Coronary heart disease

Dr. med. Fabian Sinowatz is a freelancer in the medical editorial team.

More about the experts All content is checked by medical journalists.

Coronary heart disease (CHD) is the leading cause of death in western industrialized countries. Atherosclerosis ("vascular calcification") leads to a narrowing of the coronary arteries. Coronary heart disease is also known as ischemic heart disease, as a constriction in a coronary vessel can lead to a lack of oxygen (ischemia) in parts of the heart. Coronary heart disease can cause a heart attack. Read everything you need to know about coronary heart disease here.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. I24I20I25

Coronary artery disease (CHD): description

Coronary heart disease (CHD) is a serious heart disease that causes circulatory disorders in the heart muscle. The reason for this are narrowed coronary arteries. These arteries are also called "coronary arteries" or "coronary arteries". They surround the heart muscle like a ring and supply it with oxygen and nutrients.

The cause of coronary heart disease (CHD) is arteriosclerosis (calcification of the blood vessels) of the coronary vessels: blood lipids, blood clots (thrombi) and connective tissue are deposited in the inner walls of the vessels. This reduces the inner diameter of the vessel, so that the blood flow is obstructed.

A typical symptom of coronary artery disease (CHD) is tightness in the chest (angina pectoris), which increases with physical exertion, as there is a disproportion between oxygen supply and oxygen consumption (coronary insufficiency). A heart attack or sudden cardiac death can be triggered by coronary heart disease. Coronary heart disease (CHD) is one of the most important widespread diseases and has been leading the cause of death statistics in Germany for years. Coronary heart disease (CHD) is more likely to affect men, who on average also develop the disease earlier than women.

Coronary artery disease: definition

Coronary heart disease (CHD) is defined as a condition in which arteriosclerosis ("vascular calcification") leads to insufficient blood flow and thus to a disproportion between oxygen supply and oxygen consumption (coronary insufficiency) in parts of the heart muscle.

Coronary heart disease: classification:

Depending on the extent of the arteriosclerotic changes, coronary heart disease can be divided into the following degrees of severity:

Coronary artery disease - single-vessel disease: One of the three main branches of the coronary arteries is affected by one or more constrictions (stenoses).
Coronary artery disease - two-vessel disease: Two of the three main branches of the coronary arteries are affected by one or more constrictions (stenoses).
Coronary artery disease - three-vessel disease: All three main branches of the coronary arteries are affected by one or more constrictions (stenoses).

The main branches also include their outgoing branches, i.e. the entire river area in which they supply the heart muscle.

Coronary artery disease: symptoms

The symptoms depend on how much the coronary arteries are narrowed by the coronary artery disease and where the bottleneck is. Slight constrictions often cause no symptoms. However, if the vessels are severely narrowed, coronary artery disease causes typical symptoms:

Chest pain

Coronary artery disease typically manifests itself as chest pain, tightness in the chest, or a burning sensation behind the sternum. Doctors refer to this condition as angina pectoris. The symptoms of coronary artery disease occur primarily when the heart has an increased need for oxygen, i.e. when there is physical or emotional stress. The pain in angina pectoris often radiates to the left arm, but sometimes also to the neck, throat, back, jaw, teeth or upper abdomen. ("Feeling like a ring around the chest"). A lack of oxygen in the heart muscles is responsible for the pain when the coronary arteries are narrowed as part of a CAD. If the pain is reduced by the administration of the vasodilator drug nitroglycerin, this is a clear indication of the presence of angina pectoris.If a coronary artery is narrowed by 70 percent of its normal width (stenosis), angina pectoris complaints usually occur at rest. So-called heart stitches (short stitches in the chest) are not a specific indication of coronary artery disease.

Cardiac arrhythmias

Coronary heart disease often also triggers cardiac arrhythmias. The lack of oxygen in the heart muscle also affects the electrical impulses (conduction of excitation) in the heart. Cardiac arrhythmias caused by coronary heart disease can be confirmed by an EKG (electrocardiogram) and their potential risk can be assessed. Because many people have harmless cardiac arrhythmias and do not suffer from CHD.

