What Is Coronary Artery Disease?

Coronary artery disease (CAD) is a condition in which plaque (plak) builds up inside the coronary arteries. These arteries supply your heart muscle with oxygen-rich blood. Plaque is made up of fat, cholesterol (ko-LES-ter-ol), calcium, and other substances found in the blood. When plaque builds up in the arteries, the condition is called atherosclerosis (ATH-er-o-skler-O-sis). Atherosclerosis

Figure A shows a normal artery with normal blood flow. Figure B shows an artery with plaque buildup. Plaque narrows the arteries and reduces blood flow to your heart muscle. It also makes it more likely that blood clots will form in your arteries. Blood clots can partially or completely block blood flow. Overview When your coronary arteries are narrowed or blocked, oxygen-rich blood can't reach your heart muscle. This can cause angina (an-JI-nuh or AN-juh-nuh) or a heart attack.

Angina is chest pain or discomfort that occurs when not enough oxygen-rich blood is flowing to an area of your heart muscle. Angina may feel like pressure or squeezing in your chest. The pain also may occur in your shoulders, arms, neck, jaw, or back. A heart attack occurs when blood flow to an area of your heart muscle is completely blocked. This prevents oxygen-rich blood from reaching that area of heart muscle and causes it to die. Without quick treatment, a heart attack can lead to serious problems and even death. Over time, CAD can weaken the heart muscle and lead to heart failure and arrhythmias (ahRITH-me-ahs). Heart failure is a condition in which your heart can't pump enough blood throughout your body. Arrhythmias are problems with the speed or rhythm of your heartbeat. Outlook CAD is the most common type of heart disease. It's the leading cause of death in the United States for both men and women. Lifestyle changes, medicines, and/or medical procedures can effectively prevent or treat CAD in most people.

Other Names for Coronary Artery Disease

Atherosclerosis Coronary heart disease Hardening of the arteries Heart disease Ischemic (is-KE-mik) heart disease Narrowing of the arteries

What Causes Coronary Artery Disease?

Research suggests that coronary artery disease (CAD) starts when certain factors damage the inner layers of the coronary arteries. These factors include:

Smoking High amounts of certain fats and cholesterol in the blood High blood pressure High amounts of sugar in the blood due to insulin resistance or diabetes

When damage occurs, your body starts a healing process. Excess fatty tissues release compounds that promote this process. This healing causes plaque to build up where the arteries are damaged. Over time, the plaque may crack. Blood cells called platelets (PLATE-lets) clump together to form blood clots where the cracks are. This narrows the arteries more and worsens angina or causes a heart attack.

The buildup of plaque in the coronary arteries may start in childhood. Over time, this buildup can narrow or completely block some of your coronary arteries. This reduces the flow of oxygen-rich blood to your heart muscle.

Who Is At Risk for Coronary Artery Disease?

Coronary artery disease (CAD) is the leading cause of death in the United States for both men and women. Each year, more than half a million Americans die from CAD. Certain traits, conditions, or habits may raise your chance of developing CAD. These conditions are known as risk factors. You can control most risk factors and help prevent or delay CAD. Other risk factors can't be controlled.

Major Risk Factors

Many factors raise the risk of developing CAD. The more risk factors you have, the greater chance you have of developing CAD.

Unhealthy blood cholesterol levels. This includes high LDL cholesterol (sometimes called bad cholesterol) and low HDL cholesterol (sometimes called good cholesterol). High blood pressure. Blood pressure is considered high if it stays at or above 140/90 mmHg over a period of time. Smoking. This can damage and tighten blood vessels, raise cholesterol levels, and raise blood pressure. Smoking also doesn't allow enough oxygen to reach the body's tissues. Insulin resistance. This condition occurs when the body can't use its own insulin properly. Insulin is a hormone that helps move blood sugar into cells where it's used. Diabetes. This is a disease in which the body's blood sugar level is high because the body doesn't make enough insulin or doesn't use its insulin properly. Overweight or obesity. Overweight is having extra body weight from muscle, bone, fat, and/or water. Obesity is having a high amount of extra body fat. Metabolic syndrome. Metabolic syndrome is the name for a group of risk factors linked to overweight and obesity that raise your chance for heart disease and other health problems, such as diabetes and stroke. Lack of physical activity. Lack of activity can worsen other risk factors for CAD. Age. As you get older, your risk for CAD increases. Genetic or lifestyle factors cause plaque to build in your arteries as you age. By the time you're middle-aged or older, enough plaque has built up to cause signs or symptoms.
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In men, the risk for CAD increases after age 45. In women, the risk for CAD risk increases after age 55.

Family history of early heart disease. Your risk increases if your father or a brother was diagnosed with CAD before 55 years of age, or if your mother or a sister was diagnosed with CAD before 65 years of age.

Although age and a family history of early heart disease are risk factors, it doesn't mean that you will develop CAD if you have one or both. Making lifestyle changes and/or taking medicines to treat other risk factors can often lessen genetic influences and prevent CAD from developing, even in older adults.

Emerging Risk Factors

Scientists continue to study other possible risk factors for CAD. High levels of a protein called C-reactive protein (CRP) in the blood may raise the risk for CAD and heart attack. High levels of CRP are proof of inflammation in the body. Inflammation is the body's response to injury or infection. Damage to the arteries' inner walls seems to trigger inflammation and help plaque grow. Research is under way to find out whether reducing inflammation and lowering CRP levels also can reduce the risk of developing CAD and having a heart attack. High levels of fats called triglycerides in the blood also may raise the risk of CAD, particularly in women.

Other Factors That Affect Coronary Artery Disease

Other factors also may contribute to CAD. These include:

Sleep apnea. Sleep apnea is a disorder in which your breathing stops or gets very shallow while you're sleeping. Untreated sleep apnea can raise your chances of having high blood pressure, diabetes, and even a heart attack or stroke. Stress. Research shows that the most commonly reported "trigger" for a heart attack is an emotionally upsetting eventparticularly one involving anger. Alcohol. Heavy drinking can damage the heart muscle and worsen other risk factors for heart disease. Men should have no more than two drinks containing alcohol a day. Women should have no more than one drink containing alcohol a day.

What Are the Signs and Symptoms of Coronary Artery Disease?

A common symptom of coronary artery disease (CAD) is angina. Angina is chest pain or discomfort that occurs when your heart muscle doesn't get enough oxygen-rich blood. Angina may feel like pressure or a squeezing pain in your chest. You also may feel it in your shoulders, arms, neck, jaw, or back. This pain tends to get worse with activity and go away when you rest. Emotional stress also can trigger the pain. Another common symptom of CAD is shortness of breath. This symptom happens if CAD causes heart failure. When you have heart failure, your heart can't pump enough blood throughout your body. Fluid builds up in your lungs, making it hard to breathe.

The severity of these symptoms varies. The symptoms may get more severe as the buildup of plaque continues to narrow the coronary arteries. Signs and Symptoms of Heart Problems Linked to Coronary Artery Disease Some people who have CAD have no signs or symptoms. This is called silent CAD. It may not be diagnosed until a person show signs and symptoms of a heart attack, heart failure, or an arrhythmia (an irregular heartbeat). Heart Attack A heart attack happens when an area of plaque in a coronary artery breaks apart, causing a blood clot to form. The blood clot cuts off most or all blood to the part of the heart muscle that's fed by that artery. Cells in the heart muscle die because they don't receive enough oxygen-rich blood. This can cause lasting damage to your heart. For more information, see the animation in "What Causes a Heart Attack?" Heart With Muscle Damage and a Blocked Artery

Figure A is an overview of a heart and coronary artery showing damage (dead heart muscle) caused by a heart attack. Figure B is a cross-section of the coronary artery with plaque buildup and a blood clot. The most common symptom of heart attack is chest pain or discomfort. Most heart attacks involve discomfort in the center of the chest that lasts for more than a few minutes or goes away and comes back. The discomfort can feel like pressure, squeezing, fullness, or pain. It can be mild or severe. Heart attack pain can sometimes feel like indigestion or heartburn.

