The arteries play an essential role in the vascular system; they transport oxygen and nutrients to the body's tissues. However, like any part of the body, they're susceptible to damage and disease. Coronary artery disease and carotid stenosis are two arterial diseases that, if left untreated, can lead to serious complications, including heart attack and stroke. Lifestyle habits and genetics both influence the health of our arteries, and at TCIM, our functional approach aims to find the root cause to treat and prevent serious health conditions.
What are coronary artery disease and carotid stenosis?
Coronary artery disease, also called CAD, is the most common type of heart disease in the United States (1). The coronary arteries branch and enclose the surface of the heart and supply it with oxygenated blood and nutrients (3). The carotid arteries are located in the neck and deliver oxygenated blood to the brain (2). When plaque made up of products like cholesterol, calcium and fat are deposited on the walls of the arteries and cause them to narrow, known as atherosclerosis, CAD and carotid stenosis occur (1). Unstable or ruptured plaque in coronary arteries can cause a heart attack, while a similar process in the carotid arteries and cerebral arteries can cause a stroke (1, 2, 3).
Symptoms of CAD and carotid stenosis
CAD reduces blood flow to the heart and may cause the following symptoms (1):
• A pressure or tightness in the chest, also called angina, that usually lasts a few minutes, worsens with physical activity and improves with rest
• Shortness of breath
• A heart attack will occur if the coronary artery is completely blocked. Common heart attack symptoms include left arm, jaw or shoulder pain, chest pressure, shortness of breath, and sweating.
Carotid stenosis can be asymptomatic and go undetected until it causes a stroke. Symptoms of a stroke may include (4):
• Trouble seeing in one or both eyes
• Weakness, tingling, or numbness in the face, arm, or leg, especially on one side of the body
• Sudden difficulty walking, loss of balance or coordination
• Sudden dizziness
• Difficulty speaking or swallowing
• Sudden severe headache
Risk factors of CAD and carotid stenosis
Some factors, known as modifiable risk factors, are within your control and, if managed properly, can significantly reduce the chance of vascular conditions like CAD or carotid stenosis. Modifiable risk factors include (4, 5, 6, 7, 8):
• Hypertension: high blood pressure can harden and thicken the arteries and promote plaque buildup.
• Hyperlipidemia: high cholesterol levels can increase the risk of atherosclerosis
• Diabetes mellitus: heart disease is more than two times higher in diabetics compared to non-diabetics
• Obesity: excess weight increases the risk of vascular disease and other conditions. A recent study found obese patients were twice as likely to have CAD, and a 2012 study found that a high body mass index in childhood is associated with an increased risk of heart disease in adulthood.
• Smoking increases the risk of heart disease. A 2018 study found that smoking one cigarette per day still carries a considerable risk of developing vascular diseases, and no safe level of smoking exists. Second-hand smoke exposure also increases the risk of heart disease.
• Poor Diet: consuming too much food that is high in salt, sugar, and saturated and trans fats
• Sedentary lifestyle
Others factors are non-modifiable, meaning they cannot be changed. These include (4, 5, 7):
• Age increases the risk, especially after the age of 45 for men and 55 in women
• Gender: men are at an increased risk compared to women
• Ethnicity: Blacks, Hispanics, Latinos, and Southeast Asians are at an increased risk
• A family history of developing cardiac disease before age 50 increases the risk
Diagnosis of CAD and Carotid Stenosis
Our goal at TCIM is to find the root cause of any ailments. The conventional approach to physicals usually includes taking a patient's blood pressure, providing a physical exam, blood work, and preventative cancer screening. We also offer executive physicals that take a more integrative and aggressive approach and aim to identify early changes in the body to prevent future damage. Many of the included tests in an executive physical aim to prevent vascular complications like heart attacks and strokes.
One of the most valuable tests included in the executive physical is the ultrasound. Carotid ultrasonography looks for plaque build-up, blood clots, and arterial thickening — which is often a visible symptom long before the presence of plaque (4). Other vascular tests included in an executive physical are plethysmography, a non-invasive test that measures blood flow within vessels, and EKGs, which measure the heart's electrical activity (4).
Predicting a patient's health based on blood tests and a physical exam alone isn't easy, and normal cholesterol levels and blood work do not necessarily indicate perfect health. Executive physicals are preventative and can identify existing problems. They also provide an objective marker to see if lifestyle changes are effective; for patients who have been working hard to control their high cholesterol via diet and exercise, an ultrasound will show them if their regimen is working.
