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Coronary Artery Disease

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In one line

·Coronary artery disease is fatty plaques blocking the arteries that feed the heart muscle, creating a mismatch between oxygen supply and oxygen demand that causes chest pain, heart attacks, and heart failure.

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Normal physiology

·The heart muscle receives its blood supply from the coronary arteries, which branch off the aorta (the body's main artery) just above the aortic valve. The left main coronary artery splits into two large branches — the left anterior descending artery (LAD, which runs down the front of the heart) and the circumflex artery (which wraps around the left side) — while the right coronary artery supplies the right side and often the bottom of the heart. These three main vessels then branch into smaller and smaller arteries that dive deep into the heart muscle wall, delivering oxygen and glucose to every single heart muscle cell so it can produce energy and contract powerfully with every heartbeat.

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What goes wrong

·Fatty deposits called plaques slowly build up inside the coronary arteries, making them narrower and stiffer. The trouble starts when the smooth inner lining of the artery — called the endothelium — gets damaged by high blood pressure, chemicals in cigarette smoke, high blood sugar from diabetes, or high levels of LDL cholesterol (the 'bad' cholesterol). Once that lining is injured, tiny LDL cholesterol particles sneak underneath it and get stuck in the artery wall. The body's immune system sends white blood cells called macrophages to clean up the cholesterol, but the macrophages get overwhelmed and bloat into foam cells that pile up into a growing plaque. Over years the plaque grows larger, bulging into the artery channel and blocking blood flow. The plaque is covered by a thin cap of scar tissue, but if that cap cracks or wears away, the fatty core is exposed to the bloodstream and a blood clot forms instantly, suddenly blocking the artery completely.

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Hallmark signs

·Chest pain or pressure with exertion
·Chest pain at rest lasting more than 20 minutes
·Shortness of breath with mild activity or at rest
·Pain in the jaw, neck, arm, or back during exertion
·Sudden severe weakness or loss of consciousness
·Nausea, vomiting, or indigestion-like discomfort
·New or worsening fatigue that limits daily activities
·Heavy cold sweating with chest discomfort

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Red flags · escalate now

·Chest pain lasting more than 20 minutes with sweating or nausea — suggests a heart attack happening right now and needs an ECG and trip to the catheterization lab (where doctors can open the blocked artery) immediately.
·Sudden severe chest pain that rips or tears into the back — may mean an aortic dissection (the main artery from the heart is tearing apart, not a coronary blockage). Needs an urgent CT scan and fast blood pressure control.
·New shortness of breath or leg swelling with chest pain — suggests a large heart attack or a torn valve muscle inside the heart. Needs an urgent ultrasound of the heart (echocardiogram) to see what's broken.
·Passing out or losing consciousness with chest pain — may mean a deadly heart rhythm like ventricular a fast heart rate (tachycardia) or complete heart block. Needs immediate heart monitor and shock treatment if needed.

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Workup

·12-lead electrocardiogram (ECG)
·Troponin I or troponin T (blood test)
·Transthoracic echocardiogram (ultrasound of the heart)
·Lipid panel (total cholesterol, LDL, HDL, triglycerides)
·Stress test (exercise ECG, stress echo, or nuclear imaging)
·Coronary CT angiography (CTA, a special X-ray scan with dye)
·Invasive coronary angiography (cardiac catheterization, threading a tiny tube into the heart arteries and injecting dye)
·Hemoglobin A1c and fasting blood sugar

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Treatment

·High-dose statin (atorvastatin 40–80 mg or rosuvastatin 20–40 mg daily)
·Two antiplatelet drugs: aspirin (81–162 mg daily) plus a P2Y12 inhibitor (clopidogrel 75 mg, ticagrelor 90 mg twice daily, or prasugrel 10 mg daily)
·Beta-blocker (metoprolol, carvedilol, or bisoprolol)
·ACE inhibitor (lisinopril, enalapril, ramipril) or ARB (losartan, valsartan) if ACE inhibitor causes cough
·Percutaneous coronary intervention (PCI): threading a balloon and stent through an artery in the wrist or groin to the blockage, inflating the balloon to squash the plaque, then leaving a tiny metal mesh tube (stent) to hold the artery open
·Coronary artery bypass graft surgery (CABG): taking a vein from the leg or an artery from the chest wall and sewing it to bypass the blocked segments, creating new routes for blood
·Nitrates (nitroglycerin under the tongue for acute chest pain, or long-acting isosorbide for daily prevention)

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NCLEX trap

·In coronary artery disease, the target heart rate on beta-blockers is 55 to 60 beats per minute — this slow, steady pace gives the heart more time to fill with blood between beats and cuts down how hard it works, protecting starved muscle. Hold the beta-blocker only if the heart rate drops below 50 or the patient shows signs of not enough blood reaching the body (like feeling dizzy, confused, or very weak). A rate of 58 is exactly where we want it.
·Morphine used to be standard, but newer evidence shows it may actually worsen outcomes in non-STEMI (a partial heart attack) by slowing breathing and masking symptoms that guide treatment. Current AHA/ACC guidelines say to use morphine only if chest pain does not go away after nitroglycerin. The real priorities are aspirin, a second antiplatelet drug (like ticagrelor or clopidogrel), and a blood thinner — these stop the clot from growing and save heart muscle.
·Troponin (a protein that leaks out when heart muscle dies) must be checked at least twice: once when the patient arrives and again 3 hours later. Early in a heart attack, the first troponin can still be normal because it takes time for the protein to spill into the blood. Troponin peaks around 12 to 24 hours after symptoms start, so a single test will miss many evolving heart attacks.
·Cardiac rehabilitation starts with supervised, low-intensity exercise and gradually builds up over weeks. Jumping into hard exercise without a stress test first can trigger dangerous irregular heartbeats or even a heart attack if the patient has severe narrowing (over 70 percent blockage) that has not been found yet. Safety comes first: test, then slowly progress under supervision.
·Keep the aspirin going through surgery in CAD patients unless the operation is on the brain or inside the eye. Stopping aspirin triples the risk of heart attack or stroke around surgery time, and that danger is much bigger than the small extra bleeding risk in most surgeries. ACC/AHA perioperative guidelines make this clear: aspirin stays.
·Nitroglycerin is not just rescue medicine — it is also prevention. Patients should carry it everywhere and use it before activities they know trigger angina (like climbing stairs, going out in the cold, or heavy lifting) to stop the pain before it starts. Also teach them to replace the bottle every 6 months because nitroglycerin loses its strength over time, even if the bottle looks fine.

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