Heart attacks also can cause upper body discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath or fatigue (tiredness) often may occur with or before chest discomfort. Other symptoms of heart attack are nausea (feeling sick to your stomach), vomiting, lightheadedness or fainting, and breaking out in a cold sweat. Heart Failure Heart failure is a condition in which your heart can't pump enough blood to your body. Heart failure doesn't mean that your heart has stopped or is about to stop working. It means that your heart can't fill with enough blood or pump with enough force, or both. This causes you to have shortness of breath and fatigue that tends to increase with activity. Heart failure also can cause swelling in your feet, ankles, legs, and abdomen. Arrhythmia An arrhythmia is a problem with the speed or rhythm of the heartbeat. When you have an arrhythmia, you may notice that your heart is skipping beats or beating too fast. Some people describe arrhythmias as a fluttering feeling in their chests. These feelings are called palpitations. Some arrhythmias can cause your heart to suddenly stop beating. This condition is called sudden cardiac arrest (SCA). SCA can make you faint and it can cause death if its not treated right away. For more information, see the animations in "Types of Arrhythmia."

How Is Coronary Artery Disease Diagnosed?

Your doctor will diagnose coronary artery disease (CAD) based on:

Your medical and family histories Your risk factors The results of a physical exam and diagnostic tests and procedures

Diagnostic Tests and Procedures No single test can diagnose CAD. If your doctor thinks you have CAD, he or she will probably do one or more of the following tests. EKG (Electrocardiogram) An EKG is a simple test that detects and records the electrical activity of your heart. An EKG shows how fast your heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of your heart.

Certain electrical patterns that the EKG detects can suggest whether CAD is likely. An EKG also can show signs of a previous or current heart attack. Stress Testing During stress testing, you exercise to make your heart work hard and beat fast while heart tests are performed. If you can't exercise, you're given medicine to speed up your heart rate. When your heart is beating fast and working hard, it needs more blood and oxygen. Arteries narrowed by plaque can't supply enough oxygen-rich blood to meet your heart's needs. A stress test can show possible signs of CAD, such as:

Abnormal changes in your heart rate or blood pressure Symptoms such as shortness of breath or chest pain Abnormal changes in your heart rhythm or your heart's electrical activity

During the stress test, if you can't exercise for as long as what's considered normal for someone your age, it may be a sign that not enough blood is flowing to your heart. But other factors besides CAD can prevent you from exercising long enough (for example, lung diseases, anemia, or poor general fitness). Some stress tests use a radioactive dye, sound waves, positron emission tomography (PET), or cardiac magnetic resonance imaging (MRI) to take pictures of your heart when it's working hard and when it's at rest. These imaging stress tests can show how well blood is flowing in the different parts of your heart. They also can show how well your heart pumps blood when it beats. Echocardiography This test uses sound waves to create a moving picture of your heart. Echocardiography provides information about the size and shape of your heart and how well your heart chambers and valves are working. The test also can identify areas of poor blood flow to the heart, areas of heart muscle that aren't contracting normally, and previous injury to the heart muscle caused by poor blood flow. Chest X Ray A chest x ray takes a picture of the organs and structures inside the chest, including your heart, lungs, and blood vessels. A chest x ray can reveal signs of heart failure, as well as lung disorders and other causes of symptoms that aren't due to CAD.

Blood Tests Blood tests check the levels of certain fats, cholesterol, sugar, and proteins in your blood. Abnormal levels may show that you have risk factors for CAD. Electron-Beam Computed Tomography Your doctor may recommend electron-beam computed tomography (EBCT). This test finds and measures calcium deposits (called calcifications) in and around the coronary arteries. The more calcium detected, the more likely you are to have CAD. EBCT isn't used routinely to diagnose CAD, because its accuracy isn't yet known. Coronary Angiography and Cardiac Catheterization Your doctor may ask you to have coronary angiography (an-jee-OG-ra-fee) if other tests or factors show that you're likely to have CAD. This test uses dye and special x rays to show the insides of your coronary arteries. To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization (KATH-e-ter-i-ZA-shun). A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. The tube is then threaded into your coronary arteries, and the dye is released into your bloodstream. Special x rays are taken while the dye is flowing through your coronary arteries. Cardiac catheterization is usually done in a hospital. You're awake during the procedure. It usually causes little to no pain, although you may feel some soreness in the blood vessel where your doctor put the catheter.

How Is Coronary Artery Disease Treated?

Treatment for coronary artery disease (CAD) may include lifestyle changes, medicines, and medical procedures. The goals of treatments are to:

Relieve symptoms Reduce risk factors in an effort to slow, stop, or reverse the buildup of plaque Lower the risk of blood clots forming, which can cause a heart attack Widen or bypass clogged arteries Prevent complications of CAD

Lifestyle Changes Making lifestyle changes can often help prevent or treat CAD. For some people, these changes may be the only treatment needed:

Follow a heart healthy eating plan to prevent or reduce high blood pressure and high blood cholesterol and to maintain a healthy weight

Increase your physical activity. Check with your doctor first to find out how much and what kinds of activity are safe for you. Lose weight, if you're overweight or obese. Quit smoking, if you smoke. Avoid exposure to secondhand smoke. Learn to cope with and reduce stress.

Follow a Heart Healthy Eating Plan For a heart healthy eating plan, go to the National Heart, Lung, and Blood Institute's (NHLBI's) Aim for a Healthy Weight Web site. This site provides practical tips on healthy eating, physical activity, and controlling your weight.

Therapeutic Lifestyle Changes (TLC).

Your doctor may recommend TLC if you have high cholesterol. TLC is a three-part program that includes a healthy diet, physical activity, and weight management. With the TLC diet, less than 7 percent of your daily calories should come from saturated fat. This kind of fat is mainly found in meat and poultry, including dairy products. No more than 25 to 35 percent of your daily calories should come from all fats, including saturated, trans, monounsaturated, and polyunsaturated fats. You also should have less than 200 mg a day of cholesterol. The amounts of cholesterol and the different kinds of fat in prepared foods can be found on the Nutrition Facts label. Foods high in soluble fiber also are part of a healthy eating plan. They help block the digestive track from absorbing cholesterol. These foods include:

Whole grain cereals such as oatmeal and oat bran Fruits such as apples, bananas, oranges, pears, and prunes Legumes such as kidney beans, lentils, chick peas, black-eyed peas, and lima beans

A diet high in fruits and vegetables can increase important cholesterol-lowering compounds in your diet. These compounds, called plant stanols or sterols, work like soluble fiber. Fish are an important part of a heart healthy diet. They're a good source of omega-3 fatty acids, which may help protect the heart from blood clots and inflammation and reduce the risk for heart attack. Try to have about two fish meals every week. Fish high in omega-3 fats are salmon, tuna (canned or fresh), and mackerel. You also should try to limit the amount of sodium (salt) that you eat. This means choosing low-sodium and low-salt foods and "no added salt" foods and seasonings at the table or when cooking. The Nutrition Facts label on food packaging shows the amount of sodium in the item.

Try to limit alcoholic drinks. Too much alcohol will raise your blood pressure and triglyceride level. (Triglycerides are a type of fat found in the blood.) Alcohol also adds extra calories, which will cause weight gain. Men should have no more than two alcoholic drinks a day. Women should have no more than one alcoholic drink a day. See the NHLBI's "Your Guide to Lowering Your Cholesterol With TLC" for more information.

Dietary Approaches to Stop Hypertension (DASH) eating plan.

Your doctor may recommend the DASH eating plan if you have high blood pressure. The DASH eating plan focuses on fruits, vegetables, whole grains, and other foods that are heart healthy and lower in salt/sodium. This eating plan is low in fat and cholesterol. It also focuses on fat-free or low-fat milk and dairy products, fish, poultry, and nuts. The DASH eating plan is reduced in red meat (including lean red meat), sweets, added sugars, and sugar-containing beverages. It's rich in nutrients, protein, and fiber. The DASH eating plan is a good heart healthy eating plan, even for those who don't have high blood pressure. See the NHLBI's "Your Guide to Lowering Your Blood Pressure With DASH" for more information. Increase Physical Activity Regular physical activity can lower many CAD risk factors, including LDL ("bad") cholesterol, high blood pressure, and excess weight. Physical activity also can lower your risk for diabetes and raise your levels of HDL cholesterol (the "good" cholesterol that helps prevent CAD). Check with your doctor about how much and what kinds of physical activity are safe for you. Unless your doctor tells you otherwise, try to get at least 30 minutes of moderate-intensity activity on most or all days of the week. You can do the activity all at once or break it up into shorter periods of at least 10 minutes each. Moderate-intensity activities include brisk walking, dancing, bowling, bicycling, gardening, and housecleaning. More intense activities, such as jogging, swimming, and various sports, also may be appropriate for shorter periods. See the NHLBI's "Your Guide to Physical Activity and Your Heart" for more information. Maintain a Healthy Weight Maintaining a healthy weight can decrease risk factors for CAD. If you're overweight, aim to reduce your weight by 7 to 10 percent during your first year of treatment. This amount of weight loss can lower your risk for CAD and other health problems.

