAD should be screened for heart disease. In a 2003 study, aggressive reduction of blood pressure in patients with PAD who had diabetes significantly reduced their risk for heart attack and stroke. Aggressive reduction of cholesterol levels, usually with a statin drug, is equally important.

Patients who smoke should quit. Smoking is one of the primary risk factors for PAD and a major cause of complications. Quitting smoking may not make leg pain go away, at least not in the short term, but it certainly may keep blockages from getting worse. This reduces the risk to the heart.

In addition to quitting smoking, exercise is the most important lifestyle change patients with PAD and intermittent claudication can make.

Exercise to Help the Heart. The benefits of regular moderate exercise for the heart are undisputed. People who maintain an active lifestyle have a 45% lower risk of developing heart disease than do sedentary people. And, patients with PAD who are physically active have death rates that are a third of those who are less physically active, according to a 2007 American Heart Association report. Some studies suggest it is not the length of a single exercise session that counts, but the total daily amount of energy expended. Several, short sessions of intense exercise can be particularly helpful for older people.

Exercise Training to Improve Blood Flow in the Legs. Exercise training improves blood flow in the legs and, in some cases, can work as well as medications and surgical procedures in increasing pain-free walking distance. To maintain benefits, exercise must be regular and consistent. A 2006 study suggested that a regular walking program can significantly slow the rate of functional decline associated with PAD. Patients in the study walked three times a week.

Some patients with intermittent claudication find that their leg cramps make it difficult to walk or participate in lower-extremity exercise. A 2006 study suggested that upper-body aerobic exercise can still provide benefits. By increasing oxygen and blood flow through the body, arm aerobics may help reduce leg pain and improve a patient’s ability to walk. Patients in this study used an arm ergometer, a table-top device similar to bicycle pedals that is operated with the arms rather than the legs.

The goals of a heart-healthy diet are to:

Reduce overall cholesterol levels and low-density lipoproteins (LDL), which are harmful to the heart
Increase high-density lipoproteins (HDL), which are beneficial for the heart
Reduce other harmful lipids (fatty molecules) such as triglycerides and lipoprotein(a)

Any diet should also help keep blood pressure and weight under control.

General Recommendations. Although there are many major dietary approaches for protecting health, experts generally agree on the following recommendations for heart protection:

Choose fiber-rich food (whole grains, legumes, nuts) as the main source of carbohydrates, along with a high intake of fresh fruits and vegetables.

Dietary fiber is the part of food that is not affected by the body's digestive process. Only a small amount of fiber is metabolized in the stomach and intestine. The rest is passed through the gastrointestinal tract and makes up a part of the stool. There are two types of dietary fiber, soluble and insoluble. Soluble fiber retains water and turns to gel during digestion. It also slows digestion and nutrient absorption from the stomach and intestine. Soluble fiber is found in foods such as oat bran, barley, nuts, seeds, beans, lentils, peas, and some fruits and vegetables. Insoluble fiber appears to speed the passage of foods through the stomach and intestines and adds bulk to the stool. It is found in foods such as wheat bran, vegetables, and whole grains. Fiber is very important to a healthy diet and can be a helpful aid in weight management. One of the best sources of fiber comes from legumes, the group of food containing dried peas and beans.

Avoid saturated fats (found mostly in animal products) and transfatty acids (found in hydrogenated fats and many commercial baked products and fast-foods). Choose unsaturated fats (particularly omega-3 fatty acids found in vegetable and fish oils).

Click the icon to see an image of saturated fats.

Click the icon to see an image of trans-fatty acids.

When selecting proteins, choose soy protein, poultry, and fish over meat.
Weight control, quitting smoking, and exercise are essential companions of any diet program.

[See In-Depth Report #43: Heart-healthy diet.]

In general, no vitamins have been proven to reduce the risk for PAD or heart disease. Deficiencies in the B vitamins folate and B12 have been linked with elevated levels of homocysteine, an amino acid that has been associated with a higher risk for heart disease and PAD. This association led researchers to examine the effects of vitamin B supplements on heart and vascular diseases. Results from several recent studies, however, indicate that while vitamin supplementation lowers homocysteine levels, it has no effect on heart disease outcomes.

Glutathione. Glutathione is a natural antioxidant produced in animal and plant cells. In one small study, patients who took it could walk with no pain, and there seemed to be an improvement in blood flow. More studies are needed.

Gingko. An analysis of eight studies reported that the herb ginkgo biloba has some modest effect on pain-free walking. The herbal remedy has blood-thinning properties. It is available over the counter.

Pine Bark Extract. Pine bark extract (Pycnogel) may help improve blood flow to muscles and reduce leg cramps, according to a small 2006 study of patients with intermittent claudication.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

The following is of special concern for people taking natural remedies for peripheral artery disease:

Ginkgo. Although the risks for gingko appear to be low, there is an increased risk for bleeding at high doses and interaction with high doses of vitamin E and anti-clotting medications. This is particularly important because patients with PAD often use these types of medications. Commercial gingko preparations have also been reported to contain colchicine, a chemical that can be harmful in pregnant women and people with kidney or liver problems.

Medications

Treatments for PAD help manage leg pain and improve function, as well as reduce the risk for heart attack and stroke. Drugs used for improving leg pain and function are generally those that either prevent blood clots (typically anti-platelet drugs) or open blood vessels. Such drugs also help protect the heart.

Experts now recommend that patients with PAD be given treatments for managing both heart risk factors and intermittent claudication.

Antiplatelet drugs thin the blood and reduce the risk for clots. They are used in mild PAD cases, for intermittent claudication, and to prevent blood clots after surgery.

Aspirin. Aspirin is the main antiplatelet drug used to treat chronic intermittent claudication, particularly in patients who also are at risk for heart attack and stroke. The drug improves leg circulation and, when used in early PAD, may prevent clots from forming in the veins.