Other tests used to diagnose CAD include (1):
• Echocardiogram: measures the heartbeats electrical activity, rate, and regularity
• Exercise stress test: measures heart rate while walking on a treadmill or riding a stationary bike. This test determines how well the heart works while having to pump more blood.
• X-ray of the heart, lungs, and other chest organs
• Cardiac catheterization and angiogram: A thin tube inserted into an artery or vein in the groin, neck, or arm and up to the heart. A dye can be injected to make the blood vessels more visible and display any blockages.
• Coronary artery calcium scan: detects any calcium deposits and plaque in the arteries.
Additional imaging techniques used to diagnose carotid stenosis include (4):
• Carotid angiogram: an invasive procedure where dyes are injected, and an X-ray shows how the blood flows through the vessels.
• Magnetic resonance angiogram (M.R.A.): creates detailed images of the brain and arteries and can distinguish healthy tissue from unhealthy tissue.
• Computed tomography angiogram (C.T.A.): Cross-sectional images of the carotid arteries and the brain are produced via injecting a dye into the blood vessels and using C.T. scanning.
Conventional treatment of CAD and carotid stenosis
Medications can help prevent and manage conditions, but if the underlying problem is caused by factors like stress management, diet, or exercise, and those variables aren't addressed, then adding medication will not necessarily help.
All medications have the possibility of side effects; however, not all patients will experience these symptoms. If side effects are present, it's important to consult a doctor. The following drugs can be used to treat CAD (17):
• Cholesterol-modifying medications reduce plaque deposits on the arteries by blocking the enzyme used to make cholesterol. Statins also improve the lining of the blood vessels, reduce inflammation and reduce the risk of blood clots. Side effects may include constipation, nausea, headaches, sore muscles, liver enzyme elevation, and increased blood glucose.
• Aspirin, a blood-thinner, can reduce the likelihood of blood clotting, which can lower the risk of heart attacks or strokes. However, Aspirin can be dangerous for people with bleeding disorders or those already on a blood-thinner.
• Beta-blockers slow the heart rate by blocking the effects of the hormone epinephrine; this reduces blood pressure and widens the veins and arteries to increase blood flow. Side effects may include fatigue, weight gain, and cold hands or feet.
• Calcium channel blockers prevent blood vessels from narrowing and reduce blood pressure.
• Nitroglycerin helps relieve chest pain by temporarily dilating the coronary arteries, which lowers the blood pressure, thus reducing the heart's workload. Side effects depend on the form of the drug but can include headaches and dizziness.
• Angiotensin-converting enzyme (A.C.E.) and angiotensin II receptor blockers (A.R.B.s) are usually given the first few days after a heart attack to reduce heart enlargement and increase the chance of survival.
Sometimes drugs and lifestyle changes are not enough, and a more invasive treatment is needed. There are several options for CAD (18):
• Angioplasty and stent placement: a catheter is inserted in the artery, and a deflated balloon is passed through the catheter and inflated to widen the artery. A stent that releases medication is often left in the artery to keep it open. This procedure helps return blood flow to the heart and is not a major surgery. A patient can usually return to their routine within one week of the treatment. Risks of angioplasty include re-narrowing of the artery, blood clots forming within the stents, and bleeding where the catheter is inserted.
Depending on the extent of the patient's heart disease and overall health, coronary artery bypass surgery may be a better option than angioplasty. This surgery may be needed if the main artery that brings blood to the left side of the heart is narrow, the heart muscle is weak, or the patient has diabetes and multiple severe artery blockages (18).
• Coronary artery bypass surgery: a surgeon attaches a blood vessel from elsewhere in the body to bypass the blocked arteries (18). Bypass surgery involves a one-week hospital stay and six to 12 weeks of recovery. The surgery is beneficial for patients who have serious cardiovascular disease and can help eliminate the symptoms of CAD like shortness of breath and angina. Some risks include bleeding from the site of the attached graft, blood clots, infection, kidney failure, memory loss, reactions to the anesthesia, and death (19). However, more than 95 percent of bypass surgery patients do not experience any serious complications (19).
Researchers at the Stanford School of Medicine and New York University's medical school found that patients with severe but stable heart disease treated with medications and lifestyle changes alone are at no more risk of a heart attack or death than those who undergo invasive surgeries. However, for patients with CAD who also had symptoms of angina, invasive treatment like stents or bypass surgery is more effective at relieving symptoms and improving quality of life (20).