After the first year, you may have to continue to lose weight so you can lower your body mass index (BMI) to less than 25. BMI measures your weight in relation to your height and gives an estimate of your total body fat. A BMI between 25 and 29 is considered overweight. A BMI of 30 or more is considered obese. A BMI of less than 25 is the goal for preventing and treating CAD. You can calculate your BMI using the NHLBI's online calculator, or your health care provider can calculate your BMI. For more information on losing weight and maintaining your weight, see the Diseases and Conditions Index Overweight and Obesity article. Quit Smoking If you smoke or use tobacco, quit. Smoking can damage and tighten blood vessels and raise your risk for CAD. The U.S. Department of Health and Human Services has information on how to quit smoking. Reduce Stress Research shows that the most commonly reported "trigger" for a heart attack is an emotionally upsetting eventparticularly one involving anger. Also, some of the ways people cope with stress, such as drinking, smoking, or overeating, aren't heart healthy. Physical activity can help relieve stress and reduce other CAD risk factors. Many people also find that meditation or relaxation therapy helps them reduce stress. Medicines You may need medicines to treat CAD if lifestyle changes aren't enough. Medicines can:

Decrease the workload on your heart and relieve CAD symptoms Decrease your chance of having a heart attack or dying suddenly Lower your cholesterol and blood pressure Prevent blood clots Prevent or delay the need for a special procedure (for example, angioplasty or coronary artery bypass grafting (CABG))

Medicines used to treat CAD include anticoagulants (AN-te-ko-AG-u-lants), aspirin and other antiplatelet (an-ty-PLAYT-lit) medicines, ACE inhibitors, beta blockers, calcium channel blockers, nitroglycerin, glycoprotein IIb-IIIa, statins, and fish oil and other supplements high in omega-3 fatty acids. Medical Procedures

You may need a medical procedure to treat CAD. Both angioplasty and CABG are used as treatments. Angioplasty opens blocked or narrowed coronary arteries. During angioplasty, a thin tube with a balloon or other device on the end is threaded through a blood vessel to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque outward against the wall of the artery. This widens the artery and restores the flow of blood. Angioplasty can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. Sometimes a small mesh tube called a stent is placed in the artery to keep it open after the procedure. In CABG, arteries or veins from other areas in your body are used to bypass (that is, go around) your narrowed coronary arteries. CABG can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. You and your doctor can discuss which treatment is right for you. Cardiac Rehabilitation Your doctor may prescribe cardiac rehabilitation (rehab) for angina or after CABG, angioplasty, or a heart attack. Cardiac rehab, when combined with medicine and surgical treatments, can help you recover faster, feel better, and develop a healthier lifestyle. Almost everyone with CAD can benefit from cardiac rehab. The cardiac rehab team may include doctors, nurses, exercise specialists, physical and occupational therapists, dietitians, and psychologists or other behavioral therapists. Rehab has two parts:

Exercise training. This part helps you learn how to exercise safely, strengthen your muscles, and improve your stamina. Your exercise plan will be based on your individual abilities, needs, and interests. Education, counseling, and training. This part of rehab helps you understand your heart condition and find ways to reduce your risk for future heart problems. The cardiac rehab team will help you learn how to cope with the stress of adjusting to a new lifestyle and with your fears about the future.

For more information on cardiac rehab, see the Diseases and Conditions Index Cardiac Rehabilitation article.

How Can Coronary Artery Disease Be Prevented or Delayed?

Taking action to control your risk factors can help prevent or delay coronary artery disease (CAD). Your chance of developing CAD goes up with the number of risk factors you have.

Making lifestyle changes and taking prescribed medicines are important steps. See "How Is Coronary Artery Disease Treated?" for information on heart healthy eating plans, physical activity, maintaining a healthy weight, and medicines. Know your family history of health problems related to CAD. If you or someone in your family has CAD, be sure to tell your doctor. Also, let your doctor know if you smoke.

Living With Coronary Artery Disease

Coronary artery disease (CAD) can cause serious complications. However, if you follow your doctor's advice and change your habits, you can prevent or reduce the chances of:

Dying suddenly from heart problems Having a heart attack and permanently damaging your heart muscle Damaging your heart because of reduced oxygen supply Having arrhythmias (irregular heartbeats)

Ongoing Health Care Needs

Doing physical activity regularly, taking prescribed medicines, following a heart healthy eating plan, and watching your weight can help control CAD. (See "How Is Coronary Artery Disease Treated?" for more information). See your doctor regularly to keep track of your blood pressure and blood cholesterol and blood sugar levels. A cholesterol blood test will show your levels of LDL ("bad") cholesterol, HDL ("good") cholesterol, and triglycerides. A fasting blood glucose test will check your blood sugar level and show if you're at risk for or have diabetes. These tests will show whether you need more treatments for your CAD. Talk to your doctor about how often you should schedule office visits or blood tests. Between those visits, call your doctor if you develop any new symptoms or if your symptoms worsen. CAD raises your risk for heart attack. Learn the symptoms of heart attack and arrhythmia. Call 911 if you have any of these symptoms for more than 5 minutes:

Chest discomfort or painuncomfortable pressure, squeezing, fullness, or pain in the center of the chest that can be mild or strong. This discomfort or pain lasts more than a few minutes or goes away and comes back. Upper body discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath, which may occur with or before chest discomfort.

It's important to know the difference between angina and a heart attack. During a heart attack, the pain is usually more severe than angina, and it doesn't go away when you rest or take medicine. If you don't know whether your chest pain is angina or a heart attack, call 9 11.

Let the people you see regularly know you're at risk for a heart attack. They can seek emergency care if you suddenly faint, collapse, or develop other severe symptoms. You may feel depressed or anxious if you've been diagnosed with CAD and/or had a heart attack. You may worry about heart problems or making lifestyle changes that are necessary for your health. Your doctor may recommend medicine, professional counseling, or relaxation therapy if you have depression or anxiety. Physical activity can improve mental well-being, but you should talk to your doctor before starting any fitness activities. It's important to treat any anxiety or depression that develops because it raises your risk of having a heart attack.

What To Expect During Coronary Angioplasty

Coronary angioplasty is performed in a special part of the hospital called the cardiac catheterization (kath-eh-ter-ih-ZA-shun) laboratory. The "cath lab" has special video screens and x-ray machines. Your doctor uses this equipment to see enlarged pictures of the blocked areas in your coronary arteries.

Preparation
In the cath lab, you will lie on a table. An intravenous (IV) line will be placed in your arm to give you fluids and medicines. The medicines will relax you and prevent blood clots from forming. These medicines may make you feel sleepy or as though you're floating or numb. To prepare for the procedure:

The area where the catheter will be inserted, usually the arm or groin (upper thigh), will be shaved. The shaved area will be cleaned to make it germ free and then numbed. The numbing medicine may sting as it's going in.

Steps in Angioplasty
When you're comfortable, the doctor will begin the procedure. You will be awake but sleepy. A small cut is made in your arm or groin into which a tube called a sheath is put. The doctor then threads a very thin guide wire through the artery in your arm or groin toward the area of the coronary artery that's blocked. Your doctor puts a long, thin, flexible tube called a catheter through the sheath and slides it over the guide wire and up to the heart. Your doctor moves the catheter into the coronary artery to the blockage. He or she takes out the guide wire once the catheter is in the right spot.

A small amount of dye may be injected through the catheter into the bloodstream to help show the blockage on x ray. This x-ray picture of the heart is called an angiogram. Next, your doctor slides a tube with a small deflated balloon inside it through the catheter and into the coronary artery where the blockage is. When the tube reaches the blockage, the balloon is inflated. The balloon pushes the plaque against the wall of the artery and widens it. This helps to increase the flow of blood to the heart. The balloon is then deflated. Sometimes the balloon is inflated and deflated more than once to widen the artery. Afterward, the balloon and tube are removed. In some cases, plaque is removed during angioplasty. A catheter with a rotating shaver on its tip is inserted into the artery to cut away hard plaque. Lasers also may be used to dissolve or break up the plaque. The animation below shows the process of coronary angioplasty. Click the "start" button to play the animation. Written and spoken explanations are provided with each frame. Use the buttons in the lower right corner to pause, restart, or replay the animation, or use the scroll bar below the buttons to move through the frames.