Clopidogrel. Clopidogrel (Plavix) is a powerful type of drug called a thienopyridine. Some experts recommend it for patients with both PAD and intermittent claudication. In patients with PAD, it may protect the heart and arteries better than aspirin. Ticlopidine (Ticlid) is another effective thienopyridine that has been used for patients with PAD, but dangerous blood disorders, (particularly thrombocytopenia), have been reported in patients who had taken it for heart disease.

Phosphodiesterase inhibitors are drugs that help keep blood vessels open and blood flowing.

Cilostazol. Cilostazol (Pletal) is used to treat disabling intermittent claudication. A number of studies have reported that the drug helps improve walking distance and quality of life. It also helps improve HDL and triglyceride levels. Cilostazol works better than pentoxifylline, the first drug approved for claudication. It is expensive, however, and currently only recommended for patients who do not respond to aspirin or less costly treatments. Common side effects include headache, swelling in the limbs, and stomach problems such as diarrhea and flatulence (gas). It does not appear to have bad effects on the liver or kidney. Similar drugs have had serious side effects in patients with heart failure, so such individuals should avoid cilostazol.

Pentoxifylline. Pentoxifylline (Trental) reduces the sticky properties of blood, improving its flow. It is approved in the U.S. for managing claudication, although experts do not recommend its routine use. Studies regarding the drug's effectiveness have been mixed. Some studies have reported a small effect on walking ability; another found the drug significantly improved walking distance. Other research has found that the drug does not work any better than a dummy pill (placebo). The most common side effects include headache, nausea, heartburn, flatulence (gas), dizziness, blurred vision, and flushing.

Dipyridamole. Dipyridamole may help prevent complications of PAD when taken along with aspirin. Studies are mixed on the benefits of the combination. Without aspirin, the drug does not appear to have any advantages for patients with PAD.

Alteplase (Activase), also called t-PA, and reteplase (Retavase) are thrombolytic drugs. Such drugs are commonly called "clot-busters." They break up existing clots, and may be used in cases of acute vascular occlusion (the sudden development of a blood clot). They may also be used if a clot is present. Researchers are investigating whether thrombolytics are an effective alternative to surgery in severe cases of PAD. In severe cases, the drugs can be delivered directly into the artery.

Ramipril. The ACE inhibitor ramipril (Altace) improved blood flow to the legs, reduced leg pain, and helped maximize walking time in a small 2006 study of patients with intermittent claudication. Researchers still have to study whether this medication works best for specific patients (such as those with high blood pressure or diabetes).

Naftidrofuryl. Naftidrofuryl (Nafronyl) is available in Europe for intermittent claudication. It is not approved in the United States. Nafronyl is an anti-platelet drug that also blocks serotonin. This action helps damaged muscle tissue absorb more oxygen from blood. Nafronyl appears to improve quality of life and treadmill walking. However, one study found it did not improve overall walking distance.

Growth Factors. Growth factors help new blood vessels grow, an action called angiogenesis. Studies show that recombinant fibroblast growth factor-2 (FGF-2) improves intermittent claudication, even in low doses. The drug may have severe side effects, and long-term safety is unknown. A drug called vascular endothelial growth factor (VEGF) is also under investigation.

Mesoglycan. Mesoglycan has been studied for a few years. This drug breaks up blood clots, and studies have suggested that oral mesoglycan may improve walking distance.

Prostaglandins. Prostaglandins relax smooth muscles and open the blood vessels, which improves blood flow. These types of drugs are called vasodilators. Some may have anti-clotting activity.

Prostaglandin E1. Early studies on prostaglandin E1 in intermittent claudication have been promising. However, more recent studies have not reported significant benefits. The drug is injected.
Beraprost. Beraprost is a prostaglandin that can be taken by mouth. Early studies suggested that it might allow patients with intermittent claudication to exercise for longer periods of time. Subsequent studies have not confirmed these positive results. Side effects include headache, stomach distress, and anemia, although they appear to be mild.

Phlebotomy. Phlebotomy, the removal of blood from the body, is sometimes used to reduce the excess iron that accumulates in patients with PAD. However, a 2007 Journal of the American Medical Association study found that reducing iron stores did not significantly lower the risk of heart attack, stroke, or death in patients with PAD.

Reducing Heart Risks

If a patient cannot control heart risk factors with lifestyle measures, treatment may be needed.

It is very important for people with PAD to keep their LDL ("bad cholesterol") levels to below 100 mg/dL. If patients have serious heart disease risk factors (high blood pressure, diabetes, other unhealthy lipids) in addition to PAD, they may need to aim for LDL levels below 70 mg/dL. Aggressive control of cholesterol levels is known to reduce death rates in patients with peripheral artery disease (PAD). Unhealthy cholesterol levels are major contributors to atherosclerosis, the common factor in PAD and heart disease. Many experts now recommend that patients with PAD receive drugs to lower cholesterol.

A number of medicines are available for lowering cholesterol. Those discussed in this report may have particular benefits for patients with PAD. [See In-Depth Report #23: Cholesterol.]

Statins. Statins are the most effective drugs for the treatment of high cholesterol. Statins block the liver enzyme hMG-CoA reductase, which the body uses to make cholesterol. Statins are particularly effective for lowering LDL levels and triglycerides. They also raise HDL levels, but not as much as other anti-cholesterol drugs.

Statins include:

Lovastatin (Mevacor)
Pravastatin (Pravachol)
Simvastatin (Zocor)
Fluvastatin (Lescol)
Atorvastatin (Lipitor)
Rosuvastatin (Crestor)

Statins reduce the risk of heart attack and stroke. Evidence strongly suggests that statins have specific benefits for patients with PAD. In a 2003 study, statin use was associated with improved leg function, regardless of the patients' cholesterol levels.

