Coronary artery disease and angina
Assessment and treatment of narrowed coronary arteries, chest pain and recovery after a heart attack.
Dr Farrah Othman (FRACP), interventional and general cardiologist, provides coronary artery disease treatment in Balmain within The Endocrine & Wellbeing Clinic, working with the clinic’s endocrinologists on the diabetes, cholesterol and blood pressure conditions that drive it.
What we commonly see in patients
We commonly see people with chest tightness or breathlessness on exertion, on stairs or on a hill, that settles with rest. Many have had a normal resting ECG with their GP and have been told the symptoms are probably not cardiac, but the pattern has continued. Others have no symptoms but a strong family history, or a high calcium score on a scan arranged for another reason.
We see people recently discharged after a heart attack or a stent. They have left hospital with a bag of new medications, a follow-up letter, and little explanation of what each tablet does, what they are allowed to do, and how long any of it continues.
We see people with established coronary disease who have been told their numbers are fine but whose cholesterol or blood pressure are not at the targets that apply once the disease is present.
The common thread is a disease that develops over decades and is managed over decades. The diagnoses are stable angina, acute coronary syndrome and prior myocardial infarction, with or without a stent.
How we treat the condition
Coronary artery disease (CAD) and cardiovascular disease are the leading cause of death and morbidity across the world. It develops when the arteries that supply blood to the heart muscle become narrowed or blocked by fatty deposits, called plaques. This process is known as atherosclerosis and develops over many years. There are several risk factors or contributing factors, such as family history (or genetics), smoking, high blood pressure, diabetes, age, gender, and the presence of inflammatory and/or autoimmune conditions. When the heart muscle does not receive enough oxygen-rich blood, it can cause chest pain (angina) or a heart attack (a myocardial infarction, or MI). Angina is when there is a supply/demand mismatch, particularly during periods of exertion (increased demand). Treatment for CAD has two main goals: preventing heart attacks and death, and relieving symptoms like chest pain.
1. Cardiovascular risk factors. There are modifiable (things you can change) and non-modifiable (outside of your control) risk factors that contribute to the development of heart disease. Modifiable lifestyle risk factors: obesity, inactivity, smoking, poor diet, alcohol excess. Modifiable medical risk factors: high blood pressure (hypertension), diabetes, high cholesterol, kidney disease (to some extent). Non-modifiable risk factors: age; genetics, including lipoprotein(a); gender; epigenetics, the interplay of your genes and the environment; ethnicity.
2. Investigations to test for coronary artery disease. If you present to hospital with chest pain or shortness of breath, an electrocardiogram (ECG) will be performed which can tell you if you are having a myocardial infarction and require urgent treatment. A blood test (troponin) will test for markers of damage to the heart and instruct the doctors if you require in-patient investigations and treatment. As an outpatient, an ECG will still be informative. A stress test may be performed to evaluate if there is an area of heart muscle that has reduced blood flow. An invasive coronary angiogram may be performed which uses X-ray imaging and contrast dye to visualise the coronary arteries; it is during this procedure that a stent can be placed to open up a severely narrowed (over 70%) artery to improve blood supply to the heart muscle. A CT coronary angiogram is a useful non-invasive scan using contrast dye that can show the coronary arteries and the type of plaque, and the degree of narrowing (with less accuracy than an angiogram). An echocardiogram may be performed (without a stress test) to look at the structures of the heart and the pumping function. Other blood tests will be recommended to help manage the risk factors: cholesterol levels (LDL-C or “bad cholesterol”, triglycerides, HDL), diabetes status, ApoB and lipoprotein(a) in select patients, inflammatory markers such as hsCRP, kidney function, iron levels, and other blood tests to help with treatment and look for other causes of chest pain.
3. Lifestyle interventions are very effective. Smoking cessation reduces mortality by ~29%. A Mediterranean diet, intentional weight loss and exercise reduce cardiovascular mortality and cardiovascular events (such as a heart attack). The clinic’s dietitian, Isabelle Smith (APD), and exercise physiologist, Jessica Coombe (AEP), deliver these as structured programmes; foods with good evidence for lowering cholesterol are covered on the cholesterol and statins page.