The animation shows how a doctor inserts a tube called a balloon catheter into a coronary artery narrowed by plaque. The balloon catheter compresses the plaque and widens the artery to restore blood flow. If your doctor needs to put a stent (small mesh tube) in your artery, another tube with a balloon will be threaded through your artery. A stent is wrapped around the balloon. Your doctor will inflate the balloon, which will cause the stent to expand against the wall of the artery. The balloon is then deflated and pulled out of the artery with the tube. The stent stays in the artery. After the angioplasty is done, your doctor pulls back the catheter and removes it and the sheath. The hole in the artery is either sealed with a special device, or pressure is put on it until the blood vessel seals. The animation below shows the process of coronary angioplasty and stent placement. Click the "start" button to play the animation. Written and spoken explanations are provided with each frame. Use the buttons in the lower right corner to pause, restart, or replay the animation, or use the scroll bar below the buttons to move through the frames.

The animation shows how a doctor inserts a tube called a balloon catheter into a coronary artery narrowed by plaque. The balloon catheter compresses the plaque, widens the artery, and restores blood flow. Through the catheter, a stent is placed in the artery to help maintain the restored blood flow. During angioplasty, strong antiplatelet medicines are given through the IV to prevent blood clots from forming in the artery or on the stent. These medicines help thin your blood. They're usually started just before the angioplasty and may continue for 1224 hours afterward.

What To Expect After Coronary Angioplasty

After coronary angioplasty, you will be moved to a special care unit, where you will stay for a few hours or overnight. While you recover in this area, you must lie still for a few hours to allow the blood vessels in your arm or groin (upper thigh) to seal completely. While you recover, nurses will check your heart rate and blood pressure. They also will check your arm or groin for bleeding. After a few hours, you will be able to walk with help. The place where the tube was inserted may feel sore or tender for about a week. Going Home Most people go home 1 to 2 days after the procedure. When your doctor thinks you're ready to leave the hospital, you will get instructions to follow at home, including:

How much activity or exercise you can do. When you should follow up with your doctor. What medicines you should take.

What you should look for daily when checking for signs of infection around the area where the tube was inserted. Signs of infection may include redness, swelling, or drainage. When you should call your doctor. For example, you may need to call if you have a fever or signs of infection, pain or bleeding where the catheter was inserted, or shortness of breath. When you should call 911 (for example, if you have any chest pain).

Your doctor will prescribe medicine to prevent blood clots from forming. Taking your medicine as directed is very important. If a stent was inserted, the medicine reduces the risk that blood clots will form in the stent. Blood clots in the stent can block blood flow and cause a heart attack. Recovery and Recuperation Most people recover from angioplasty and return to work about 1 week after being sent home. Your doctor will want to check your progress after you leave the hospital. During the followup visit, your doctor will examine you, make changes to your medicines if needed, do any necessary tests, and check your overall recovery. Use this time to ask questions you may have about activities, medicines, or lifestyle changes, or to talk about any other issues that concern you. Lifestyle Changes Although angioplasty can reduce the symptoms of coronary artery disease (CAD), it isn't a cure for CAD or the risk factors that led to it. Making healthy lifestyle changes can help treat CAD and maintain the good results from angioplasty. Talk with your doctor about your risk factors for CAD and the lifestyle changes you'll need to make. For some people, these changes may be the only treatment needed.

Follow a healthy diet to prevent or reduce high blood pressure and high blood cholesterol and to maintain a healthy weight. Quit smoking if you smoke. Be physically active. Lose weight if you're overweight or obese. Reduce stress. Take medicines as your doctor directs to lower high blood pressure or high blood cholesterol.

"Your Guide to Living Well With Heart Disease," from the National Heart, Lung, and Blood Institute, will give you more detailed information about making healthy lifestyle changes.

Cardiac Rehabilitation Your doctor may want you to take part in a cardiac rehabilitation (rehab) program. Cardiac rehab helps people with heart disease recover faster and return to work or daily activities. Cardiac rehab includes supervised physical activity, education on heart healthy living, and counseling to cut down on stress and help you return to an active life. Your doctor can tell you where to find a cardiac rehab program near your home. "Your Guide to Living Well With Heart Disease," will give you more information on cardiac rehab.

What Are the Risks of Coronary Angioplasty?

Coronary angioplasty is a common medical procedure. Although angioplasty is normally safe, there is a small risk of serious complications, such as:

Bleeding from the blood vessel where the catheter was placed. Damage to blood vessels from the catheter. An allergic reaction to the dye given during the angioplasty. An arrhythmia (irregular heartbeat). The need for emergency coronary artery bypass grafting during the procedure (24 percent of people). This may occur when an artery closes down, instead of opening up. Damage to the kidneys caused by the dye used. Heart attack (35 percent of people). Stroke (less than 1 percent of people).

As with any procedure involving the heart, complications can sometimes, though rarely, cause death. Less than 2 percent of people die during angioplasty. Sometimes chest pain can occur during angioplasty because the balloon briefly blocks off the blood supply to the heart. The risk of complications is higher in:

People aged 75 and older People who have kidney disease or diabetes Women People who have poor pumping function in their hearts People who have extensive heart disease and blockages

Research on angioplasty is ongoing to make it safer and more effective, to prevent treated arteries from closing again, and to make the procedure an option for more people. Complications From Stents

Restenosis There is a chance that the artery will become narrowed or blocked again in time, often within 6 months of angioplasty. This is called restenosis. Stent Restenosis

The illustration shows the restenosis of a stent-widened coronary artery. The coronary artery is located on the surface of the heart. In figure A, the expanded stent compresses plaque, allowing normal blood flow. The inset image on figure A shows a cross-section of the compressed plaque and stent-widened artery. In figure B, the plaque grows (over time) through and around the stent, causing a partial blockage and abnormal blood flow. The inset image on figure B shows a cross-section of the growth of the plaque around the stent. When a stent isn't used, 4 out of 10 people have restenosis. When a nonmedicine-coated stent is used, 2 out of 10 people have restenosis. The growth of scar tissue in and around the stent also can cause restenosis. Medicinecoated stents reduce the growth of scar tissue around the stent and lower the chance of

restenosis. When medicine-coated stents are used, the chance of restenosis is lowered even more, to around 1 in 10 people. Other treatments, such as radiation, can help prevent tissue growth within a stent. For this procedure, the doctor puts a wire through a catheter to where the stent is placed. The wire releases radiation to stop any tissue growth that may block the artery. Blood Clots Recent studies suggest that there is a higher risk of blood clots forming in medicine-coated stents compared to bare metal stents (nonmedicine-coated). The Food and Drug Administration (FDA) reports that medicine-coated stents usually don't cause complications due to blood clots when used as recommended. When medicine-coated stents are used in people with advanced CAD, there is a higher risk of blood clots, heart attack, and death. The FDA is working with researchers to study medicine-coated stents, including their use in people with advanced CAD. Taking medicine as prescribed by your doctor can lower the risk of blood clots. People with medicine-coated stents are usually advised to take an anticlotting drug, such as clopidogrel and aspirin, for months to years to lower the risk of blood clots. As with all procedures, it's important to talk to your doctor about your treatment options, including the risks and benefits to you.

Key Points

Coronary angioplasty is a medical procedure in which a balloon is used to open a blockage in a coronary (heart) artery narrowed by atherosclerosis. This procedure improves blood flow to the heart. Atherosclerosis is a condition in which a material called plaque builds up on the inner walls of the arteries. When atherosclerosis affects the coronary arteries, the condition is called coronary artery disease (CAD). Angioplasty can improve some of the symptoms of CAD, such as angina (chest pain) and shortness of breath. It also can reduce damage to the heart muscle from a heart attack and reduce the risk of death in some patients. You may need angioplasty if medicines and lifestyle changes haven't improved your symptoms of CAD. You also may need angioplasty as emergency treatment during a heart attack. Angioplasty is less invasive than surgery. General anesthesia isn't needed. You will be given medicines to help you relax, but you will be awake during the procedure. Angioplasty is performed in a special part of the hospital called the cardiac catheterization laboratory. Before angioplasty is done, your doctor will need to know whether your coronary arteries are blocked. To find out, he or she will do an angiogram and take an x-ray

picture of your arteries to show any blockages and where they're located. Once your doctor has this information, the angioplasty can proceed.