Statins improve the function of the lining of blood vessels, which improves blood flow.
Statins appear to reduce inflammation in the arteries, which is now believed to be a major factor in blood vessel injury.
Some evidence suggests that statins might promote growth of new blood vessels and help prevent intermittent claudication.

Side effects of statins include headaches, skin rashes, muscle aches, sexual dysfunction, drowsiness, dizziness, nausea, constipation, and peripheral neuropathy (numbness or tingling in the hands and feet).

Statins can also cause an uncommon condition called myopathy. Myopathy can cause muscle damage and, in some cases, muscle and joint pain. The risk for myopathy increases with higher doses. The following increases one's risk of myopathy

Older age
Small size or frailty
Alcohol abuse
Hypothyroidism
Use of multiple medications

There is also a higher risk of myopathy if statins are used before surgery.

Statins also can affect the liver, particularly at higher doses, so periodic liver function tests should be done. Statins should not be taken by anyone with liver problems or by women who are pregnant or breast-feeding.

Nicotinic Acid (Niacin). Nicotinic acid is the active compound found in niacin (vitamin B3). It raises HDL levels more than any other anti-cholesterol drug, and is the first choice for patients with low HDL levels. Nicotinic acid is also extremely effective in reducing triglyceride levels. It may be beneficial for some patients with PAD.

Brands of nicotinic acid include Niacor, Nicolar, and Slo-Niacin. An extended-release form (Niaspan), taken at bedtime, may have fewer side effects than other types of niacin. Although niacin is available over-the-counter, the active form used for cholesterol is given in much higher doses and is available only by prescription. It is important to take this medication under a doctor's direction in order to ensure its safety and effectiveness. Combinations with other drugs, particularly statins, may add significant benefits.

Many patients can not tolerate the side effects of niacin. About a quarter of patients taking rapid-acting forms of nicotinic acid stop taking them. The most common side effects are flushing of the face and neck, itching, headache, blurred vision, and dizziness. They can occur between 5 minutes to hours after taking the drug and can last for varying lengths of time. The body does get used to these effects eventually, so they generally go away. Gastrointestinal problems are common. Other side effects include dry skin and mucous membranes and darkening of the skin.

About 3 - 5% of people taking nicotinic acid develop liver abnormalities, which go away after the medication is stopped. The extended form of Niaspan appears to be safe for the liver, but people with chronic liver disease should not use any form of nicotinic acid. People with gout should avoid nicotinic acid, since it elevates uric acid.

The role of nicotinic acid in people with diabetes is less clear. About 30% of patients who take niacin have a jump in blood glucose levels. But some studies have reported that diabetics who use niacin had little trouble with glucose control. Niacin's effects on HDL and triglycerides are especially suited for the lipid imbalances that are common in diabetes.

Fibrates. Fibrates (sometimes called fibric acid derivatives) break down the particles that make triglycerides. Gemfibrozil (Lopid) is the standard fibrate. Newer fibrates, including fenofibrate (Tricor) and bezafibrate (Bezalip), may be more effective in lowering cholesterol than gemfibrozil. Most fibrates have been shown to lower the risk of heart attack. A study on fenofibrate suggested that it reduced certain clotting factors (another risk factor for heart disease).

Fibrates may be good choices for many patients who need to lower triglyceride levels and increase HDL, but who cannot take nicotinic acid.

In one study, patients with PAD who took bezafibrate experienced fewer non-fatal heart attacks and the severity of intermittent claudication was reduced.

Side effects of fibrates may include gastrointestinal discomfort, aching muscles, sensitivity to sunlight, and skin rashes. Impotence has been associated with fibrates in less than 1% of patients. Fibrates have been known to cause gallstones, so people with gallbladder problems should not use these drugs. The drugs may cause abnormal heart rhythms and can affect the liver and kidney. They interact with a number of drugs including warfarin, some oral drugs used for diabetes, and certain antibiotics. Fibrates also interact with grapefruit juice.

Evidence suggests that best drugs for patients with high blood pressure and PAD may be angiotensin-converting-enzyme (ACE) inhibitors. These drugs block the effects of the angiotensin-renin-aldosterone system, which is thought to have many harmful effects on the heart and blood vessels.

ACE inhibitors include:

Captopril (Capoten)
Enalapril (Vasotec)
Quinapril (Accupril)
Benazepril (Lotensin)
Ramipril (Altace)
Perindopril (Aceon)
Lisinopril (Prinivil, Zestril)

They are important drugs for patients with PAD and diabetes who also have high blood pressure.

Side effects include an irritating cough, excessive drop in blood pressure, and allergic reactions. In some people, the cough is intolerable. Iron supplements or the drug picotamide may help reduce the frequency of coughs.

One rare, but severe, side effect is granulocytopenia, which is an extreme reduction in white blood cells.

In rare cases (0.3%), patients who take ACE inhibitors suffer a sudden and severe allergic reaction called angioedema, which causes swelling in the eyes and mouth and may close off the throat.

Although ACE inhibitors can protect against kidney disease, they also increase potassium retention in the kidneys. This increases the risk for cardiac arrest if levels become too high. Because of this, ACE inhibitors are generally not given with potassium-sparing diuretics or potassium supplements.

ACE inhibitors can harm a developing fetus and should not be used during pregnancy.

[See In-Depth Report #14: High blood pressure.]

Surgery

In severe cases, surgery may be needed to open blocked blood vessels. Many surgical procedures can be accomplished with minimally invasive endovascular techniques, such as angioplasty and stenting, which can help open small blocked arteries below the knee and prevent amputation. If there is extreme blockage in the leg artery, bypass surgery and vein grafting may be required.

