1. Coronary Heart Disease Coronary heart disease (CHD) is one of the commonest diseases to affect the heart. The most common cause is atherosclerosis ; a build up of fatty materials within the walls of the arteries throughout the body, most importantly in the arteries to the tissues of the heart - the coronary arteries. A heart attack occurs when one of the coronary arteries blocks completely. This final step usually happens when a plaque splits open for some reason, causing a blood clot to form on its surface that obstructs the flow of blood. It’s not yet understood why plaques split open, but inflammation seems to play a part. When the supply of oxygen and nutrients is completely blocked, the heart muscle and tissue supplied by that artery dies. For many people with heart disease, there is a combination of factors that can cause problems. Some people are particularly predisposed towards developing atherosclerosis, due to inherited genetic factors. They may have a family history of people dying at a young age from CHD. An unhealthy diet, lack of exercise, diabetes, high blood pressure and smoking all increase the risk. At the same time, the blood becomes more prone to clotting. These growing plaques may block the delivery of nutrients to the artery walls, causing the arteries throughout the circulation to lose their elasticity. In turn, this can lead to high blood pressure, which also increases the risk of CHD. Resource sheet During this process, the inner lining of the arteries becomes furred with a thick, porridge-like sludge (atheroma), consisting of fatty deposits of cholesterol, cell waste and other substances. These form raised patches on the artery wall - known as 'plaques' - that narrow the arteries, reducing the space through which blood can flow.

2. What are the symptoms of heart disease? The main symptom is Angina - a heart condition that is caused when the blood supply to the muscles of the heart is restricted. It usually occurs when the arteries that supply the heart become hardened and narrowed. The main symptom of angina is a dull, heavy or tight pain in the chest that can sometimes spread to the left arm, neck, jaw or back. The pain is usually triggered by physical activity or stress and usually only lasts for a few minutes. A major concern for people with angina is that their atherosclerosis will continue to get worse. This can lead to the blood supply to their heart becoming blocked, which could trigger a heart attack. Similarly, a blockage of the blood supply to the heart could trigger a stroke. When having a heart attack, the chest can feel like it is being pressed or squeezed by a heavy object, and pain can radiate from the chest to the jaw, neck, arms and back, the person will experience shortness of breath, feel weak and/or lightheaded and may experience an overwhelming feeling of anxiety. Not everyone experiences severe chest pain; often the pain can be mild and mistaken for indigestion. Other symptoms include: Unusual breathlessness when doing light activity or at rest, or breathlessness that comes on suddenly Palpitations - awareness of your heart beat or a feeling of having a rapid and unusually forceful heartbeat, especially if they last for several hours or recur over several days and/or cause chest pain, breathlessness or dizziness Fainting - although not always a serious symptom, fainting is due to insufficient oxygen reaching the brain, so you should report it to your doctor Fluid retention or puffiness (oedema) is an abnormal accumulation of fluid in the tissues of the ankles, legs, lungs or abdomen, for example. Although a mild degree of ankle oedema may be quite normal - for example, on a hot day - it can be a sign that the heart isn’t pumping as well as it should (this is known as heart failure). Fluid retention in the lungs, or pulmonary oedema, can cause intense shortness of breath, and may be life-threatening Bluish -tinged fingernails or lips (cyanosis) can be the result of too little oxygen in the blood Fatigue is a common symptom of heart disease, but has numerous causes, including depression. It's always worth seeing your doctor if you feel unusually tired, especially if this is combined with symptoms that can’t be explained Resource sheet Can’t go on.. Describing symptoms.. Any longer.. Infection - bacterial infections can damage the valves of the heart as well as other tissues. Viral infections can damage the heart muscle leading to heart failure, or cause abnormal heart rhythms. Congenital heart disease - there's a range of structural abnormalities that can develop in the heart as a baby grows in the womb. These may cause abnormal flow through the heart (for example, through a septal defect or hole in the heart) or through the rest of the circulation, and put excessive strain on the infant's heart after it's born. It may not be a heart attack! Other heart problems include:

