Coronary Artery Disease
Coronary Artery Disease: A Complete Patient Guide
Coronary artery disease (CAD), also called coronary heart disease or ischaemic heart disease, occurs when the coronary arteries, the blood vessels that supply the heart muscle, become narrowed by a build-up of fatty deposits called atheroma (plaque). This restricts blood flow to the heart, particularly when it is working harder, and can cause chest pain (angina), breathlessness and, if a plaque ruptures and a clot forms, a heart attack.
CAD is the most common form of heart disease in the UK and a leading cause of death worldwide. It usually develops silently over many years. The main risk factors are smoking, high blood pressure, high cholesterol, diabetes, obesity, physical inactivity, a family history of early heart disease and increasing age. Importantly, most of these can be treated or modified.
The European Society of Cardiology (2024) now uses the term chronic coronary syndromes (CCS) for the long-term phase of the disease, recognising that coronary disease is dynamic and can be controlled and even stabilised with treatment. This includes people with stable angina, people who have had a heart attack or stents, and people with coronary disease found on scans, with or without symptoms.
The aims of treatment are to relieve symptoms, prevent heart attack and heart failure, and extend life. A combination of lifestyle change, medication and, where appropriate, stents or bypass surgery achieves this for most people.
Many people have no symptoms until the arteries are significantly narrowed, and some have their first symptom as a heart attack. Symptoms often follow a pattern: they appear with exertion, emotion or cold weather and settle with rest.
Angina (typical symptoms)
A tight, heavy or squeezing discomfort in the centre of the chest, brought on by effort and relieved within a few minutes by rest or a GTN spray
Spread of the discomfort to the arm (usually left), neck, jaw, back or stomach
Worse after meals, in cold weather or with stress
Other symptoms
Breathlessness on exertion, sometimes without any chest discomfort (an “anginal equivalent”)
Unusual tiredness, nausea or sweating with effort
Light-headedness or palpitations
Who may present differently
Women, older people and people with diabetes more often describe breathlessness, fatigue, nausea or upper abdominal, jaw or back discomfort rather than classic chest pain. These symptoms are just as important and should not be dismissed.
Silent coronary disease
Coronary disease can be present with no symptoms at all, which is why assessing risk factors, and sometimes imaging, matters in people at higher risk.
CAD develops when cholesterol, inflammatory cells and scar tissue gradually build up in the artery wall. The process is accelerated by damage to the lining of the arteries.
Main risk factors
Smoking and vaping nicotine – among the strongest modifiable risks
High blood pressure and high cholesterol (particularly raised LDL cholesterol and lipoprotein(a))
Diabetes and pre-diabetes, and obesity or a large waist
Family history of heart disease in a male relative before 55 or a female relative before 65
Chronic kidney disease, chronic inflammatory conditions (such as rheumatoid arthritis and psoriasis) and a history of pre-eclampsia or early menopause
Physical inactivity, an unhealthy diet, excess alcohol and chronic stress
Can it be prevented?
Largely, yes. Not smoking, a Mediterranean-style diet, regular exercise, a healthy weight, and treating blood pressure, cholesterol and diabetes substantially reduce risk, including in people with a strong family history.
Do not ignore new or changing chest symptoms. Early assessment can identify coronary disease before it causes a heart attack.
Arrange a prompt assessment if you have:
Chest tightness, pressure or discomfort on exertion that settles with rest
Unexplained breathlessness, fatigue or reduced exercise tolerance
Angina that is becoming more frequent, occurs at lower levels of effort or is less responsive to your spray
Risk factors such as diabetes, high cholesterol, high blood pressure, smoking or a strong family history, particularly with symptoms
Known coronary disease with new symptoms or side effects from your medication
Call 999 immediately if you have:
Chest pain or pressure lasting more than 15 minutes, or not settling with rest or GTN
Chest pain with sweating, nausea, breathlessness or pain spreading to the arm, jaw or back
Chest pain with fainting or severe light-headedness
Sudden severe breathlessness
Diagnosis aims to confirm that the arteries are narrowed, to judge how much it limits blood flow, and to estimate your risk of future events. The best test depends on your symptoms and likelihood of CAD.
1. Consultation, ECG and blood tests
A detailed history and examination, a resting ECG and blood tests (cholesterol, diabetes, kidney function and blood count) are the starting point. A normal ECG does not exclude coronary disease.
2. Echocardiogram
An echocardiogram assesses the pumping function and valves, and looks for areas of heart muscle that have been damaged.
3. Tests for blocked arteries or reduced blood flow
CT coronary angiography (CTCA) – a non-invasive scan that shows the coronary arteries and plaque directly, and is recommended as the first-line test in many people with suspected CAD
Stress echocardiography or exercise ECG – look for reduced blood flow or rhythm changes during exertion
Cardiac MRI or nuclear perfusion scanning – assess blood flow and scarring in selected people
4. Invasive coronary angiography
Angiography (a catheter test through the wrist or groin) is used when symptoms are severe, when non-invasive tests show significant disease, or when treatment such as a stent is likely.