Diabetics and the elderly are often symptom-free

Some people with CAD, especially diabetics, have no or hardly any noticeable symptoms. In this case, one speaks of silent ischemia (insufficient blood flow). Usually, the nerves in the heart and in the entire body of those affected are so damaged by diabetes mellitus that they can no longer properly transmit the pain signals caused by coronary heart disease (diabetic neuropathy). The heart muscle is damaged without the diabetic noticing. Coronary artery disease symptoms can also be atypical in people over 75 years of age. They can manifest themselves as nausea and dizziness, without typical chest or left arm pain.

Coronary artery disease: causes and risk factors

Coronary heart disease (CHD) develops over the years as a result of the interplay of various causes and risk factors. Numerous scientific studies prove that coronary heart disease is related to the risk factors mentioned here. Many of these can be avoided by adopting an appropriate lifestyle. This can drastically reduce the risk of developing CHD.

Lack of oxygen in the heart (ischemic heart disease)

In people with coronary heart disease, the blood flow to the heart muscle is disturbed. The reason for this is a narrowing of the coronary arteries due to fat or calcium deposits (arteriosclerosis or coronary sclerosis). These deposits are located in the vascular wall of the coronary arteries and form so-called plaques, which narrow the diameter of the vessel in one or more places. As a result, too little blood flows through the coronary vessels and there is a lack of oxygen in the heart muscle (ischemic heart disease). There is a disproportion between oxygen demand and oxygen supply (coronary insufficiency). This is particularly noticeable during exercise. If the diameter of the coronary vessels is reduced by half, circulatory disorders also occur as a rule.

Manageable risk factors for coronary heart disease:

Risk factor	Explanation
Unhealthy diet and obesity	Overweight people usually have elevated blood lipids: Too much cholesterol and other blood lipids are harmful because they cause excess cholesterol particles to be deposited in the arterial vessel walls and lead to inflammation and calcification. This makes the vessels more rigid and narrower. In addition, inflammatory messengers are formed in the belly fat, which have a direct damaging effect on the vessel walls and contribute to coronary heart disease
Sedentary lifestyle	Adequate exercise lowers blood pressure, improves cholesterol levels and increases the insulin sensitivity of muscle cells. If there is a lack of exercise, these protective effects are missing and coronary heart disease can be the result after years.
smoking	Substances from tobacco smoke (cigarettes, cigars, pipes) promote, among other things, the formation of unstable deposits (plaques) in the vessels. According to the German Cardiac Society (DGK), each cigarette shortens life by around 30 minutes.
High blood pressure	High blood pressure (hypertension) directly damages the vessel walls.
Increased cholesterol level	High levels of LDL cholesterol and low levels of HDL cholesterol encourage plaque build-up.
Diabetes mellitus	Poorly controlled diabetes leads to permanently high blood sugar levels, which in turn damage the blood vessels and promote coronary artery disease.

Risk factors for coronary artery disease that cannot be influenced:

Risk factor	Explanation
Male gender	Women before menopause (menopause) have a lower risk of coronary artery disease (CHD). Because according to current opinion, they seem to be better protected by the female sex hormones (especially estrogen). Men are at higher risk for coronary artery disease.
Genetic predisposition	Cardiovascular diseases occur more frequently in some families, which is why genes are very likely to play a role in coronary artery disease.
age	The incidence of the disease in men increases from the age of 45, that of women from the age of 50. The older a person is, the more likely it is that they have coronary artery disease.

Coronary artery disease: examinations and diagnosis

Coronary heart disease (CHD) is diagnosed and treated by a cardiologist. The family doctor is also a point of contact if there are signs of ischemic heart disease. The anamnesis discussion (medical history) is of great importance for the diagnosis and monitoring of the progress. The physical exam can identify risk factors for coronary artery disease (CHD) and provide a rough estimate of general physical fitness. Coronary heart disease is confirmed by various apparatus-based examinations.