During angioplasty, your doctor will use a small tube called a catheter with a balloon at the end. He or she will thread the balloon through an artery to the blockage. The balloon is blown up (inflated), pushing the plaque outward against the artery wall. This opens the artery more and improves blood flow through it. During angioplasty, a stent (mesh tube) is often placed in the artery that has been opened. The stent reduces the chance that the artery will become blocked again in the future. The stent remains in place after the procedure. Most people go home 1 to 2 days after having angioplasty. Full recovery from the procedure is usually 1 week or less. Lifestyles changes are recommended after angioplasty to improve CAD and to prevent the arteries from becoming narrowed or blocked again. Lifestyle changes include a healthy diet, weight control, medicines to lower high blood pressure and high blood cholesterol, regular physical activity, and quitting smoking. Angioplasty is a common medical procedure and is generally safe, but there is a small risk of serious complications. Renarrowing of the treated artery and growth of scar tissue within a stent can occur. The use of medicine-coated stents can lower the chance of this happening, but these stents aren't without risk. In some cases, blood clots can form in the medicine-coated stents. Research on angioplasty is ongoing to make it safer and more effective, to prevent treated arteries from closing again, and to make the procedure an option for more people.

Risk of a Repeat Heart Attack Once youve had a heart attack, youre at higher risk for another one. Its important to know the difference between angina and a heart attack. The pain of angina usually occurs after exertion and goes away in a few minutes when you rest or take medicine as directed. During a heart attack, the pain is usually more severe than angina, and it doesnt go away when you rest or take medicine. If you dont know whether your chest pain is angina or a heart attack, call 911. Remember, the symptoms of a second heart attack may not be the same as those of a first heart attack. Dont take a chance if youre in doubt. Always call 911 within 5 minutes if you or someone youre with has symptoms of a heart attack. Unfortunately, most heart attack victims wait 2 hours or more after their symptoms begin before they seek medical help. This delay can result in lasting heart damage or death. Key Points

A heart attack occurs when blood flow to a section of heart muscle becomes blocked. If the flow of blood isnt restored quickly, the section of heart muscle becomes damaged from lack of oxygen and begins to die.

Heart attack is a leading killer of both men and women in the United States. Today there are excellent treatments for heart attack that can save lives and prevent disabilities. Treatment is most effective when started within 1 hour of the beginning of symptoms. Unfortunately, many heart attack victims wait 2 hours or more after their symptoms begin before they seek medical help. This delay can result in lasting heart damage or death. If you think you or someone with you is having a heart attack, call 911 right away. Heart attacks occur most often as a result of a condition called coronary artery disease (CAD). Heart attack also can be caused by a condition called microvascular disease, which involves the microscopic blood vessels of the heart. Less commonly, a spasm (tightening) of a coronary artery can cause a heart attack. Certain risk factors increase the changes of developing CAD and having a heart attack (for example, age, a family history of CAD, smoking, and being overweight or obese). Some risk factors cant be controlled, while others can. The warning signs of heart attack arent the same for everyone. However, common signs and symptoms of a heart attack are:
o

Chest discomfort or painuncomfortable pressure, squeezing, fullness, or pain in the center or the chest that can be mild or strong. This discomfort or pain lasts more than a few minutes or goes away and comes back. Upper body discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath may occur with or before chest discomfort. Other signs include nausea (feeling sick to your stomach), vomiting, lightheadedness or fainting, or breaking out in a cold sweat.

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Treatments for heart attack include medicines and procedures to open blocked arteries (such as angioplasty). Lowering your risk for CAD can decrease your chances of having a heart attack (or second heart attack). This usually involves making healthy lifestyle choices and treating conditions related to CAD such as high cholesterol, high blood pressure, overweight and obesity, and diabetes. Most people are able to return to their normal activities after a heart attack. Ask your doctor when you can resume daily activities such as driving, exercise, work, sexual activity, strenuous activities (for example, running or heavy lifting), and travel. Many people survive heart attacks and live active and full lives.

What Is Cholesterol?
To understand high blood cholesterol (ko-LES-ter-ol), it is important to know more about cholesterol.

Cholesterol is a waxy, fat-like substance that is found in all cells of the body. Your body needs some cholesterol to work the right way. Your body makes all the cholesterol it needs. Cholesterol is also found in some of the foods you eat. Your body uses cholesterol to make hormones, vitamin D, and substances that help you digest foods.

Blood is watery, and cholesterol is fatty. Just like oil and water, the two do not mix. To travel in the bloodstream, cholesterol is carried in small packages called lipoproteins (lip-o-PROteens). The small packages are made of fat (lipid) on the inside and proteins on the outside. Two kinds of lipoproteins carry cholesterol throughout your body. It is important to have healthy levels of both:

Low-density lipoprotein (LDL) cholesterol is sometimes called bad cholesterol.

o

High LDL cholesterol leads to a buildup of cholesterol in arteries. The higher the LDL level in your blood, the greater chance you have of getting heart disease. HDL carries cholesterol from other parts of your body back to your liver. The liver removes the cholesterol from your body. The higher your HDL cholesterol level, the lower your chance of getting heart disease.

High-density lipoprotein (HDL) cholesterol is sometimes called good cholesterol.

o

What Is High Blood Cholesterol? Too much cholesterol in the blood, or high blood cholesterol, can be serious. People with high blood cholesterol have a greater chance of getting heart disease. High blood cholesterol on its own does not cause symptoms, so many people are unaware that their cholesterol level is too high. Cholesterol can build up on the walls of your arteries (blood vessels that carry blood from the heart to other parts of the body). This buildup of cholesterol is called plaque (plak). Over time, plaque can cause narrowing of the arteries. This is called atherosclerosis (ath-er-oskler-O-sis), or hardening of the arteries.

The illustration shows a normal artery with normal blood flow (Figure A) and an artery containing plaque buildup (Figure B). Special arteries, called coronary arteries, bring blood to the heart. Narrowing of your coronary arteries due to plaque can stop or slow down the flow of blood to your heart. When the arteries narrow, the amount of oxygen-rich blood is decreased. This is called coronary artery disease (CAD). Large plaque areas can lead to chest pain called angina (an-JI-nuh or AN-juh-nuh). Angina happens when the heart does not receive enough oxygen-rich blood. Angina is a common symptom of CAD. Some plaques have a thin covering and burst (rupture), releasing fat and cholesterol into the bloodstream. The release of fat and cholesterol may cause your blood to clot. A clot can block the flow of blood. This blockage can cause angina or a heart attack. Lowering your cholesterol level decreases your chance for having a plaque burst and cause a heart attack. Lowering cholesterol may also slow down, reduce, or even stop plaque from building up. Plaque and resulting health problems can also occur in arteries elsewhere in the body. February 2006 Other Names for High Blood Cholesterol

Hypercholesterolemia (HI-per-ko-LES-ter-ol-E-me-a) Hyperlipidemia (HI-per-lip-i-DE-me-a)

What Causes High Blood Cholesterol? A variety of things can affect the cholesterol levels in your blood. Some of these things you can control and others you cannot. You can control:

What you eat. Certain foods have types of fat that raise your cholesterol level.
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Saturated fat raises your low-density lipoprotein (LDL) cholesterol level more than anything else in your diet. Trans fatty acids (trans fats) are made when vegetable oil is hydrogenated to harden it. Trans fatty acids also raise cholesterol levels. Cholesterol is found in foods that come from animal sources, for example, egg yolks, meat, and cheese.

Your weight. Being overweight tends to increase your LDL level, lower your highdensity lipoprotein (HDL) level, and increase your total cholesterol level. Your activity. Lack of regular exercise can lead to weight gain, which could raise your LDL cholesterol level. Regular exercise can help you lose weight and lower your LDL level. It can also help you raise your HDL level.

