Navigating coronary heart disease

Following on from his previous article on coronary heart disease, Dr Dwayne Conway gives us his insights into diagnostic tests to detect coronary heart disease and treatment options.

What diagnostic tests are used to detect coronary heart disease?

The most effective test for detecting coronary heart disease is a CT scan, which provides high-resolution images of the coronary arteries to identify atherosclerotic plaque and assess narrowing. To achieve optimal results, a gated CT is used, which synchronises image capture with the cardiac cycle and often requires heart rate-reducing medications. Not all CT units can perform cardiac CT, as it requires specialised equipment and monitoring, but it is becoming increasingly available in most areas of the UK.

Although a CT scan is excellent for identifying the presence of coronary artery disease, it may not reveal whether the disease affects blood flow. To assess its impact, several tests are available:

Electrocardiogram (ECG): This simple test measures the heart's electrical activity through leads on the chest and can detect circulation problems during chest pain.

Exercise ECG: This test involves treadmill walking while monitoring heart rate, blood pressure, and ECG to identify heart blood flow issues under physical stress.

Stress echo: Similar to an exercise ECG but with the addition of ultrasound to observe how the heart functions during exercise.

Nuclear perfusion scan: A radioactive substance is introduced into the bloodstream and taken up by the heart muscle. It helps compare blood flow at rest and during increased blood flow to assess abnormalities.

These tests focus on ischaemia, the decreased blood flow to the heart caused by coronary heart disease. They provide information about the impact of the coronary atherosclerosis on blood flow and heart function.

Invasive coronary angiography is another option, involving x-ray images with a contrast agent directly introduced into the coronary arteries via specially designed arterial catheters that need to be placed by expert cardiologists. It offers high-resolution images of arterial narrowings, blockages and the blood flow within the arteries. While CT excels at detecting plaque, invasive coronary angiography is better at assessing the severity of artery narrowing and artery flow.

What are the treatment options for coronary heart disease?

The treatment options for coronary heart disease are determined by the individual's condition. Atherosclerosis, the underlying disease, is managed primarily with statins, such as atorvastatin and rosuvastatin, which reduce harmful LDL cholesterol, slow down atherosclerosis progression, and have strong evidence for preventing heart attacks and strokes.

Other medications reduce the symptoms of angina, with options like beta blockers, amlodipine, and nitrates. Beta blockers lower the heart rate during exercise (reducing cardiac oxygen demand), while amlodipine and nitrates dilate blood vessels slightly (improving blood flow and also reducing cardiac oxygen demand).

During a heart attack, prompt medical attention is crucial, as there are additional medications which can reduce blood clots in the heart arteries, as well as procedures like angioplasty and stent placement aim to restore blood flow by physically unblocking the artery. Physical intervention, such as stents or bypass surgery, may also be considered for patients with stable angina if symptoms persist despite medications.

Aspirin is a notable therapy, as it inhibits platelets' clot-forming capability, reducing likelihood of sudden artery blockage. It is a simple and potentially life-saving treatment for a heart attack, where a blood clot is the usual culprit, and is recommended lifelong after a heart attack or stroke to reduce risk of recurrence. Aspirin is also recommended long-term after coronary angioplasty/stent procedures or heart bypass surgery, usually in combination with an additional anti-platelet drug, such as clopidogrel, prasugrel or ticagrelor for a few months.

Treatment for coronary heart disease is highly individualised, with statins being a cornerstone for managing the causative disease: atherosclerosis. Other medications are chosen based on symptoms and the stability of the condition, and physical interventions (coronary angioplasty, stents or bypass surgery) may also be offered according to the clinical situation.

Dr Dwayne Conway is a distinguished consultant interventional and general cardiologist with over 25 years of experience. You can schedule an appointment with Dr Conway on his Top Doctors profile.