For many years, leg bypass surgery was the main type of surgery used for extensive PAD. This procedure involves the creation of a tube (graft) that acts as a new blood vessel. Grafts can be made from synthetic material (artificial vein) or from a vein taken from a different location in the patient's leg (natural vein). The graft reroutes blood flow in the leg, around the blocked artery. In one study, the natural vein remained open after 4 years in nearly half of the patients, while the synthetic vein (made from polytetrafluoroethylene [PTFE]) had closed in all but 12% of patients.

Artificial veins tend to pose a much higher risk for blood clots, and the consequences of re-blockage are must more severe than when the natural vein recloses. To keep the artificial vein open, oral anti-clotting drugs such as aspirin or warfarin, may be used. (Such drugs do not work at all with natural vein bypass.)

In general, less invasive surgical procedures such as balloon angioplasty and stenting are now more frequently performed.

Percutaneous transluminal angioplasty (PTA) is an approach that has several variations. The object of the procedure is to open the blocked blood vessels that are causing intermittent claudication. Angioplasty is being increasingly used, especially in patients who have other medical conditions. Some experts believe that it is less expensive and more effective than leg bypass surgery.

The PTA procedure requires only a local anesthetic. Patients can return to normal activity in 24 - 48 hours. Complication rates are low. The effects are not permanent, but the procedure can be repeated without any greater risk than with the original one.

Anticoagulants such as warfarin or heparin and antiplatelets such as aspirin may used to prevent blood clots occurring during surgery. All of these drugs increase the risk for bleeding. Thrombolytic drugs may be used before, during, or after angioplasty if a blood clot is present.

Reclosure of the blood vessels from blood clotting, even long after surgery, is an important complication. Repeat surgery may be needed. Major complications following surgery include pneumonia, stroke, kidney failure and heart attack.

Balloon Angioplasty. The standard procedure is balloon angioplasty. A thin tube is inserted through an artery in the groin and passed through the blocked artery. A wire is threaded through the tube. A deflated balloon is passed over the wire to the blockage. When inflated, it opens the artery.

Because of the risk for reclosure from blood clots after balloon angioplasty, various other procedures are used or are being investigated.

Stenting. More recent angioplasty techniques use an expandable metal mesh tube (stent). A self-expanding stent called the SMART stent was approved in late 2003. The SMART stent is used specifically for patients whose PAD is caused by a blockage in the iliac artery, which runs through the pelvic area. Stents can be effective in opening arteries, but 20 - 30% of patients have new blockages within a year of surgery. In 2005, researchers began testing a drug-eluting stent coated with paclitaxel. They hope that the drug may prevent blockages from recurring in the leg arteries. A paclitaxel-eluting stent is already approved in the U.S. for treating coronary artery disease.

Drug-eluting stents may not be recommended for patients who had recent heart surgery, or women who are nursing or pregnant. Patients who receive a drug-eluting stent may need blood thinning drugs for at least several months.

Drug-Coated Balloon. A new technique uses a drug-coated balloon instead of a stent. The balloon is sprayed with paclitaxel. When the balloon is inflated inside the leg artery, the drug is transferred to the plaque that is causing the blockage. Doctors think that this type of minimally invasive angioplasty surgery might provide an important alternative to stents. Although stents have been very useful in heart surgery, they can sometimes cause later complications in PAD.

Brachytherapy. Another approach uses radioactive implants (brachytherapy) in combination with PTA, which help prevent the arteries from closing after angioplasty. In a major 2002 analysis, this approach produced greater benefits compared to PTA alone, at least in the short term.

Laser Treatment. Laser light pulses are being investigated as a way to vaporize cholesterol plaque and blood clots from the blood vessels. A 2004 report suggested that laser therapy may be particularly useful in patients with PAD who are not good candidates for bypass surgery.

PolarCath. A new type of angioplasty treatment called PolarCath opens blocked arteries by cooling and dilating them with a nitrous oxide-filled balloon. A 2004 study showed that this procedure, also called CryoPlasty therapy, has a 9-month failure rate of less than 20%, which is significantly lower the 40 - 50% failure rate reported after angioplasty or stenting procedures.

Intermittent pneumatic compression (Arterial Flow, VenaFlow) is a mechanical technique normally used to treat leg ulcers or swelling from fluid build-up. The device is an inflatable fabric device that goes around the lower leg. The inflated device puts pressure on the limb. Some devices apply pressure in a wave-like motion that simulates the natural increase in blood flow during walking. A 2002 analysis of 26 studies suggested that this treatment may be beneficial for patients with PAD who cannot undergo surgery. It may even prove to be a viable alternative to medical treatments in some cases.

Resources

www.padcoalition.org/wp -- Peripheral Arterial Disease Coalition
www.nhlbi.nih.gov -- National Heart, Lung, and Blood Institute
www.americanheart.org -- American Heart Association
www.acc.org -- American College of Cardiology
www.diabetes.org -- American Diabetes Association
www.vdf.org -- Vascular Disease Foundation
www.sirweb.org -- Society of Interventional Radiology

References

Aboyans V, Criqui MH, Denenberg JO, Knoke JD, Ridker PM, Fronek A. Risk factors for progression of peripheral arterial disease in large and small vessels. Circulation. 2006 Jun 6;113(22):2623-9.

Ahimastos AA, Lawler A, Reid CM, Blombery PA, Kingwell BA. Brief communication: ramipril markedly improves walking ability in patients with peripheral arterial disease: a randomized trial. Ann Intern Med. 2006 May 2;144(9):660-4.

Garg PK, Tian L, Criqui MH, Liu K, Ferrucci L, Guralnik JM, et al. Physical activity during daily life and mortality in patients with peripheral arterial disease. Circulation. 2006 Jul 18;114(3):242-8.

