What are the symptoms of coronary artery disease?

Stable angina presents as chest pressure, heaviness, or tightness during physical exertion or emotional stress that resolves within minutes of resting. Acute coronary syndromes cause chest pain at rest, often more severe and prolonged, sometimes accompanied by sweating, nausea, dizziness, or pain radiating to the jaw, neck, or arms. About 40-48% of patients have atypical symptoms.

What causes coronary artery disease and who is at risk?

The major modifiable risk factors are high blood pressure, high LDL cholesterol, diabetes, smoking, obesity, and physical inactivity. Non-modifiable factors include age, male sex, and family history of premature heart disease. Emerging risk factors like lipoprotein(a), metabolic syndrome, chronic inflammatory conditions, and sleep apnea are increasingly recognized.

How is coronary artery disease diagnosed?

For stable symptoms, coronary CT angiography (CCTA) is now a first-line test with sensitivity above 90%. Stress testing evaluates whether blockages limit blood flow during exertion. Cardiac catheterization is reserved for high-risk patients or when a procedure is being considered, and can include fractional flow reserve (FFR) measurements.

Do I need a stent or bypass surgery for coronary artery disease?

Not necessarily. The ISCHEMIA trial showed that medical therapy alone was just as effective as catheterization plus revascularization at preventing death and heart attacks for stable disease. When revascularization is needed, CABG is superior for complex disease and multivessel disease with diabetes, while PCI is reasonable for less complex anatomy or high surgical risk.

Coronary Artery Disease: Your Questions Answered

Q: What is coronary artery disease?

Coronary artery disease (CAD) is a condition where the arteries that supply blood to your heart muscle become narrowed by a buildup of fatty deposits called atherosclerotic plaque. This process, driven by cholesterol accumulation and chronic inflammation in the artery wall, develops over years and decades. CAD is the most common form of heart disease and the leading cause of death in the United States.

Q: What medications are used to treat coronary artery disease?

Most patients take a high-intensity statin, aspirin, blood pressure medications targeting below 130/80, and antianginal medications. Patients with diabetes benefit from SGLT2 inhibitors or GLP-1 receptor agonists. Colchicine is a newer addition, now FDA-approved for atherosclerotic disease, shown to reduce major cardiac events by 23-31%.

What is coronary artery disease?

Coronary artery disease (CAD) is a condition where the arteries that supply blood to your heart muscle become narrowed by a buildup of fatty deposits called atherosclerotic plaque. This process, driven by cholesterol accumulation and chronic inflammation in the artery wall, develops over years and decades. CAD is the most common form of heart disease and the leading cause of death in the United States. In my Encinitas cardiology practice, I manage it more than any other condition. The spectrum ranges from no symptoms at all, to chest pain with exertion (stable angina), to heart attacks when a plaque ruptures suddenly and a blood clot blocks the artery.

What are the symptoms?

Stable angina presents as chest pressure, heaviness, or tightness during physical exertion or emotional stress that resolves within minutes of resting. Some patients experience shortness of breath rather than chest pain, particularly women, older adults, and patients with diabetes. Acute coronary syndromes (heart attacks and unstable angina) cause chest pain at rest, often more severe and prolonged, sometimes accompanied by sweating, nausea, dizziness, or pain radiating to the jaw, neck, or arms. About 40-48% of patients with acute coronary syndromes have atypical symptoms, so if something feels wrong, get evaluated immediately.

What causes it and who's at risk?

The major modifiable risk factors are high blood pressure, high LDL cholesterol, diabetes, smoking, obesity, and physical inactivity. Non-modifiable factors include age (men 45 and older, women 55 and older), male sex, and family history of premature heart disease. Emerging risk factors like lipoprotein(a), metabolic syndrome, chronic inflammatory conditions, and sleep apnea are increasingly recognized. The heritability of fatal CAD approaches 50%, but even with unfavorable genetics, lifestyle changes and medical therapy make a substantial difference.

How is it diagnosed?