You cannot control:

Heredity. High blood cholesterol can run in families. An inherited genetic condition (familial hypercholesterolemia) results in very high LDL cholesterol levels. It begins at birth, and may result in a heart attack at an early age. Age and sex. Starting at puberty, men have lower levels of HDL than women. As women and men get older, their LDL cholesterol levels rise. Younger women have lower LDL cholesterol levels than men, but after age 55, women have higher levels than men.

What Are the Signs and Symptoms of High Blood Cholesterol?

There are usually no signs or symptoms of high blood cholesterol. Many people don't know that their cholesterol level is too high. Everyone age 20 and older should have their cholesterol levels checked at least once every 5 years. You and your doctor can discuss how often you should be tested.

How Is High Blood Cholesterol Diagnosed? High blood cholesterol is diagnosed by checking levels of cholesterol in your blood. It is best to have a blood test called a lipoprotein profile to measure your cholesterol levels. Most people will need to not eat or drink anything (fast) for 9 to 12 hours before taking the test.

The lipoprotein profile will give information about your:

Total cholesterol Low-density lipoprotein (LDL) bad cholesterol: the main source of cholesterol buildup and blockage in the arteries High-density lipoprotein (HDL) good cholesterol: the good cholesterol that helps keep cholesterol from building up in arteries Triglycerides: another form of fat in your blood

If it is not possible to get a lipoprotein profile done, knowing your total cholesterol and HDL cholesterol can give you a general idea about your cholesterol levels. Testing for total and HDL cholesterol does not require fasting. If your total cholesterol is 200 mg/dL or more, or if your HDL is less than 40 mg/dL, you will need to have a lipoprotein profile done. Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dL) of blood. See how your cholesterol numbers compare to the tables below. Total Cholesterol Level Less than 200 mg/dL 200239 mg/dL 240 mg/dL and above LDL Cholesterol Level Less than 100 mg/dL 100129 mg/dL 130159 mg/dL 160189 mg/dL 190 mg/dL and above HDL Cholesterol Level Less than 40 mg/dL 4059 mg/dL 60 mg/dL and above Total Cholesterol Category Desirable Borderline high High LDL Cholesterol Category Optimal Near optimal/above optimal Borderline high High Very high HDL Cholesterol Category A major risk factor for heart disease The higher, the better Considered protective against heart disease

Triglycerides can also raise your risk for heart disease. If you have levels that are borderline high (150199 mg/dL) or high (200 mg/dL or more), you may need treatment. Things that can increase triglyceride levels include:

Overweight Physical inactivity

Cigarette smoking Excessive alcohol use Very high carbohydrate diet Certain diseases and drugs Genetic disorders

How Is High Blood Cholesterol Treated? The main goal of cholesterol-lowering treatment is to lower your low-density lipoprotein (LDL) level enough to reduce your risk of having a heart attack or diseases caused by hardening of the arteries. In general, the higher your LDL level and the more risk factors you have, the greater your chances of developing heart disease or having a heart attack. (A risk factor is a condition that increases your chance of getting a disease.) Some people are at high risk for heart attack because they already have heart disease. Other people are at high risk for developing heart disease because they have diabetes or a combination of risk factors for heart disease. Follow the steps below to find out your risk for getting heart disease. Check the list to see how many of the risk factors you have. These are the risk factors that affect your LDL goal:

Cigarette smoking High blood pressure (140/90 mg/dL or higher), or if you are on blood pressure medicine Low high-density lipoprotein (HDL) cholesterol (less than 40 mg/dL)1 Family history of early heart disease (heart disease in father or brother before age 55; heart disease in mother or sister before age 65) Age (men 45 years or older; women 55 years or older)

If you have two or more of the risk factors in the list above, use the NHLBI 10-Year Risk Calculator to find your risk score. Risk scores refer to the chance of having a heart attack in the next 10 years, given as a percentage. Use your medical history, number of risk factors, and risk score to find your risk of developing heart disease or having a heart attack according to the table below. If You Have Heart disease, diabetes, or a risk score higher than 20% You Are in Category I. Highest risk And Your LDL Goal Is Less than 100 mg/dL Less than 130 mg/dL Less than 130 mg/dL

Two or more risk factors and a II. Next highest risk risk score 1020% Two or more risk factors and a III. Moderate risk risk score lower than 10%

One or no risk factors

IV. Low to moderate risk

Less than 160 mg/dL

After following the above steps, you should have an idea about your risk for getting heart disease or having a heart attack. The higher your risk is, the lower your LDL goal will be. There are two main ways to lower your cholesterol:

Therapeutic Lifestyle Changes (TLC)includes a cholesterol-lowering diet (called the TLC Diet), physical activity, and weight management. TLC is for anyone whose LDL is above goal. Drug Treatmentif cholesterol-lowering drugs are needed, they are used together with TLC treatment to help lower your LDL.

The higher your risk for heart disease, the lower your LDL goal will be. Your doctor will set your LDL goal. Using the following guide, you and your doctor can develop a possible plan for treating your high blood cholesterol. Category I, highest risk, your LDL goal is less than 100 mg/dL. Your LDL Level If your LDL is 100 or above Even if your LDL is below 100 Treatment You will need to begin the TLC Diet together with drug treatment. You should follow the TLC Diet on your own to keep your LDL as low as possible.

Category II, next highest risk, your LDL goal is less than 130 mg/dL. Your LDL Level If your LDL is 130 mg/dL or above If your LDL is 130 mg/dL or more after 3 months on the TLC Diet If your LDL is less than 130 mg/dL Treatment You will need to begin the TLC Diet. You may need drug treatment along with the TLC Diet. You will need to follow the Heart Healthy Diet.

Category III, moderate risk, your LDL goal is less than 130 mg/dL. Your LDL Level If your LDL is 130 mg/dL or above If your LDL is 160 mg/dL or more after Treatment You will need to begin treatment with the TLC Diet. You may need drug treatment along with

you have tried the TLC Diet for 3 months the TLC Diet. If your LDL is less than 130 mg/dL You will need to follow the Heart Healthy Diet.

Category IV, low to moderate risk, your LDL goal is less than 160 mg/dL. Your LDL Level If your LDL is 160 mg/dL or above If your LDL is still 160 mg/dL or more after 3 months on the TLC Diet If your LDL is less than 160 mg/dL Treatment You will need to begin the TLC Diet. You may need drug treatment along with the TLC Diet. You will need to follow the Heart Healthy Diet.

Lowering Cholesterol With TLC TLC is a set of lifestyle changes you can make to help lower your LDL cholesterol. The main parts of TLC are:

The TLC Diet, which recommends:

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Limiting the amount of saturated fat and cholesterol you eat. Eating only enough calories to achieve or maintain a healthy weight. Increasing the soluble fiber in your diet. For example, oatmeal, kidney beans, and apples are good sources of soluble fiber. Adding cholesterol-lowering food, such as margarines that contain plant sterol or stanol esters that lower cholesterol for some people. Losing weight if you are overweight can help lower LDL. Weight management is especially important for those with a group of risk factors that includes high triglyceride and/or low HDL levels and being overweight with a large waist measurement (more than 40 inches for men and more than 35 inches for women). Regular physical activity is recommended for everyone. It can help raise HDL levels and lower LDL levels, and is especially important for those with high triglyceride and/or low HDL levels who are overweight with a large waist measurement.

Weight management:
o

Physical activity:
o

Cholesterol-Lowering Medicines Along with suggesting that you change the way you eat and exercise regularly, your doctor may prescribe medicines to help lower your cholesterol. Even if you begin drug treatment,

you will need to continue TLC. Drug treatment controls but does not "cure" high blood cholesterol. Therefore, you must continue taking your medicine to keep your cholesterol level in the recommended range. The five major types of cholesterol-lowering medicines are:

Statins
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Very effective in lowering LDL (bad) cholesterol levels Safe for most people Rare side effects to watch for are liver and muscle problems Help lower LDL cholesterol levels Sometimes prescribed with statins Not usually prescribed as the only medicine to lower cholesterol Lowers LDL cholesterol and triglycerides, and raises HDL (good) cholesterol Should only be used under a doctor's supervision Lower triglycerides May increase HDL (good) cholesterol levels When used with a statin, may increase the chance of muscle problems Lowers LDL cholesterol May be used with statins or alone Acts within the intestine to block cholesterol absorption

Bile Acid Sequestrants (seh-KWES-trants)

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Nicotinic (Nick-o-TIN-ick) Acid

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Fibrates
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Ezetimibe
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When you are under treatment, you will be checked regularly to:

Make sure your cholesterol level is controlled Check for other health problems

You may take medicines for other health problems. It is important that you take ALL medicines as your doctor prescribes. The combination of medicines may lower your risk for heart disease or heart attack. When trying to lower your cholesterol or keep it low, it is important to remember to follow your treatments for other conditions you may have, such as high blood pressure. Get help with quitting smoking and losing weight if they are risk factors for you. ____________ 1 If your HDL cholesterol is 60 mg/dL or higher, subtract 1 from your total count.

