Living a Healthy Life with Chronic Pain (46 page)
Read Living a Healthy Life with Chronic Pain Online
Authors: Sandra M. LeFort,Lisa Webster,Kate Lorig,Halsted Holman,David Sobel,Diana Laurent,Virginia González,Marian Minor
HAPTER
19
Coronary Artery Disease,
and Related Conditions
A
NGINA IS A COMMOM, AND OFTEN CHRONIC, PAINFULL SYMPTOMS
of coronary artery disease. Angina occurs when an area of the heart does not receive enough oxygen-rich blood due to poor circulation. The pain from angina may be on the left side of the chest over the heart, but it can also radiate to the back, shoulders, arms, neck, and jaw. For some, it may be just a vague sense of discomfort or weakness. In addition to angina and coronary artery disease, in this chapter we also discuss two other problems of the circulatory system common among people with angina: high blood pressure and peripheral vascular disease.
Special thanks to the following individuals for their help with this chapter: Dr. Michael McGillion, RN, PhD, Assistant Professor and Heart and Stroke Foundation Michael G. DeGroote Endowed Chair of Cardiovascular Nursing Research, McMaster University; Shelley Gershman, RN, Research Coordinator, McMaster University; Dr. Sheila O’Keefe-McCarthy, RN, PhD, Adjunct Scientist, Ross Memorial Hospital; and Noorin Jamal, RN(EC), MN-NP, University Health Network, Toronto, Canada
Coronary artery disease is the most common form of heart disease. It causes most heart attacks and heart failure. Coronary arteries are blood vessel “pipelines” that wrap around the heart (see
Figure 19.1
). They deliver the oxygen and nutrients the heart needs to perform its job. Healthy arteries are elastic, flexible, and strong. The inside lining of a healthy artery is smooth, so blood flows easily. Unhealthy arteries narrow when they become clogged with cholesterol and other substances. This thickening or hardening process is called atherosclerosis.
Atherosclerosis is a gradual process that occurs over many years. The first step is damage to the wall of the artery. This can be caused by high cholesterol, high triglycerides, diabetes, smoking, or high blood pressure. This damage allows LDL cholesterol (the “bad” cholesterol) to enter the artery wall and cause inflammation. Some people experience this problem as early as their teens.
Over time, more cholesterol is deposited in the damaged arteries and the fatty areas grow larger and larger. These fatty areas are plaques. Plaque is a sticky, yellow material made up of cholesterol, calcium, and waste products from cells in your body. Plaques can completely block off blood flow in an artery, causing reduced blood circulation and oxygen supply to the heart muscle. Plaques can also crack open, causing a blood clot to form at the injured site. In both cases, blood flow to the heart is blocked, and the person may experience angina (temporary chest pain) or a heart attack. If not treated immediately, a heart attack can cause permanent damage to the heart muscle. When a part of the heart muscle has been damaged, that part can no longer help the heart pump blood.
There are a number of risk factors for coronary artery disease. You can control some of these factors, but not all of them. The risk factors for coronary artery disease that you can’t control include:
Figure 19.1
The Arteries of the Heart
Age—The older you get, the more at risk you are for coronary artery disease.
Sex—Men over the age of 55 and women who are postmenopausal are at higher risk for coronary artery disease.
Family history—You are at higher risk for coronary artery disease if a close family member such as a parent or sibling developed it before age 55 or before menopause.
Ethnicity—First Nations of Canada, Native Americans, African, or South Asian individuals are more likely to have high blood pressure and are at greater risk of coronary artery disease and stroke than the general population.
The risk factors for coronary artery disease that you can control include:
High blood pressure—High blood pressure is consistently higher than 140/90 when measured in a clinic or 135/85 when measured using a blood pressure cuff at home. (We discuss blood pressure figures in more detail on
pages 236
–
240
.)Diabetes—This includes type 1 diabetes, type 2 diabetes, and gestational diabetes.
High cholesterol—LDL (bad) and HDL (good) cholesterol must be evaluated in relation to each other.
Being overweight—A person with a body mass index (BMI) over 25 is considered to be overweight. (For more on BMI, see
Chapters 14
,
pages 236
–
239
)Smoking—This includes exposure to secondhand smoke.
Lack of exercise—Those who are physically inactive are twice as likely to be at risk for coronary artery disease than those who are physically active.
Stress—People who experience prolonged periods of stress are more susceptible to atherosclerosis, high blood pressure, and high cholesterol.
Excessive alcohol consumption—Excess is defined as more than 10 drinks per week for women and more than 15 drinks per week for men.