Medical history (anamnesis):

Before the actual examination, the doctor asks a few questions in order to find out more about the nature and duration of the current symptoms. Any previous illnesses or accompanying symptoms are also relevant for the doctor. Describe the nature, duration and severity of the symptoms and, most importantly, the situations in which they occur. The doctor will ask various questions, for example:

What complaints do you have?
When (in which situation) do the complaints occur?
Does physical exertion make the pain worse?
What medications are you taking?
Do you have similar symptoms or a known coronary heart disease in your family, for example your parents or siblings?
Have you had any abnormalities in your heart in the past?
Do you smoke? If so, how much and how long?
Are you active in sports?
What is your nutrition like? Have you already known high cholesterol or blood lipid levels?

Physical examination

After the anamnesis discussion, the doctor will examine you. It is particularly important to listen to the heart and lungs with a stethoscope (auscultation). The physical examination gives the doctor a general impression of your physical performance. Some doctors will also carefully press on your chest to check whether a problem with the musculoskeletal system (for example a spinal disease or muscular tension) is not the cause of your chest pain.

Further investigations:

Whether a coronary heart disease is present can be clearly answered primarily through targeted measurements and a graphic representation of the heart and its vessels. Other examinations include:

Blood pressure measurement

High blood pressure (arterial hypertension) is a decisive risk factor for the development of coronary heart disease. According to current European guidelines, the blood pressure is too high if it is systolic above 140 mmHg and diastolic above 90 mmHg at rest (above: "140 to 90") - then medical treatment should be given to lower the blood pressure.

Doctors often also perform long-term blood pressure measurements. For this purpose, patients are given a blood pressure monitor by the practice team and go home with it. There the device measures the blood pressure at regular intervals. Hypertension is present if the average value from all measurements is above 130 mmHg systolic and 80 mmHg diastolic.

Blood test:

On the one hand, the blood lipid values (cholesterol, triglycerides) are determined in a blood test. On the other hand, in the case of acute chest pain, the doctor can use certain blood values (markers: CK, CK-MB, troponine) to check whether the heart muscle has been damaged. Other parameters such as kidney and sugar levels play a decisive role in terms of possible concomitant diseases.

Resting electrocardiogram (resting ECG)

A basic examination is the resting ECG. The electrical excitation of the heart is derived from electrodes on the skin. Coronary artery disease (CHD) can sometimes show typical changes in the EKG.

However, the EKG can also be normal, although there is coronary heart disease!

Stress electrocardiogram (stress EKG)

With this variant of the EKG, the electrical potentials of the heart are not recorded at rest, but rather during physical exertion, usually on a bicycle ergometer. This makes sense because some pathological changes that can be seen in the ECG only show up when you exert yourself.

Cardiac ultrasound (echocardiography)

Echocardiography can show the size of the heart, the movement of the heart muscle and the pumping function, as well as possible heart valve problems. The examination can be carried out both during physical rest (resting echocardiography) and during physical exertion (exertion echocardiography). If, for example, the patient cannot exercise properly on the bicycle ergometer due to a pronounced coronary heart disease, the heartbeat can also be accelerated by administering medication.

Myocardial scintigraphy

In myocardial scintigraphy, a weakly radioactive marker is injected into the vein. This substance mainly accumulates in healthy heart muscle tissue. The radioactive radiation can then be recorded like a photo. This examination can also be carried out under stress and is therefore an alternative to stress echocardiography. If the radioactive substance does not accumulate properly in some heart muscle sections, this indicates an oxygen deficiency and thus coronary heart disease.

Cardiac catheterization (coronary angiography)

For coronary heart disease (CHD), coronary angiography ("cardiac catheter") is one of the most important examinations for diagnosis and treatment. A thin tube (catheter) is advanced through a large artery to the heart via an access in the groin or arm . When the catheter tip is in the correct position, an X-ray contrast medium is released from it and an X-ray image is made at the same time. In this examination you can see the individual coronary vessels and possible constrictions very precisely. Doctors can also assess the heart's pumping capacity. In the case of a constriction (stenosis), for example, a stent (small tube made of metal) can be used therapeutically to keep the constriction open or to widen the constriction.

Other imaging procedures

In some cases, special imaging techniques are needed to determine the severity of coronary artery disease (CHD). These include:

Positron Emission Tomography (Myocardial Perfusion PET)
Cardiac multi-slice computed tomography (cardio-CT)
Cardiac magnetic resonance imaging (cardio MRI)

The MRI can also be performed under "stress". As with the stress tests mentioned, the patient is given a drug and contrast agent.