Carotid Artery Stenosis
Medications used to treat carotid artery stenosis include (4, 21):
• Antiplatelet medications, including Aspirin, prevent platelets from sticking together and creating blood clots
• Anticoagulants decrease the ability of the blood to clot
• Antihyperlipidemics lower lipids in the blood
• Antihypertensives lower blood pressure
If the narrowing of the carotid artery is more than 50 percent, a more aggressive treatment may be necessary. The risks and benefits of the following options depend upon the patient's age, blockage, and if they've had a stroke (4, 21):
• Carotid Endarterectomy: while the patient is under general anesthesia, an incision is made so the surgeon can remove plaques and clots from the carotid artery.
• Carotid Artery Angioplasty with Stenting (C.A.S.): a less invasive procedure than carotid endarterectomy, a catheter is threaded to the narrowing artery. Once in place, a balloon is inflated to open the artery, and a stent is placed inside to expand it and keep it open.
Functional treatment of CAD and carotid stenosis
Despite angiography and pharmaceutical therapies reducing the number of cardiovascular deaths in the United States, it's not uncommon for patients to be prescribed a minimum of four to six medications which can be expensive, reduce compliance rates, and lead to side effects (9). For these reasons, patients often desire a more functional medicine approach. Functional treatment of CAD and carotid stenosis focuses on lifestyle factors like diet and exercise. Our executive physicals enable us to find the underlying cause and contributing factors; we can then create an individualized treatment plan based on our findings. The American College of Cardiology and the American Heart Association state in their 2019 guideline that most atherosclerotic cardiovascular disease is preventable by controlling modifiable risk factors (10).
One study found that participants at high cardiovascular risk who followed a Mediterranean diet versus those assigned to a reduced-fat diet had a lower incidence of major cardiovascular events (11). A diet high in vegetables, fruits, and whole grains with fish, legumes, and poultry as a source of protein are best (10]) Eating less food that contains trans and saturated fats, added sugars, red meats, and sodium is recommended (8). Whole grains can also reduce the risk of cardiovascular events. One study found that women who ate more than three servings of whole grains per day versus those who ate less than one serving per day had a 25% decrease in cardiovascular events (9).
Regular physical activity and a high fitness level are associated with a lower risk of premature death from cardiovascular disease and a reduction in other risk factors like hypertension, obesity, and diabetes mellitus (12). The American Heart Association recommends that adults get at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic exercise throughout the week (13). Moderate-to-high intensity muscle strengthening should be done at least two days per week, and increasing daily movements while reducing sitting can also offset some of the risks of being sedentary (13).
Smokers should aim to quit smoking instead of cutting down the number of cigarettes to reduce their risk of cardiovascular events (6, 7). Social support can influence tobacco use, therefore individual and group social support counseling may be beneficial (10).
Getting less than six hours of sleep is associated with hypertension. Recent studies have found a connection between poor sleep and preclinical atherosclerosis and a higher rate of mortality among those with heart disease (14). The American Academy of Sleep Medicine recommends limiting bright light exposure at night, keeping a regular bedtime, and avoiding caffeine late in the day as habits that promote good sleep (14).
Learning how to reduce or manage stressors is essential in reducing the risk of a heart attack and stroke and living an overall healthier life. Meditation has been shown to lower cortisol (the stress hormone) and blood pressure (9), and there is evidence that it can help with insomnia, depression, and anxiety (15). Meditation comes in many forms, including moving practices like yoga, Tai Chi, and qi gong (15). Exercise, sleep, deep breathing, and grounding techniques are also proven methods in reducing stress and are best used in combination with other lifestyle changes (16).
CAD and carotid stenosis are serious diseases, but they are treatable. Taking control of your health with exercise, diet, sleep, and stress management can help prevent and manage the conditions. However, it's important to note that these lifestyle changes may not work for everyone, and some patients may also require medications or a medical procedure to help manage their CAD and carotid stenosis. At TCIM, we create personalized treatment plans based on our patient’s needs, including functional changes, like diet and exercise, and conventional changes, like medications and medical procedures. Finding the root cause of the disease is an important first step in finding the best treatment approach, and at TCIM, our executive physicals aim to do just that.
Jonathan Vellinga, MD is an Internal Medicine practitioner with a broad interest in medicine. He graduated Summa cum laude from Weber State University in Clinical Laboratory Sciences and completed his medical degree from the Medical College of Wisconsin.
Upon graduation from medical school, he completed his Internal Medicine residency at the University of Michigan. Dr. Vellinga is board-certified with the American Board of Internal Medicine and a member of the Institute for Functional Medicine.
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