Saw J, Bhatt DL, Moliterno DJ, Brener SJ, Steinhubl SR, Lincoff AM, et al. The influence of peripheral arterial disease on outcomes: a pooled analysis of mortality in eight large randomized percutaneous coronary intervention trials. J Am Coll Cardiol. 2006 Oct 17;48(:1567-72.

Steg PG, Bhatt DL, Wilson PWF, D’Agostino R, Ohman EM, Rother, J. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA. Mar 21 2007;29(11)7:1197-1206.

Zacharski LR, Chow BK, Howes PS, Shamayeva G, Baron JA, Dalman RL, et al. Reduction of iron stores and cardiovascular outcomes in patients with peripheral arterial disease: a randomized controlled trial. JAMA. 2007 Feb 14;297(6):603-10.

Review Date:
3/29/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Arterial embolism

admin — Wed, 03 Sep 2008 17:54:30 -0700

Overview

Definition
Causes, incidence, and risk factors
Symptoms
Signs and tests
Treatment
Expectations (prognosis)
Complications
Calling your health care provider
Prevention
References

Illustrations

Arterial embolism

Circulatory system

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Arterial embolism is a sudden interruption of blood flow to an organ or body part due to a clot (embolus).

Causes, incidence, and risk factors

An embolus is a blood clot or a piece of plaque that acts like a clot. Emboli means more than one clot. If the clot travels from the site where it formed to another location in the body it is called an embolism.

An arterial embolism may be caused by one or more clots. The clots can get stuck in an artery and block blood flow. The blockage starves tissues of blood and oxygen, which can result in damage or tissue death (necrosis).

Arterial emboli often occur in the legs and feet. Some may occur in the brain, causing a stroke, or in the heart, causing a heart attack. Less common sites include the kidneys, intestines, and eyes.

Atrial fibrillation is a major risk factor for arterial embolism. The risk of an embolism increases when factors that tend to form clots are increased. Such factors include injury or damage to an artery wall and conditions that increase blood clotting (such as increased platelet count).

Another condition that poses a high risk for embolization (especially to the brain) is mitral stenosis. Endocarditis (infection of the inside of the heart) can also cause arterial emboli.

A common source for an embolus is from areas of hardening (atherosclerosis) in the aorta and other large blood vessels. These clots can break loose and flow down to the legs and feet.

Paradoxical embolization can take place when a clot in a vein enters the right side of the heart and passes through a hole into the left side. The clot can then move to an artery and block blood flow to the brain (stroke) or other organs.

If a clot involves the arteries supplying blood flow to the lungs, it is called a pulmonary embolus.

Symptoms

Symptoms may begin quickly or slowly depending on the size of the embolus and how much it blocks the blood flow.

Symptoms of an arterial embolism in the arms or legs may include:

Cold arm or leg
Decreased or no pulse in an arm or leg
Fingers or hands feel cool
Lack of movement in the arm or leg
Muscle pain in the affected area
Muscle spasm in the affected area
Numbness and tingling in the arm or leg
Pale color of the arm or leg (pallor)
Weakness of an arm or leg

Later symptoms:

Blisters of the skin fed by the affected artery
Shedding (sloughing) of skin
Skin erosion (ulcer)
Tissue death (necrosis; skin is dark and damaged)

Symptoms of a clot in an organ vary with the organ involved but may include:

Pain in the part of the body that is involved
Temporarily decreased organ function

Signs and tests

The health care provider may find decreased or no pulse, and decreased or no blood pressure in the arm or leg. There may be signs of tissue death or gangrene.

Tests to diagnose arterial embolism or reveal the source of emboli may include:

Angiography of the affected extremity or organ
Doppler ultrasound exam of an extremity
Duplex Doppler ultrasound exam of extremity
Echocardiogram
MRI
Myocardial contrast echocardiography (MCE)
Plethysmography
Transcranial Doppler exam of arteries to the brain
Transesophageal echocardiography (TEE)

This disease may also affect the results of the following tests:

Euglobulin lysis time (ELT)
Factor VIII assay
Isotope study of the affected organ
Plasminogen activator inhibitor-1 (PAI-1) activity
Platelet aggregation test
Tissue-type plasminogen activator (t-PA) levels

Treatment

Arterial embolism requires prompt treatment at a hospital. The goals of treatment are to control symptoms and to improve the interrupted blood flow to the affected area of the body. The cause of the clot, if found, should be treated to prevent further problems.

Medications include:

Anticoagulants (such as warfarin or heparin) can prevent new clots from forming
Antiplatelet medications (such as aspirin, ticlopidine, and clopidogrel) can prevent new clots from forming
Painkillers given through a vein (by IV)
Thrombolytics (such as streptokinase) can dissolve clots

Some people need surgery. Procedures include:

Bypass of the artery (arterial bypass) to create a second source of blood supply
Clot aspiration (thromboaspiration)
Clot removal through a balloon catheter placed into the affected artery or through open surgery on the artery (embolectomy)
Opening of the artery with a balloon catheter (angioplasty) with or without a stent implanted

Expectations (prognosis)

How well a patient does depends on the location of the clot and how much the clot has blocked blood flow. Arterial embolism can be serious if not treated promptly.

The affected area can be permanently damaged. Up to approximately 25% of cases require amputation.

Arterial emboli can come back (recur) even after successful treatment.

Complications

Acute MI
Infection in the affected tissue
Septic shock
Stroke (CVA)
Temporary or permanent decrease or loss of other organ functions
Temporary or permanent kidney failure
Tissue death (necrosis) and gangrene
Transient ischemic attack (TIA)

Calling your health care provider

Go to the emergency room or call the local emergency number (such as 911) if you have symptoms of arterial embolism.

Prevention

Prevention begins with identifying the source of the blood clot. If your health care provider determines you have a high risk for blood clots, you may be prescribed blood thinners (such as warfarin or Coumadin) to prevent them from forming. Antiplatelet drugs may also be needed.