Diagnosis of a suspected heart attack

If an acute coronary syndrome is suspected, an ECG and special blood tests (cardiac troponin) are performed immediately. An acute coronary syndrome is a collective term for various phases of acute circulatory disorders of the coronary arteries, which can be immediately life-threatening. These include myocardial infarction with and without ST elevations (STEMI or Non-STEMI / NSTEMI) in the ECG as well as the so-called unstable angina pectoris. If an EKG and / or blood tests indicate a heart attack, a cardiac catheter examination is carried out.

Coronary artery disease: treatment

In coronary heart disease (CHD), the main goal of therapy is to improve the patient's quality of life and stop the disease from progressing. In addition, complications such as a heart attack should be prevented. The CHD cannot be cured. As a rule, however, the symptoms, for example angina pectoris, can be treated effectively and sequelae such as heart attack can be successfully avoided. As a result, many patients have a similar quality of life to healthy people.

Coronary heart disease can also trigger mental illnesses such as depression. Mental stress, in turn, has a negative effect on coronary heart disease. Therefore, in the case of coronary heart disease, any psychological problems are also taken into account during treatment. The therapy of coronary heart disease includes not only the targeted elimination of risk factors, but also above all a drug-based and often surgical approach.

Reduction of risk factors

Regular physical activity is useful for patients with coronary heart disease, as it can lower blood pressure and have a positive effect on blood sugar and blood lipid metabolism. You should determine the intensity and duration of the training in consultation with your doctor and adjust it regularly. Smoking is an important risk factor for coronary artery disease and should be stopped urgently to prevent the disease from progressing (stop smoking). The right diet, e.g. a Mediterranean diet, improves the metabolism. Severely obese patients are advised to reduce weight.

Medication

Coronary artery disease can be treated with a number of medications that not only relieve symptoms (such as angina pectoris), but also prevent complications and increase life expectancy.

Drugs that improve the prognosis of coronary heart disease and prevent heart attacks:

Platelet inhibitors: Platelet aggregation inhibitors prevent the clumping of blood platelets (thrombocytes) and thus prevent blood clots (thrombosis) in the coronary arteries. The active ingredient of choice for coronary heart disease is acetylsalicylic acid (ASA).

Beta-receptor blockers (“beta blockers”): They lower blood pressure, slow down the heartbeat, thereby reducing the heart's need for oxygen and relieving the heart. After a heart attack or CHD with heart failure, the risk of death is reduced. Beta blockers are the drug of choice for patients with coronary artery disease and high blood pressure.

Lipid-lowering drugs: The blood lipid-lowering therapy is mainly carried out with statins. They lower cholesterol and slow the progression of arteriosclerosis. Patients with normal blood lipid levels also benefit.

Drugs That Relieve Coronary Heart Disease Symptoms:

Nitrates: They widen the blood vessels in the heart and so it is better supplied with oxygen. They also widen the vessels throughout the body, which is why the blood flows back to the heart more slowly. The heart has to pump less and uses less oxygen. Nitrates act particularly quickly and are therefore suitable as emergency medication in the event of an acute angina pectoris attack.

Under no circumstances should nitrates be taken with agents against impotence (phosphodiesterase 5 inhibitors, e.g. sildenafil)! This can lead to a life-threatening drop in blood pressure!

Calcium antagonists: This group of substances also dilates the coronary arteries, lowers blood pressure and relieves the heart.

Other drugs:

ACE inhibitors: They improve the prognosis in patients with heart failure or high blood pressure.

Angiotensin-I receptor blockers: They are used when there is an intolerance to ACE inhibitors.

Cardiac catheter and bypass surgery

If the coronary artery disease cannot be adequately controlled by medication, an expansion of the coronary arteries (PTCA / PCI) or a bypass operation are also possible:

During the bypass operation, the narrow point in the coronary artery is bridged. To do this, a healthy vessel is first removed from the chest or lower leg and sewn onto the coronary artery behind the constriction (stenosis). The bypass operation is particularly suitable if the three main trunks of the coronary arteries are severely narrowed (three-vessel disease). Although the operation is complex, it significantly improves the quality of life and prognosis for most people.