Cholesterol is a waxy fat that is found in all cells of the body and can be measured in your blood. You need cholesterol in order to make hormones, vitamin D, and substances that allow food to be digested. The body makes enough cholesterol for your body to function properly, but it is not good to have too much cholesterol in your blood. High blood cholesterol level is a major risk factor for heart disease. High cholesterol can lead to a buildup of plaque in the artery walls, narrowing your arteries and not leaving enough space for the blood to flow freely. This narrowing of the space in your arteries can lead to angina pain because the heart is not able to receive enough blood and oxygen to work properly.
There are “good” and “bad” forms of cholesterol. Low-density lipoprotein (LDL) is known as the bad cholesterol because high levels of it in your blood causes the buildup of plaque in your arteries. One way to remember is to think of LDL as “lousy” (L) cholesterol. High-density lipoprotein (HDL) is good cholesterol because it helps protect your body from developing heart disease by carrying away the LDL from your arteries. To remember its meaning, think of the H as a sign for “healthy” cholesterol.
When Should I Test My Cholesterol?
Some general rules for testing your cholesterol are if:
You are male and over 40.
You are female and over 50 or postmenopausal.
You have heart disease, stroke, diabetes, or high blood pressure.
You have a family history of heart disease or stroke.
Your waist measures more than 40 inches (102 centimeters) for men or 35 inches (88 centimeters) for women. For persons of Chinese or South Asian descent, if your waist measures more than 35 inches (90 centimeters) for men or 32 inches (80 centimeters) for women.
Table 19.1
Guidelines for Cholesterol Values
| Total cholesterol (U.S. and some other countries) | Total cholesterol (Canada and most of Europe) | |
| Below 200 mg/dL | Below 5.2 mmol/L | Desirable |
| 200–239 mg/dL | 5.2–6.2 mmol/L | Borderline high |
| 240 mg/dL and above | Above 6.2 mmol/L | High |
| LDL (bad) cholesterol (U.S. and some other countries) | LDL cholesterol (Canada and most of Europe) | |
| Below 70 mg/dL | Below 1.8 mmol/L | Ideal for people at very high risk of heart disease |
| Below 100 mg/dL | Below 2.6 mmol/L | Ideal for people at risk of heart disease |
| 100–129 mg/dL | 2.6–3.3 mmol/L | Near ideal |
| 130–159 mg/dL | 3.4–4.1 mmol/L | Borderline high |
| 160–189 mg/dL | 4.1–4.9 mmol/L | High |
| 190 mg/dL and above | Above 4.9 mmol/L | Very high |
| HDL (good) cholesterol (U.S. and some other countries) | HDL cholesterol (Canada and most of Europe) | |
| Below 40 mg/dL (men) Below 50 mg/dL (women) | Below 1 mmol/L (men) Below 1.3 mmol/L (women) | Poor |
| 40–49 mg/dL (men) 50–59 mg/dL (women) | 1–1.3 mmol/L (men) 1.3–1.5 mmol/L (women) | Better |
| 60 mg/dL and above | 1.6 mmol/L and above | Best |
| Triglycerides (U.S. and some other countries) | Triglycerides (Canada and most of Europe) | |
| Below 150 mg/dL | Below 1.7 mmol/L | Desirable |
| 150–199 mg/dL | 1.7–2.2 mmol/L | Borderline high |
| 200–499 mg/dL | 2.3–5.6 mmol/L | High |
| 500 mg/dL and above | Above 5.6 mmol/L and above | Very high |
Tryglycerides are another form of fat in your body. When you eat a meal, your body stores any calories it doesn’t immediately need into triglycerides. These triglycerides are stored in your fat cells. Triglycerides are released by hormones in your body for energy between meals. Over time, consuming more calories than you burn can lead to having high triglycerides (hypertriglyceridemia).
High levels of cholesterol in your body are often linked to uncontrolled diabetes, being overweight, or a high alcohol intake. You can control your cholesterol levels by losing weight, eating a heart-healthy diet, exercising regularly, quitting smoking, and drinking alcohol in moderation. If these lifestyle changes are not enough, medications will be added to lower cholesterol levels. Recommended blood levels of cholesterol (total, LDL, and HDL) and triglycerides tend to range by country, as shown in
Table 19.1
. These recommended levels are guidelines only and may change. So, talk to your health care provider about getting your levels checked and what your results mean for your health.
As previously mentioned, angina is a common symptom of coronary artery disease. It is often brought on by emotional stress or physical exertion and is usually relieved with medication or rest.