The risk for both atherosclerosis and clot formation increases in persons who:

Are inactive and do little exercise
Are overweight
Are under stress
Smoke

Taking steps to reduce hardening of the arteries (atherosclerosis) may reduce your risk of an arterial embolus forming from a piece of plaque.

References

Clagett GP, Sobel M, Jackson MR, Lip GY, Tangelder M, Verhaeghe R. Antithrombotic therapy in peripheral arterial occlusive disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):609S-26S.

Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic). Circulation. 2006;113:e463-e654.

Goldman L. Approach to the patient wtih possible cardiovascular disease. In: Goldman L, Ausiello D. Goldman: Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 48.

Review Date: 5/8/2008

Reviewed By: Sean O. Stitham, MD, Private Practice in Internal Medicine, Seattle, Washington; and David C. Dugdale III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M. Copyright

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Source Doc: 1_001102

Retinal artery occlusion

admin — Wed, 03 Sep 2008 17:53:54 -0700

Overview

Definition
Alternative Names
Causes, incidence, and risk factors
Symptoms
Signs and tests
Treatment
Expectations (prognosis)
Complications
Calling your health care provider
Prevention
References

Illustrations

Retina

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Retinal artery occlusion is a blockage of the blood supply in the arteries to the retina -- the light-sensitive tissue in the back of the eye.

Alternative Names

Central retinal artery occlusion; Branch retinal artery occlusion; CRAO; BRAO

Causes, incidence, and risk factors

Retinal arteries may become blocked by a blood clot or substances (such as fat or plaque) that get stuck in the arteries. These blockages may occur due to hardening of the arteries in the eye.

Also, clots may travel from other parts of the body and block an artery in the retina. A common source of a clot would be from the carotid artery in the neck or from the heart lining.

Most clots are caused by conditions such as:

Diabetes
Disease of the two large blood vessels in the neck (carotid artery disease)
Disorder of high blood fats (hyperlipidemia)
Heart rhythm problem (atrial fibrillation)
High blood pressure

If a branch of the retinal artery is blocked, part of the artery will not have enough blood and oxygen. If this happens, you may lose part of your vision.

Retinal artery blockage or occlusions may last from only a few seconds to a few minutes. They also may cause permanent vision loss. The amount of vision loss is partly related to the location of the blockage.

People with retinal arterial occlusion, whether it is temporary or permanent, have a risk of stroke because clots may also move to the brain.

Retinal vessel occlusion more often affects older people. Risk factors are related to the disorders that cause the blockage.

Symptoms

Sudden blurring or loss of vision in all or part of one eye

Signs and tests

Tests to evaluate the retina may include:

Color vision
Examination of the retina after the pupil is dilated
Fluorescein angiography
Intraocular pressure
Pupil reflex response
Refraction test
Retinal photography
Slit lamp examination
Testing of side vision (visual field examination)
Test that measures the electrical activity of the retina (electroretinogram)
Visual acuity

Tests to identify the source of a clot from another part of the body:

Echocardiogram
Heart monitor for abnormal heart rhythm
Ultrasound or Doppler ultrasound of the carotid arteries

Other tests may include:

Blood pressure
Cholesterol and triglyceride levels
Complete physical exam

Treatment

Breathing in (inhaling) a carbon dioxide/oxygen mixture has been used to treat blockages in the arteries. This treatment causes the arteries of the retina to widen (dilate). It may allow the clot to move down the artery and sometimes break up, which reduces the area of the retina that is affected.

The health care provider should look for the cause of the blockage. Blockages may be signs of a life-threatening medical problem. Patients with retinal artery occlusions should be screened for:

Cranial arteritis
Carotid artery blockage
Heart rhythm disturbances
Heart valve disease
High blood pressure

The use of the clot-busting drug, tissue plasminogen activator (tPA) within a few hours of retinal artery occlusion may be helpful.

Expectations (prognosis)

People with blockages of the retinal artery may not get their vision back.

Complications

Partial or complete loss of vision in the affected eye
Similar problem occurring again in the same or the other eye
Stroke

Calling your health care provider

Call your health care provider if you have sudden blurring or vision loss.

Prevention

Measures used to prevent other blood vessel (vascular) diseases, such as coronary artery disease, may decrease the risk of retinal artery occlusion. These include:

Eating a low-fat diet
Exercising
Stopping smoking
Losing weight if you are overweight

Aspirin is commonly used to prevent the artery from becoming blocked again. It is also helpful to control atrial fibrillation.

References

Vortmann M, Schneider JI. Acute monocular visual loss. Emerg Med Clin North Am. 2008;26:73-96.

Pokhrel PK, Loftus SA. Ocular emergencies. Am Fam Physician. 2007;76:829-836.

Review Date: 4/22/2008

Reviewed By: Andrew A. Dahl, MD, F.A.C.S., Director of Ophthalmology Training, Institute for Family Health, Assistant Professor of Ophthalmology, New York College of Medicine, New York, NY. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M. Copyright

adam.com

Source Doc: 1_001028

Coronary artery balloon angioplasty - series

admin — Thu, 04 Sep 2008 19:44:25 -0700

Back

Overview

Normal anatomy
Indication
Procedure, part 1
Procedure, part 2
Procedure, part 3
Procedure, part 4
Procedure, part 5
Aftercare, part 1
Aftercare, part 2

HEALTH GUIDE REFERENCE FROM A.D.A.M

Normal anatomy

The coronary arteries supply blood to the heart muscle. The right coronary artery supplies both the left and the right heart; the left coronary artery supplies the left heart.