In PTCA (percutaneous transluminal coronary angioplasty), the constriction is expanded a little with an inflatable balloon as part of a cardiac catheter treatment. If necessary, doctors can then insert a flexible metal cylinder (stent) into the constriction in the coronary artery to keep it open (PCI = Percutaneous Coronary Intervention).

Coronary artery disease can also be treated with bypass surgery or PCI if multiple coronary arteries are affected or the narrowing is at the beginning of a large vessel. The decision for a bypass operation or an expansion is always made on an individual basis.In addition to the findings, it also depends on comorbidities and age.

Sport as therapy for CHD

In patients with coronary artery disease (CHD), exercise can have a positive effect on the course of the disease and the prognosis. With regular training, the patient increases his fitness and is symptom-free for longer under physical exertion. This in turn increases the quality of life significantly.

Sport therefore targets precisely the risk factors that cause coronary artery disease. But regular training also has a positive influence on the course of the disease. Endurance sports can slow down the progression of the disease in CHD, stop it in some cases and in individual cases even reverse it.

Training entry at KHK

Before a patient with CHD begins training, they must be in a stable clinical condition. Physical training with heart disease should never take place without first consulting a doctor. Participation in a long-term follow-up program (e.g. outpatient cardiac sports group) is recommended for patients with CHD.

If the CHD patient has had a heart attack (STEMI and NSTEMI), scientific studies recommend starting training early - as early as seven days after the heart attack. This early mobilization supports the healing process.

After an uncomplicated operation to widen the coronary arteries (percutaneous transluminal coronary angioplasty, PTCA), the patient can start an individual sports program on the fourth day after the operation. However, this should take place under medical or therapeutic supervision.

In the case of bypass surgery, the person affected can begin early mobilization as early as 24 to 48 hours after the operation. However, restrictions due to the procedure are to be expected in the first few weeks. Training should start with gentle exercises.

Support, tensile and pressure loads are to be avoided for at least six weeks. Pressure on the chest is also not advisable in the first few weeks after the procedure. There should be no jerky movements. If the procedure was carried out in a minimally invasive manner, this period of time can be shorter.

Always discuss the start of training with your doctor in advance if you have heart disease.

Training plan at KHK

The cardiac sport comprises different disciplines. Each patient receives a training plan depending on their state of health and individual fitness. This usually comprises the following modules

Moderate endurance training

The focus of cardiac sports is primarily endurance training. Because cardiopulmonary endurance is the most important protective factor in CHD. According to the recommendation of the German Society for Prevention and Rehabilitation of Cardiovascular Diseases, cardiac patients should do at least 30 minutes of moderate endurance training four to five times a week.

For CHD patients, ten minutes of fast walking a day at around 5 km / h at the start of training is sufficient to reduce the risk of death by up to 33 percent. Alternatively, if the pace is too fast, those affected can walk slowly (approx. 3 to 4 km / h) for 15 to 20 minutes.

Suitable endurance sports at KHK are, for example:

(quick) walking
Walking on a soft mat / in the sand
Walking / Nordic walking
Step aerobics
hike
Cycle
Climbing stairs (e.g. on the stepper)
rowing
swim

It is important that cardiac patients choose short exercise phases of five to a maximum of ten minutes at the beginning. The duration of the exercise is then slowly increased over the course of the training. Because the greatest effects are seen in patients who exert themselves the most. With each doubling of the activity level, the risk of death decreases by a further ten percent within four weeks.

It is important for heart patients to find the right exercise intensity. As a rule of thumb, if you sweat and breathe faster, but can still talk to your training partner without any problems, the training intensity is good. Also make sure to keep the intensity as constant as possible. So when jogging, for example, avoid the quick sprint at the end of the unit.

Make sure that you do not exceed the pulse limits, which can be determined, for example, in an exercise ECG. A heart rate monitor can help you keep within the right framework and train optimally while exercising.