3. Risk factors Angina is a common condition among older adults. It England it is estimated that 1 in 12 men and 1 in 30 women 55 - 64 years of age have angina. This figure rises to 1 in 7 men and 1 in 12 women who are over 65 years of age. Angina is thought to be more common in men than women because in the past more men smoked and smoking is a significant risk factor. Each year it is estimated that just 1 in 100 people with stable angina will have a fatal heart attack or stroke. However, it is thought that as many as 1 in 40 people may experience a non-fatal heart attack or stroke, both of which can have a considerable impact on a person’s quality of life. Depending on a number of possible risk factors, the outlook for people with unstable angina can vary considerably. These risk factors include: o The age of the person o Their history of heart disease o Their blood pressure ( if it’s high, they could have hypertension) o The presence of a long-term condition, such as type 2 diabetes Heart attacks are one of the most common reasons why a person requires emergency medical treatment. There were just over 92,000 heart attacks in England between April 2010 and April 2011. Most heart attacks occur in older people over 45 years of age. Men are two to three times more likely to have a heart attack than women. Complications of heart attack can be serious and possibly life-threatening, and include:  Cardiogenic shock – this is where the muscles of the heart are severely damaged, meaning the heart can no longer supply enough blood to maintain many body functions  Heart rupture – is where the heart’s muscles, walls or valves split apart (rupture)  Arrhythmia – is an abnormal heartbeat, such as a ventricular arrhythmia, where the heart begins beating faster and faster before going into a kind of spasm and then stops beating (cardiac arrest) These complications can occur quickly after a heart attack and are a leading cause of death. Many people will die suddenly from a complication of a heart attack before reaching hospital. The outlook for people who have had a heart attack can be highly variable depending on: In general around one third of people who have a heart attack die as a result. These deaths often occur before a person reaches hospital, or alternatively, within the first 28 days after the heart attack. If a person survives for 28 days after having a heart attack, their outlook improves dramatically and most people will go on to live for many years. CTD back of this page Resource sheet  The age – the older you are the more likely you are to experience serious complications  The severity of the heart attack – specifically how much of the muscle of the heart has been damaged during the attack  Length of time before a person received treatment – the longer the delay the worse the outlook tends to be

4. Resource sheet Most diseases are multi factorial and the risk of suffering from heart disease is increased when combining together risk-factors. For example, smoking, high blood pressure, cholesterol, and diet. Smoking Carbon monoxide combines irreversibly with haemoglobin in red blood cells to form carboxyhaemoglobin and thus reduces oxygen carrying capabilities of the blood. The heart has to then work harder – causing increased blood pressure that increases coronary heart disease and strokes. Angina (chest pain) can be caused by insufficient supply of oxygen to the heart muscle. Nicotine stimulates the production of the hormone adrenaline which increases heart rate and raises blood pressure. Thus smokers are at greater risk of suffering coronary heart disease or a stroke. Niicotine makes the red blood cells more ‘sticky’ leading to ha higher risk of thrombosis (thus strokes or myocardial infarction) High blood pressure High blood pressure may be a result of your genes – thus lifestyle will not change this. High blood pressure may also be caused by life style choices – e.g. prolonged stress, certain diets, lack of exercise, smoking. High blood pressure increases the risk of heart disease because: o The heart must work harder to pump blood into the arteries o High blood pressure in the arteries means more likely to develop an aneurysm and burst (causing a haemorrhage) o To resist higher pressure, arteries thicken and may harden – restricting blood flow Blood cholesterol Cholesterol cannot dissolve in the blood and need lipoproteins to carry it to and from cells. High-density lipoprotein or HDL, is known as ‘good’ cholesterol. Removes cholesterol from tissues and transports them to the liver for excretion. HDLs help protect arteries against heart disease. Low density lipoprotein or LDL is known as ‘bad’ cholesterol. Transports cholesterol from the liver to the tissues, including the artery walls, which they infiltrate (leading to atheroma & ultimately heart disease) -This is on the syllabus, however it has recently been refuted by scientists. Diet Bad - High levels of Salt raises blood pressure. High-levels of saturated fat increase LDL levels and hence blood cholesterol concentration – leading to atheroma. Good - Antioxidants (e.g. vitamin C) and non-starch polysaccharides (dietary fibre) REDUCE the risk of heart disease. (again, this is questionable in terms of evidence)

5. Resource sheet Clotted Blood Atheroma Atheroma is a fatty deposit that forms WITHIN the wall of an artery. Atheroma begins as fatty streaks that are accumulations of white blood cells that have taken up low-density lipoproteins (LDLs). These streaks enlarge to an irregular patch (atheromatous plaques) containing deposits of cholesterol, fibres and dead muscle cells. These cause bulges in the lumen which reduce blood flow – causing two potentially very dangerous conditions: thrombosis and aneurysm. Thrombosis If an atheroma breaks through the lining (endothelium) of the blood vessel, it forms a rough surface that interrupts the otherwise smooth flow of blood. This may result in the formation of a blood clot, or thrombus, in a condition known as thrombosis. This thrombus may block the blood vessel – thus preventing the supply of blood to tissues beyond it – thus depriving tissue of oxygen, glucose and other nutrients that blood provides. Sometimes a thrombus may be carried away from its place of origin and gets lodged and blocks another artery. Aneurysms Atheromas that lead to the formation of thrombus also weaken artery walls which may swell to form a balloon-like blood structure called an aneurysm. Aneurysms frequently burst leading to haemorrhage leading to haemorrhage and thus a loss of blood to the region of the body served by that artery. A brain aneurysm is known as a stroke. Heart Attack A myocardial infarction refers to a reduced supply of oxygen to the muscle (myocardium) of the heart. It results for a blockage in the coronary arteries. If the blockage is close to the junction of the aorta and coronary artery, the heart will have its blood supply completely cut off. If the blockage is further along the coronary artery, the symptoms will be milder because less of the muscle is affected. Half a million people a year have a heart attack – of which fewer than 1/3 die. Almost all show signs of atheroma and thrombosis.