Sometimes angina will not be experienced as chest pain; it can also be experienced as pressure, tightness, squeezing, or a vague sense of discomfort. Some people (especially women) may only experience some of the following symptoms:
Persistent indigestion with or without nausea
Breathlessness
Cold sweats
Cramping or burning pain
Numbness in arms, shoulders, or wrists
Weakness
Unusual tiredness
Sleep disturbances
Angina episodes are
not
heart attacks, and angina pain does
not
mean that the heart is permanently damaged. Angina is, however, a warning sign of increased risk of a heart attack or heart failure. A heart attack occurs when the heart is damaged because the blood supply to an area of the heart has been cut off. The pain of a heart attack generally lasts longer, is more severe than angina pain, and it is not alleviated by resting or taking prescription medicine.
It is important to note that angina symptoms usually last only for a few minutes. Changes in the nature of your usual angina pain are cause for concern. If episodes become more frequent, occur at rest, or last longer than they have previously, seek medical help immediately. It is also important to note that for some, angina may be “atypical.” When angina is atypical, the common symptoms are not experienced. Instead, the individual with atypical angina may feel vague forms of chest discomfort along with additional symptoms listed above. There is some evidence to suggest that women are more prone to atypical angina, particularly prior to menopause. This may be because women tend to have blockages not only in their main arteries but also in the smaller arteries that supply blood to the heart.
Seek Emergency Care Immediately
If you are having symptoms that might mean a heart attack,
you must seek medical care immediately
. New treatments are available that can dissolve blood clots, restore blood flow, and prevent heart or brain damage. However, these treatments
must be given within hours of the heart attack
—the sooner, the better. In the United States and Canada, call 911 or emergency services if you have any of the following symptoms:
Severe, crushing, or squeezing chest pain
Pain or discomfort in one or both arms, the back, neck, jaw, or stomach
Chest pain lasting longer than five minutes when there is no apparent cause and it is not relieved by rest or heart medications
Chest pain occurring with any of the following: rapid or irregular heartbeat, sweating, nausea or vomiting, shortness of breath, light-headedness or passing out, or unusual weakness
For women, chest pain may not be present. Instead, symptoms such as chest discomfort, rapid or irregular heartbeat, sweating, persistent indigestion with or without nausea or vomiting, shortness of breath, light-headedness or passing out, or unusual weakness may indicate a heart attack.
Stop what you are doing.
Sit down.
Call 911. (Do not try to drive yourself to the hospital.)
If you are not allergic to aspirin, take one adult (325 mg) or four baby (81 mg) aspirin tablets.
Minutes matter!
Fast action can save lives—maybe your own. Don’t wait more than five minutes to call 911 or your local emergency response number.
The major types of angina include stable angina, refractory angina, unstable angina, variant or Prinzmetal’s angina, and microvascular angina.
Each of these is described in detail in the following material.
Stable angina.
Stable angina is the most common form of angina. It usually follows a predictable pattern. Stable angina can vary with respect to how often it occurs, how severe it is, and factors that trigger it. The pain typically comes at about the same point during exertion or exercise or while under emotional stress. It is relieved with rest, medication, or both. Other triggers of stable
angina include extreme cold or heat, eating heavy meals, consuming alcohol, and smoking cigarettes.Refractory angina
. Refractory angina is a severe form of stable angina that cannot be controlled by typical treatments for coronary artery disease such as medication, angioplasty, or coronary artery bypass surgery. (Common coronary artery disease treatments are discussed later in this chapter on
pages 316
–
319
). Refractory angina requires specialized treatments. For information on these treatments, talk with your health care provider.Unstable angina
. Unstable angina is more severe than stable angina. It does not follow a predictable pattern and may occur with or without physical exertion. It may not be relieved by rest or medication. Unstable angina is a dangerous condition requiring emergency medical attention.Variant angina
. Variant angina, also known as Prinzmetal’s angina, is a rare form of angina that usually happens when a person is at rest during the night. It is caused by coronary artery spasm and is characterized by severe chest pain. Almost 70% of people who experience variant angina have severe atherosclerosis in at least one coronary artery (see
page 304
). The pain from variant angina can be relieved with medication.Microvascular angina
. Microvascular angina is a severe form of chest pain that typically lasts longer than other types of angina. People who experience it do not have any disease of the coronary arteries that can be detected with currently available technology. In other words, there is no visible blockage of a coronary artery. Medication may or may not be helpful in relieving microvascular angina. This condition is sometimes referred to as cardiac syndrome X.