The desired training zone for CHD patients is 40 to 85% VO2max. VO2max describes the maximum amount of oxygen that can be absorbed by the body during maximum exertion. The heart rate should be 60 to 90 percent during endurance training.

Strength exercises

Strengthening exercises serve to promote and build up the muscles. Muscle mass consumes more energy than fat at rest and helps in the fight against extra pounds. If carried out conscientiously under professional guidance, strength exercises do not represent an above-average risk for cardiac patients. In order to avoid blood pressure peaks, it is important to avoid pressure breathing during exertion. In addition, the athlete should make sure to relax the muscles as completely as possible between repetitions.

Gentle exercises for heart patients to build muscle in the upper body are, for example:

Strengthening the chest muscles: Sit upright on a chair, press your hands against each other in front of your chest and hold for a few seconds. Then let go and relax. Repeat several times
Strengthening the shoulders: Sit upright in a chair, hook your fingers in front of your chest and pull outwards. Hold the train for a few seconds, then relax completely.
Strengthening the arms: Stand in front of a wall and place your hands on the wall at about shoulder height. Bend your arms and do push-ups on the wall. Ten to 15 repetitions.

Exercise your legs particularly gently with these exercises:

Strengthening the abductors (extensor muscles): Sit upright on a chair and press your hands against your knees from the outside. The legs work against the hands. Hold the pressure for a few seconds and then relax.
Strengthening the adductors (flexor muscles): Sit upright on a chair with your hands between your knees. Now push outwards with your hands. The legs work against the hands. Hold the tension for a few seconds and then relax completely.

Light circuit training

In cardiac sports groups, light circuit training is often carried out. The participants complete eight different stations, for example. Depending on the exercises chosen, this promotes endurance, strength, flexibility and coordination at the same time. One minute of exercise is followed by a 45-second break. Then the athletes rotate to the next station. There are one or two rounds depending on individual fitness.

All disciplines contribute to improving the quality of life of patients and to better mastering everyday challenges.

Coronary artery disease: disease course and prognosis

The prognosis of coronary heart disease (CHD) depends, among other things, on how many constrictions there are in the coronary vessels, where they are located and how far the disease has progressed. It is also important for the prognosis whether there are other diseases, for example high blood pressure, diabetes, chronic liver or lung diseases, arterial circulatory disorders in other organs (brain, kidneys, legs), cardiac insufficiency or malignant tumors. The prognosis is unfavorable if you have survived a heart attack in the past. Loneliness, depression and withdrawal from active social life also have a negative effect on the prognosis of CHD.

In most cases it is possible to get the coronary artery disease under control with medication and - if necessary - by removing the bottleneck. If coronary heart disease is well treated, many of those affected can lead a similarly symptom-free life as healthy people. The long-term prognosis for coronary artery disease also depends crucially on whether the person affected succeeds in making sustainable changes to their lifestyle. That means: abstaining from nicotine, a lot of exercise, avoiding excessive weight and a healthy diet. Continuous use of the prescribed medication and regular check-ups with a doctor are also important.

If coronary artery disease (CHD) is discovered late or treated inadequately, cardiac insufficiency may develop as a secondary disease. In this case, the prognosis worsens. With an untreated CHD, the risk of a heart attack also increases.

Coronary artery disease complication: acute myocardial infarction

Coronary heart disease (CHD) is the basis for the development of an acute heart attack. In CAD, one or more coronary arteries are constricted by the so-called plaque build-up in the vascular wall. If such a plaque suddenly ruptures (plaque rupture), blood clotting is activated locally and platelets (thrombocytes) attach to the plaque. This leads to an occlusion (thrombosis) of the coronary artery in a relatively short time. Those parts that were previously supplied with blood by the now closed coronary artery suffer from a lack of oxygen (acute coronary insufficiency) and are thereby damaged.

In the case of an acute heart attack, there are usually additional symptoms such as shortness of breath, sweating, nausea and fear of death. If a heart attack is suspected, the most important measure is to go to a hospital with a cardiac catheter laboratory as soon as possible. With a cardiac catheter, the blood flow in the closed coronary artery can often be restored in good time, thus averting greater damage. Existing coronary artery disease is the most important risk factor for developing a heart attack and should therefore always be treated.

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