4. Medications for coronary disease and angina. The mainstay of treatment of stable coronary artery disease is medical therapy. Antiplatelets prevent blood clots from forming in the arteries. Aspirin is the most common, reducing major cardiovascular events by approximately 19% annually in patients with established CAD. After a heart attack or stent placement, dual antiplatelet therapy (aspirin plus another antiplatelet, such as clopidogrel) is typically used for a period. If you have CAD, and after a stent or a heart attack, you will remain on one antiplatelet for life provided there has been no major bleeding. If you require non-cardiac surgery or a dental procedure, please contact your cardiologist to discuss the best course of action before stopping any of these medications. Statins are medications that lower cholesterol in the blood, particularly “bad” cholesterol (LDL-C); they work by blocking an enzyme in the liver that produces cholesterol. Other cholesterol treatments such as PCSK9 inhibitors reduce heart attacks and stroke in select patients with persistently high cholesterol and in certain high-risk population groups. Blood pressure management reduces cardiovascular events by 23% per 10 mmHg reduction in systolic BP. Typically the target is below 125/80 mmHg (or 135/85 mmHg if elderly with a falls risk). Diabetes management with medications like SGLT2 inhibitors and GLP-1 receptor agonists can reduce cardiac events by 14% and death from any cause by ~15%. Diabetes, lipid and weight management are provided by Dr Isobelle Smith (FRACP) and the clinic’s endocrinologists in the same rooms.
What happens at your first appointment
- Consultation and examination. Dr Othman will see you first and examine you for around 20 minutes.
- Investigations in-rooms. You will then have investigations, such as an ECG, echocardiogram, or stress echocardiogram, which will take 20 to 30 minutes. If it is your first appointment, please wear comfortable clothing in case you need to walk on a treadmill.
- Your plan. She will then speak to you again and arrange any further investigations, management and follow-up.
- Letter to your GP. A letter will be written and sent to your GP or referrer within the week.
A note about stents for stable angina
PCI plays different roles depending on the clinical situation. In an acute heart attack, a stent is a life-saving treatment. It opens the blocked artery and restores blood flow to the heart muscle. In stable angina, stents are reserved as a last resort for refractory symptoms that don’t respond to medication. Stents in this situation do not improve survival or reduce heart attacks when compared to medical therapy, and this was proven in two large, randomised controlled, sham trials (ORBITA, 2018; ORBITA-2, 2023). Coronary artery bypass surgery may be offered if there are multiple vessels severely diseased or blocked; this is performed by cardiac surgeons.
Frequently asked questions
Angina is when there is a supply/demand mismatch, particularly during periods of exertion. Chest pain that comes on with activity and settles with rest should be assessed. If you have chest pain, feel unwell or have issues with bleeding, please attend the nearest emergency department or call an ambulance.
Not necessarily. As an outpatient an ECG, echocardiogram, stress test or CT coronary angiogram may answer the question. An invasive angiogram is used when those tests suggest a significant narrowing, when symptoms persist despite treatment, or after an acute event.
If you have CAD, and after a stent or a heart attack, you will remain on one antiplatelet for life provided there has been no major bleeding. If you require non-cardiac surgery or a dental procedure, please contact your cardiologist before stopping any of these medications.
Statins stabilise plaque in the arteries, prevent progression of the plaque and over time can reduce the plaque. The most important mechanism is plaque stabilisation, preventing progression of the plaque, and the absence of heart attacks.
A referral from your GP or another specialist is required for a Medicare rebate on a specialist cardiology consultation. Ask reception if you are unsure whether yours is current.
Book an appointment
The Endocrine & Wellbeing Clinic
Phone: (02) 9870 3256
Locations: Balmain (inner west Sydney) and Telehealth Australia-wide
Affiliated with: Cardiac Society of Australia and New Zealand, Australian Atherosclerosis Society, European Society of Cardiology
This page is not a substitute for individual medical advice. Book a consult for assessment specific to your situation.