Indication

Fat and cholesterol accumulates on the inside of arteries (atherosclerosis). The small arteries of the heart muscle (the coronary arteries) can be narrowed or blocked by this accumulation. If the narrowing is small, percutaneous transluminal coronary angioplasty, or PTCA for short, may be the course for treatment. PTCA is a minimally invasive procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle. The indications for PTCA are:

Persistent chest pain (angina)
Blockage of only one or two coronary arteries

Procedure, part 1

While the patient is awake and pain-free (local anesthesia), a catheter is inserted into an artery at the top of the leg (the femoral artery). The procedure begins with the doctor injecting some local anesthesia into the groin area and putting a needle into the femoral artery (the blood vessel that runs from the heart down the leg). Once the needle is inserted, a guide wire is placed through the needle, into the blood vessel. Following this step, the guide wire is left in the blood vessel and the needle is removed. A large needle called an introducer is then placed over the guide wire and the guide wire is removed.

Procedure, part 2

Next, a diagnostic catheter, which is a long narrow tube, is advanced through the introducer over a .035"guidewire, into the blood vessel. This catheter is then guided to the aorta and the guidewire is removed. Once the catheter is placed in the opening or ostium of one of the coronary arteries, the doctor injects dye and takes a series of X-rays (film of the images).

Procedure, part 3

The first catheter is exchanged out over the guidewire for a guiding catheter and the guidewire is removed. A smaller guidewire is advanced across the blocked section of the coronary artery and a balloon -tipped tube is positioned so the balloon part of the tube is beside the blockage. The balloon is then inflated for a few seconds to compress the blockage against the artery wall. Then the balloon is deflated. The doctor may repeat this a few times, each time pumping up the balloon a little more to widen the passage for the blood to flow through. This treatment may be repeated at each blocked site in the coronary arteries.

Procedure, part 4

A device called a stent may be placed. A stent is a latticed, metal scaffold that is placed within the coronary artery to keep the vessel open.

Procedure, part 5

Once the catheter has been positioned at the coronary artery origin, contrast media is injected and a series of X-rays (film) are taken to check for any change in the arteries. Following this, the catheter is removed and the procedure is completed.

Aftercare, part 1

This procedure can greatly improve the blood flow through the coronary arteries and to the heart tissue in about 90% of patients and may eliminate the need for coronary artery bypass surgery. The outcome is relief from chest pain symptoms and an improved exercise capacity. In 2 out of 3 cases, the procedure is considered successful with complete elimination of the narrowing or blockage. This procedure treats the condition but does not eliminate the cause and recurrences happen in 1 out of 3 to 5 cases. Patients should consider diet, exercise, and stress reduction measures. If adequate widening of the narrowing is not accomplished, heart surgery (coronary artery bypass graft surgery, also called a CABG) may be recommended.

Aftercare, part 2

Immediately after the procedure, a ten-pound sandbag may be placed over the femoral artery puncture site in the leg and remain there for 6 hours. This is done to help the artery heal.

Review Date: 3/30/2007

Reviewed By: Glenn Gandelman, MD, MPH, Assistant Clinical Professor of Medicine, New York Medical College, Valhalla, NY, and Alan Berger, MD, Assistant Professor, Divisions of Cardiology and Epidemiology, University of Minnesota, Minneapolis, MN. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

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Source Doc: 3_100160

Carotid artery surgery

admin — Thu, 04 Sep 2008 19:02:30 -0700

Overview

Definition
Alternative Names
Description
Indications
Risks
Expectations after surgery
Convalescence

Illustrations

Carotid stenosis, X-ray of the left artery

Carotid stenosis, X-ray of the right artery

Arterial tear in internal carotid artery

Atherosclerosis of internal carotid artery

Arterial plaque build-up

Carotid artery surgery - series

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Carotid artery surgery is a surgical procedure to restore adequate blood flow to the brain.

Alternative Names

Carotid endarterectomy

Description

Each side of the neck has an artery called the common carotid. Each common carotid splits into two branches -- the internal branch, which brings oxygen-rich blood to the brain, and the external branch, which brings blood to the face.

Blockage of the internal carotid artery can reduce blood supply to the brain, causing a stroke. When the internal carotid arteries become blocked by fat and cholesterol build-up of atherosclerosis (also called plaque) can result.

Over time, the plaque slowly begins to block the flow of blood. The plaque itself may block the artery enough to cause a stroke. In addition, the plaque often causes the blood to flow abnormally, which leads to a blood clot. A clot can stay at the site of narrowing and prevent blood flow to all of the smaller arteries it supplies. This type of clot, which doesn't travel, is called a thrombus. In other cases, the clot can travel and wedge into a smaller vessel. A clot that travels is called an embolism.

If you develop a thrombus in the internal carotid artery or an embolism in a smaller blood vessel, you may experience symptoms such as blurred vision, slurred speech, or weakness (all signs of stroke).

By restoring adequate blood flow to the internal carotid artery, strokes can be prevented. This may be accomplished either by a surgery called endarterectomy or a procedure known as angioplasty with stent placement. Traditionally used for the heart, this latter procedure is now being used on blood vessels to the brain as well. Stent placement is an alternative to surgery that enlarges the blockage in the artery. This new technique must only be performed by an experienced physician.

During the procedure, there are steps the surgeon takes to reduce the risk of stroke from the operation. These include shunting (using a plastic tube to re-route blood flow to the brain), EEG monitoring, or even doing the operation under local anesthetic so the patient can talk to the surgeon. Usually, however, general anesthesia is used, which allows the patient to be unconscious and pain free.