For stable symptoms, we use a risk-stratified approach. Coronary CT angiography (CCTA) is now a first-line test, with sensitivity above 90% and the ability to detect plaque even before it causes significant narrowing. Stress testing (exercise ECG, stress echo, nuclear imaging) evaluates whether blockages are limiting blood flow during exertion. Cardiac catheterization is reserved for high-risk patients or when a procedure is being considered, and can include fractional flow reserve (FFR) measurements to assess whether a blockage is functionally significant. For suspected heart attacks, an ECG within 10 minutes and serial troponin blood tests guide urgent management.

Do I need a stent or bypass surgery?

Not necessarily. The landmark ISCHEMIA trial (5,179 patients with stable CAD and moderate-to-severe ischemia) showed that medical therapy alone was just as effective as catheterization plus revascularization at preventing death and heart attacks. Revascularization did provide better symptom relief for patients with frequent angina. So for stable disease, the decision to proceed with a stent or surgery should be based on your symptom burden and quality of life, not on the blockage alone. When revascularization is needed, CABG (bypass surgery) is superior for complex disease, multivessel disease with diabetes, and reduced heart function, while PCI (stenting) is reasonable for less complex anatomy or high surgical risk.

What medications will I need?

Most patients with CAD take a combination of high-intensity statin (to lower LDL cholesterol by at least 50%), aspirin (for secondary prevention), blood pressure medications targeting below 130/80, and antianginal medications (beta-blockers or calcium channel blockers for chest pain). Patients with diabetes benefit from SGLT2 inhibitors or GLP-1 receptor agonists for their cardiovascular protection. If your LDL remains high despite statins, options like ezetimibe, PCSK9 inhibitors, or inclisiran can be added. Colchicine (0.5 mg daily) is a newer addition, now FDA-approved for atherosclerotic disease, shown to reduce major cardiac events by 23-31% by targeting residual inflammation.

Can coronary artery disease be reversed?

Atherosclerosis can be slowed, stabilized, and in some cases partially reversed with aggressive treatment. Very low LDL cholesterol levels (below 70 mg/dL, ideally below 55 mg/dL for very high-risk patients) can halt plaque progression and even promote modest plaque regression. Lifestyle changes including a Mediterranean-style diet, regular exercise, smoking cessation, and weight management form the foundation. The key message is that CAD is a chronic condition requiring lifelong management, but with today's medications and lifestyle interventions, most patients live long, active lives. If you have questions about your heart health, I encourage you to schedule an evaluation at San Diego Cardiovascular Associates in Encinitas.

References

Stone, Peter H., Peter Libby, and William E. Boden. "Fundamental Pathobiology of Coronary Atherosclerosis and Clinical Implications for Chronic Ischemic Heart Disease Management." JAMA Cardiology 8, no. 2 (2023): 192-201.

Virani, Salim S., et al. "2023 AHA/ACC Guideline for the Management of Patients With Chronic Coronary Disease." Journal of the American College of Cardiology 82, no. 9 (2023): 833-955.

Gulati, Martha, et al. "2021 AHA/ACC Guideline for the Evaluation and Diagnosis of Chest Pain." Journal of the American College of Cardiology 78, no. 22 (2021): e187-e285.

Ferraro, Riccardo, et al. "Evaluation and Management of Patients With Stable Angina: Beyond the Ischemia Paradigm." Journal of the American College of Cardiology 76, no. 19 (2020): 2252-2266.

Nelson, Katherine, Valentin Fuster, and Paul M. Ridker. "Low-Dose Colchicine for Secondary Prevention of Coronary Artery Disease." Journal of the American College of Cardiology 82, no. 7 (2023): 648-660.

Bhatt, Deepak L., Renato D. Lopes, and Robert A. Harrington. "Diagnosis and Treatment of Acute Coronary Syndromes: A Review." JAMA 327, no. 7 (2022): 662-675.

Rao, Sunil V., et al. "2025 ACC/AHA Guideline for the Management of Patients With Acute Coronary Syndromes." Journal of the American College of Cardiology 85, no. 15 (2025): 1-98.

Ridker, Paul M., et al. "Inflammation and Cholesterol as Predictors of Cardiovascular Events Among Patients Receiving Statin Therapy." Lancet 401, no. 10384 (2023): 1293-1301.

Published on damianrasch.com

The above information was composed by Dr. Damian Rasch, drawing on individual insight and bolstered by digital research and writing assistance. The information is for educational purposes only and does not constitute medical advice.