Key Points

Cholesterol is a fat-like substance that is made in your body. Cholesterol is also in some foods that you eat. Your body needs some cholesterol to work the right way. Your body makes all the cholesterol it needs. Too much cholesterol in the blood is hypercholesterolemia. called high blood cholesterol or

High blood cholesterol increases the chance of having a heart attack or some other symptom of heart disease, like chest pain (angina). Lowering cholesterol is important for everyoneyoung, middle-aged, and older adults, and both men and women. Eating too much saturated fat and cholesterol raises the level of cholesterol in your blood. Too much cholesterol in your blood can build up in the walls of arteries. This is called plaque. There are no signs or symptoms of high blood cholesterol. Many people don't know that their cholesterol level is too high. High blood cholesterol is diagnosed by checking cholesterol levels in your blood. A blood test called a lipoprotein profile measures the cholesterol levels in your blood and is the recommended test. It is important that everyone age 20 and older get their cholesterol checked at least once every 5 years. Many people are able to lower their cholesterol levels by eating a low saturated fat and low cholesterol diet, exercising, and losing weight if needed. Some people will need to take medicines prescribed by their doctor to lower their cholesterol in addition to eating a low saturated fat and low cholesterol diet, exercising, and losing weight if needed.

What Is a Stent?
A stent is a small mesh tube thats used to treat narrowed or weakened arteries in the body. You may have a stent placed in an artery as part of a procedure called angioplasty (AN-jeeoh-plas-tee). Angioplasty can restore blood flow through narrowed or blocked arteries. Stents help prevent arteries from becoming narrowed or blocked again in the months or years after treatment with angioplasty. You may also have a stent placed in a weakened artery to improve blood flow and to help prevent the artery from bursting. Stents are usually made of metal mesh, but sometimes theyre made of fabric. Fabric stents, also called stent grafts, are used in larger arteries. Some stents are coated with medicines that are slowly and continuously released into the artery. These medicines help prevent the artery from becoming blocked again.

May 2007 How Are Stents Used? Stents for Arteries in the Heart With age and some health conditions, the inside openings of the coronary arteries (arteries of the heart) tend to narrow due to deposits of a fatty substance called plaque (plak). High cholesterol, diabetes, and smoking can cause the arteries to narrow. This narrowing of the coronary arteries can cause angina (chest pain) or lead to heart attack. During angioplasty, doctors use an expanding balloon inside the artery to compress the plaque and widen the passageway. The result is improved blood flow to the heart and a decreased chance of heart attack. Unless an artery is too small, doctors usually place a stent in the treated portion of the artery during angioplasty. The stent supports the inner artery wall and reduces the chance of the artery closing up again. A stent also can keep an artery open that was torn or injured during angioplasty. When stents are placed in coronary arteries, there's a 1 in 5 chance that the arteries will close in the first 6 months after angioplasty. When stents aren't used, the risk of the arteries closing can be twice as high. Stents for the Carotid Arteries in the Neck Both the right and left sides of your neck have blood vessels called carotid (ka-ROT-id) arteries. These arteries carry blood from the heart to the brain. Carotid arteries can become narrowed by plaque. These plaque deposits limit blood flow to the brain and increase your risk for stroke. Your chance of developing plaque in your carotid arteries increases with age, and may increase if you smoke. A new procedure uses stents to help keep the carotid arteries fully open after they're widened with angioplasty. Not all hospitals offer this procedure. How effective it is long term is still not known. The National Institute of Neurological Disorders and Stroke supports clinical studies to explore the risks and benefits of angioplasty and stenting of carotid arteries. Stents for Other Arteries The arteries in the kidneys also can become narrowed. This reduces blood flow to the kidneys, which can affect their ability to control blood pressure. This can cause severe high blood pressure. The arteries in the arms and legs also can narrow with plaque over time. This narrowing can cause pain and cramping in the affected limbs. If the narrowing is severe, it can completely cut off the blood flow to a limb, which could require surgical treatment.

To relieve these problems, doctors may perform angioplasty on the narrowed kidney, arm, or leg arteries. This procedure often is followed by placing a stent in the treated artery. The stent helps keep the artery fully open. Stents for the Aorta in the Abdomen or Chest The major artery coming out of the heart and supplying blood to the body is called the aorta. The aorta travels through the chest and then down into the abdomen. Over time, some areas of the walls of the aorta can become weak. These weakened areas can cause a bulge in the artery called an aneurysm. An aorta with an aneurysm can burst, leading to potentially deadly internal bleeding. When aneurysms occur, they're usually in the part of the aorta in the abdomen. To help avoid a burst, doctors place a fabric stent in the weakened area of the abdominal aorta. The stent creates a stronger inner lining for the artery. Aneurysms also can develop in the part of the aorta in the chest. These aneurysms also can be treated with stents. But this new use of stents is not offered by all hospitals, and how effective it is long term is still not known. Stents To Close Off Aortic Tears Another problem that can develop in the aorta is a tear in the inside wall. Blood can be forced into this tear, causing it to widen and eventually block blood flow through the artery or burst. When this occurs, it's usually in the part of the aorta that's in the chest. Fabric stents are being developed and used experimentally to prevent aortic dissection by stopping blood from flowing into the tear. Tears in the aorta reduce blood flow to the tissues the aorta serves. A fabric stent placed within the torn area of the artery can help restore normal blood flow and reduce the risk of a burst aorta. Stents to treat aortic tears are still being researched. Only a few hospitals offer this procedure. How Are Stents Placed? To place a stent, your doctor will make a small opening in a blood vessel in your groin (upper thigh), arm, or neck. Through this opening, your doctor will thread a flexible, plastic tube (catheter) with a deflated balloon on the end. A stent may be placed around the deflated balloon. The tip of the catheter is threaded up to the narrowed artery section or to the aneurysm or aortic tear site. Special x-ray movies are taken of the tube as it is threaded up into your blood vessel. These movies help your doctor position the catheter. For Arteries Narrowed by Plaque Once the tube is in the area of the artery that needs treatment:

Your doctor uses a special dye to help see narrowed areas of the blood vessel.

Your doctor inflates the balloon. It pushes against the plaque and compresses it against the artery wall. The fully extended balloon also expands the surrounding stent, pushing it into place in the artery. The balloon is deflated and taken out along with the catheter. The stent remains in your artery. Cells in your artery eventually grow to cover the mesh of the stent and create an inner layer that resembles what is normally seen inside a blood vessel.

Coronary Artery Stent Placement

The illustration shows the placement of a stent in a coronary artery with plaque buildup. The coronary artery is located on the surface of the heart. Figure A shows the deflated balloon catheter and closed stent inserted into the narrowed coronary artery. The insert image on figure A shows a cross-section of the artery with the inserted balloon catheter and closed stent. In figure B, the balloon is inflated, expanding the stent and compressing the plaque to restore the size of the artery. Figure C shows normal blood flow restored in

the stent-widened artery. The insert image on figure C shows a cross-section of the compressed plaque and stent-widened artery. The animation below shows coronary angioplasty and stent placement. Click the "start" button to play the animation. Written and spoken explanations are provided with each frame. Use the buttons in the lower right corner to pause, restart, or replay the animation, or use the scroll bar below the buttons to move through the frames.