Indications

The procedure may be used to treat symptoms of carotid artery blockage, such as:

Weakness of the arm, leg, or face on one side of the body
Inability to move the arm, leg, or face on one side of the body (paralysis)
Numbness, tingling, or noticeable change in the sensation of the arm, leg, or face on one side of the body
Difficulty swallowing
Loss of all or part of vision (blindness) in one eye
Slurred speech or inability to speak
Dizziness (vertigo)
Confusion, fainting, or coma
Stroke with complete recovery (TIA)
Severe blockage without any symptoms at all

Seek urgent medical attention if you experience these symptoms. The symptoms may be permanent, but even if they occur transiently and then get better by themselves (TIA, or transient ischemic attack), they still might be a sign of a serious problem.

Surgery should also be done for those who have carotid artery blockages which cut off between 75-99% of blood flow through this major artery. Large studies have shown that for people with such severe blockages, even if they have no symptoms at all, the risk of stroke is reduced with surgery.

If the blockage is complete (100%), however, surgery will not be performed because the risk of stroke and significant brain damage from the procedure is too great.

X-ray studies using special dyes (carotid angiogram) can show the degree of blockage of the carotid arteries. Other studies that can visualize blockages in the carotid arteries are ultrasound and magnetic resonance angiography (MRA).

Risks

The risks for any anesthesia are:

Reactions to medications
Problems breathing

The risks for any surgery are:

Bleeding
Infection

Additional risks of carotid surgery include:

Blood clots
Brain damage
Strokes (1-3% in the hands of an experienced surgeon)
Heart attacks

Expectations after surgery

Carotid artery surgery usually helps prevent further brain damage and reduces the risk of stroke. However, unless lifestyle changes (like diet and exercise when approved by your physician) are made, plaque buildup, clot formation, and other problems in the carotid arteries can return.

Convalescence

After surgery, you are usually observed overnight to watch for any signs of bleeding, stroke, or compromised blood flow to the brain. However, there is a recent trend to send the patient home the same day, if the operation is done early and the patient is doing well.

Erratic blood pressure (requiring monitoring in an intensive care unit) is relatively common, tends to improve within 24 hours, and should not be a cause for concern.

Review Date: 7/14/2006

Reviewed By: J.A. Lee, M.D., Division of Surgery, UCSF, San Francisco, CA. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

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Mesenteric artery ischemia

admin — Wed, 03 Sep 2008 17:54:51 -0700

Overview

Definition
Alternative Names
Causes, incidence, and risk factors
Symptoms
Signs and tests
Treatment
Expectations (prognosis)
Complications
Calling your health care provider
Prevention
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Mesenteric artery ischemia is a narrowing or blockage of one or more of the three mesenteric arteries, which are the major arteries supplying the small and large intestines.

Alternative Names

Mesenteric Vascular Disease

Causes, incidence, and risk factors

Narrowing of the arteries that supply blood to the intestine causes mesenteric ischemia. The arteries that supply blood to this area run directly from the aorta, the main artery from the heart.

Mesenteric artery ischemia is often seen in people with hardening of the arteries elsewhere in the body (for example, with coronary artery disease or peripheral vascular disease). The condition is more common in smokers and in patients with high cholesterol.

Mesenteric ischemia may also be caused by a blood clot (embolus) that moves through the blood and suddenly blocks one of the mesenteric arteries. The clots usually come from the heart or the aorta. These clots are more commonly seen in patients with abnormal heart rhythms (arrhythmias), such as atrial fibrillation.

Symptoms

Symptoms of long-term (chronic) mesenteric artery ischemia caused by atherosclerosis:

Abdominal pain after eating
Diarrhea

Symptoms of sudden (acute) mesenteric artery ischemia due to a traveling blood clot:

Diarrhea
Sudden severe abdominal pain
Vomiting

Signs and tests

In acute mesenteric ischemia, blood tests may show a higher-than-normal white blood cell (WBC) count and changes in the blood-acid level.

A CT scan may show problems with the blood vessels and the intestine.

A mesenteric angiogram is a test that involves injecting a special dye into your bloodstream to highlight the arteries of an intestine. Then x-rays are taken of the area. This can show the location of the blockage in the artery.

Treatment

Acute mesenteric artery ischemia is an emergency. Surgery is performed to remove the clot. In some cases, the surgeon must also create a bypass around blockage.

Surgery for chronic mesenteric artery ischemia involves removing the blockage and reconnecting the arteries to the aorta. A bypass around the blockage is another procedure. It is usually done with a plastic tube graft.

An alternative to surgery is a stent. It may be inserted to enlarge the blockage of the mesenteric artery or deliver medicine directly to the affected area. This is a rather new technique and should only be done by experienced health care providers.

Expectations (prognosis)

In the case of chronic mesenteric ischemia, the outlook after a successful surgery is good. However, if appropriate lifestyle changes (such as a healthy diet and exercise) are not made, any problems with hardening of the arteries will generally get worse over time.

Persons with acute mesenteric ischemia usually do poorly, since death of the intestine often occurs before surgery is done. However, when diagnosed and treated right away, patients with acute mesenteric ischemia can be treated successfully.

Complications

Tissue death from lack of blood flow (infarction) in the intestines is the most serious complication of mesenteric artery ischemia.

Calling your health care provider

Call your health care provider if you have:

Changes in bowel habits
Fever
Nausea
Severe abdominal pain
Vomiting

Prevention

Prevention includes following lifestyle changes that reduce your risk for atherosclerotic disease. This includes:

Exercise
Follow a healthy diet
Keep your blood pressure under control
Stop smoking

To prevent acute mesenteric artery ischemia, also control any heart rhythm problems.

References

Belkin M, Owens CD, Whittemore AD, Donaldson MC, Conte MS, Gravereaux E. Peripheral Arterial Occlusive Disease. In: Townsend CM Jr., Beauchamp RD, Evers BM, Mattox KL. Townsend: Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2008: chap 66.

Review Date: 5/15/2008

Reviewed By: Robert A. Cowles, MD, Assistant Professor of Surgery, Columbia University College of Physicians and Surgeons, New York, NY. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M. Copyright

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