The animation shows how a doctor inserts a tube called a balloon catheter into a coronary artery narrowed by plaque. The balloon catheter compresses the plaque, widens the artery, and restores blood flow. Through the catheter, a stent is placed in the artery to help maintain the restored blood flow. A very narrow artery, or one that is difficult to reach with the catheter, may require more steps to place a stent. This type of artery usually is first expanded by inflating a small balloon. The balloon is then removed and replaced by another larger balloon with the collapsed stent around it. At this point, your doctor can follow the standard practice of compressing the plaque and placing the stent. When angioplasty and stent placement are performed on carotid arteries, a special filter device is used. The filter helps keep blood clots and loose pieces of plaque from passing into the bloodstream and brain during the procedure. For Aortic Aneurysms Placing a stent to treat an aneurysm in an artery is slightly different than treating an artery narrowed by plaque. The stent used to treat an aneurysm is made out of pleated fabric, often with one or more tiny hooks. Once the catheter is positioned at the aneurysm site, the stent is threaded through the tube to the area that needs treatment. Then, your doctor places a balloon inside the stent. The balloon is inflated to expand the stent and have it fit tight against the artery wall. The hooks on the stent latch on to the artery wall to anchor the stent. Your doctor then removes the balloon and catheter, leaving the fabric stent behind.

The stent creates a new inner lining for that portion of the artery. Cells in the artery eventually grow to cover the fabric and create an inner layer that resembles whats normally seen inside a blood vessel. What To Expect Before a Stent Procedure Most stent procedures require an overnight stay in the hospital and someone to take you home. Discuss with your doctor:

When to stop eating and drinking before coming to the hospital What medicines you should or shouldn't take on the day of the procedure When to come to the hospital and where to go

You also should let your doctor know if you have diabetes, kidney disease, or other conditions that may require taking extra steps during or after the procedure to avoid complications. What To Expect During a Stent Procedure For Arteries Narrowed by Plaque This procedure usually takes a few hours. Before the procedure starts, you will get medicine to help you relax. You will be on your back and awake during the procedure so you can follow the doctor's instructions. The area where the catheter is inserted will be numbed and you won't feel the doctor threading the catheter, balloon, or stent inside the artery. You may feel some pain when the balloon is expanded to push the stent into place. For Aortic Aneurysms This procedure takes a few hours. It usually requires a 2- to 3-day stay in the hospital. Before the procedure, you will be given medicine to help you relax. If a stent is placed in the abdominal portion of the aorta, your doctor may give you a regional anesthetic. This will make you numb from the area of the stent placement down, but it will allow you to be awake during the procedure. If a stent is placed in the chest portion of the aorta, usually a general anesthetic will be used, which will make you sleep through the procedure. Once you're numbed or asleep, your doctor will make a small cut in your groin (upper thigh). The doctor will insert a catheter into the blood vessel through this cut. Sometimes, two cuts (one above each leg) are needed to place fabric stents that come in two parts. You will not feel the doctor threading the catheter, balloon, or stent into the artery. What To Expect After a Stent Procedure Recovery

After either type of stent procedure (for arteries narrowed by plaque or aortic aneurysm), once the stent has been placed and the balloon and catheter have been removed, the tube insertion site will be bandaged. A small sandbag or other type of weight may be put on top of the bandage to apply pressure to help prevent bleeding. You will recover in a special care area where your movement will be limited. While you're in recovery, a nurse will check your heart rate and blood pressure regularly. The nurse also will see if there's any bleeding from the insertion site. Eventually, a small bruise and sometimes a small, hard "knot" will appear at the insertion site. This area may feel sore or tender for about a week. You should let your doctor know if:

You have a constant or large amount of bleeding at the site that can't be stopped with a small bandage. You have any unusual pain, swelling, redness, or other signs of infection at or near the insertion site.

Common Precautions After a Stent Procedure After a stent procedure, your doctor may have you take blood-thinning or anticlotting medicines for at least a few months. These medicines help prevent the development of blood clots in the stent. If your stent is coated with medicine, your doctor may advise you to take aspirin and an anticlotting medicine for months to years to lower the risk of blood clots. You should avoid vigorous exercise and heavy lifting for a short time after the procedure. Your doctor will discuss with you when you can resume normal activities. If you have a metal stent placed, you shouldn't have a magnetic resonance imaging (MRI) test within the first couple of months after the procedure. Metal detectors used in airports and other screening areas don't affect stents. If you have an aortic fabric stent, your doctor will probably recommend that you have followup imaging tests (for example, x ray) within the first year of having the procedure, and yearly imaging tests after that. What Are the Risks of Having a Stent? Risks Related to Angioplasty Any medical procedure has risks, but major complications from angioplasty are rare. The most common risks from angioplasty include:

Bleeding from the site where the catheter was inserted into the skin Damage to the blood vessel from the catheter Infection

Allergic reaction to the dye used during the procedure

Another common problem after angioplasty is too much tissue growth within the treated portion of the artery. This can cause the artery to narrow or close again, which is called restenosis. This problem is often avoided with the use of newer stents coated with medicines that help prevent too much tissue growth. Treating the tissue around the stent with radiation also can prevent tissue growth. For this procedure, the doctor puts a wire through a catheter to where the stent is placed. The wire releases radiation and stops cells around the stent from growing and blocking the artery. Restenosis of a Stent-Widened Coronary Artery

The illustration shows the restenosis of a stent-widened coronary artery. The coronary artery is located on the surface of the heart. In figure A, the expanded stent compresses plaque, allowing normal blood flow. The inset image on figure A shows a cross-section of the compressed plaque and stent-widened artery. In figure B, over time, the plaque grows through and around the stent, causing a partial blockage and abnormal blood flow. The inset image on figure B shows a cross-section of the growth of the plaque around the stent. Risks Related to Stent

About 1 to 2 percent of people with a stented artery develop a blood clot at the stent site. Blood clots can cause heart attacks, strokes, or other serious problems. The risk of blood clots is greatest during the first few months after the stent is placed in the artery. Your doctor will probably have you take blood-thinning or anticlotting medicines for at least a few months after having a stent procedure to prevent blood clots. Stents coated with medicine (drug-releasing stents), which are often used to keep clogged heart arteries open, may increase your risk for potentially dangerous blood clots. But an expert Food and Drug Administration panel found no conclusive evidence that these stents increase the chances of having a heart attack or dying, if used as recommended. Patients with drug-releasing stents are usually advised to take aspirin and an anticlotting drug, such as clopidogrel, for months to years to lower the risk of blood clots. Risks Related to Aortic Stents in the Abdomen Whenever an aneurysm in the abdomen region of the aorta is repaired with either surgery or with a fabric stent, few rare but serious complications can occur, including:

A burst artery (aneurysm rupture). Blocked blood flow to the stomach or lower body. Paralysis in the legs due to interruption of blood flow to the spinal cord. This is an especially rare complication.

Another possible complication is the fabric stent moving further down the aorta. This sometimes happens years after the stent is first placed. Such stent movement may require a doctor to place another fabric stent in the area of the aneurysm. Key Points

A stent is a small mesh tube thats used to treat narrowed or weakened arteries in the body. A stent is usually placed in an artery after it has been widened with a procedure called angioplasty. Angioplasty and stents are often used to relieve chest pain and minimize damage to the heart due to narrowed or blocked heart arteries. They also are used in other arteries in the body to prevent loss of blood flow to the limbs, and to prevent weakened arteries from bursting. Stents are usually made of metal mesh, but sometimes theyre made of fabric. Fabric stents, also called stent grafts, are used in larger arteries. Stents can be placed in the carotid arteries or the aorta, and in leg, arm, or kidney arteries to prevent stroke or loss of a limb, or to relieve high blood pressure. Stents are used to repair aortic arteries that have bulges called aneurysms. To place a stent, your doctor makes a small opening in a blood vessel in your groin (upper thigh), arm, or neck. Through this opening, a flexible, plastic tube (catheter) with a collapsed balloon and stent on the end is threaded up to the area of the artery

that needs treatment. The balloon is then expanded, which widens the narrowed artery and pushes the stent into place.

The placement of a stent only takes a few hours. You may have to stay in the hospital for up to 3 days, depending on which artery was treated. You may feel some pain when the balloon is expanded to push a stent into place. To prevent blood clots, you will probably take blood-thinning medicines for at least a few months after having a stent placed. Vigorous exercise and heavy lifting should be avoided for a short time after a stent procedure. Your doctor will discuss with you when you can resume normal activities. Developing a blood clot at the stent site is the main risk of having a stent. Blood clots can cause heart attack, stroke, and other serious problems. This risk is greatest during the first few months after the stent is placed in the artery. Taking bloodthinning or anticlotting medicines can decrease the risk for a blood clot. There also are risks related to angioplasty and to the placement of the stent. Patients with drug-releasing stents are usually advised to take aspirin and an anticlotting drug, such as clopidogrel, for months to years to lower the risk of blood clots.