Treatment is individualised. The 2024 ESC guideline recommends combining lifestyle change with medication to control symptoms and reduce events, and considering revascularisation (stenting or bypass) in selected people.
Medicines to prevent heart attack and stroke
Antiplatelet therapy (usually low-dose aspirin or clopidogrel) reduces the risk of clots in people with established coronary disease
Statins, with ezetimibe or other cholesterol-lowering drugs if needed, aiming for a substantial reduction in LDL cholesterol
ACE inhibitors or ARBs where there is high blood pressure, diabetes, heart failure or kidney disease
In some people with diabetes or obesity, newer medicines (SGLT2 inhibitors, GLP-1 receptor agonists) provide additional heart protection
Medicines for symptoms
Beta-blockers and calcium channel blockers reduce heart rate and blood pressure, and relieve angina
Nitrates (a GTN spray for attacks, long-acting forms for prevention).
Ranolazine, Ivabradine and Nicorandil are options if symptoms persist
Stents and bypass surgery
Percutaneous coronary intervention (PCI), with a stent, opens a narrowed artery and relieves symptoms
Coronary artery bypass grafting (CABG) is often preferred for extensive disease, left main stem disease or in some people with diabetes and a weak heart
Revascularisation relieves symptoms and improves outcomes in selected high-risk anatomy, but medicines remain essential afterwards
Cardiac rehabilitation and risk factors
Exercise-based cardiac rehabilitation, stopping smoking, a Mediterranean-style diet, weight loss and blood pressure and diabetes control are as important as any procedure.
Take medicines regularly, particularly antiplatelets and statins, and never stop them without advice. Carry your GTN spray and know how to use it.
Stay active. Regular moderate exercise (around 150 minutes a week) is safe for most people and improves symptoms and survival.
Stop smoking – this is one of the most effective measures to reduce risk.
Eat a Mediterranean-style diet, low in processed food and saturated fat, and limit alcohol.
Control weight, blood pressure, cholesterol and diabetes and attend regular reviews.
Vaccinations: annual influenza and COVID-19 vaccination are recommended.
Mental health: low mood and anxiety are common after a heart diagnosis and are treatable. Support is available from the British Heart Foundation and the NHS.
Driving: DVLA rules apply to angina and after heart attack, stents or bypass. Discuss with your cardiologist.
CAD is usually a long-term condition, but outcomes have improved markedly. Many people live for decades with good quality of life.
Your outlook depends on how many arteries are affected, the strength of the heart, other conditions such as diabetes and kidney disease, and above all how well risk factors are controlled.
Statins, antiplatelets, blood pressure control and stopping smoking each reduce the chance of heart attack and death, and the benefits add up.
Angina often improves with treatment, and symptoms that persist despite medicines can be treated with stents or bypass surgery.
Regular follow-up allows early detection of progression and adjustment of treatment.
CAD is a build-up of plaque in the heart arteries that reduces blood flow and can cause angina or a heart attack.
It often causes no symptoms until advanced, and women, older people and those with diabetes may present with breathlessness or fatigue.
Chest pain on effort that settles with rest is the classic symptom. Chest pain lasting more than 15 minutes needs a 999 call.
Main risk factors are smoking, high blood pressure, high cholesterol, diabetes, obesity and family history.
Diagnosis uses an ECG, blood tests, echocardiography and either CT coronary angiography, stress testing or angiography.
Treatment is based on lifestyle change, antiplatelet, statin and other preventive medicines, symptom relief, and stents or bypass in selected people.
The 2024 ESC guideline uses the term chronic coronary syndromes for long-term coronary disease.
Cardiac rehabilitation and regular exercise improve symptoms and survival.
With modern treatment, the outlook is good for most people who control their risk factors.
Guidelines and sources
This page follows current UK and European guidance:
NICE NG238: Cardiovascular disease: risk assessment and reduction, including lipid modification.
Vrints C et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. European Heart Journal 2024;45:3415-3537.
Byrne RA et al. 2023 ESC Guidelines for the management of acute coronary syndromes. European Heart Journal 2023;44:3720-3826.
DVLA: Cardiovascular disorders: assessing fitness to drive (GOV.UK).
These are the questions patients most often ask about coronary artery disease.
What is coronary artery disease?
Coronary artery disease is a narrowing of the arteries that supply the heart muscle, caused by a build-up of fatty plaque. It reduces blood flow to the heart and can cause angina or a heart attack.
What are the symptoms of coronary artery disease?
The classic symptom is chest tightness or pressure on exertion that eases with rest. Others are breathlessness, fatigue, nausea or discomfort in the arm, jaw or back. Some people have no symptoms.
Is angina the same as a heart attack?
No. Angina is temporary chest discomfort when the heart does not get enough blood during effort, and it settles with rest. A heart attack occurs when an artery is suddenly blocked by a clot, causes lasting pain and needs emergency treatment.
How is coronary artery disease diagnosed?
Through a consultation, ECG, blood tests and echocardiogram, followed by a test of the arteries or their blood flow, such as CT coronary angiography, stress echo, exercise ECG or angiography.
Can coronary artery disease be reversed?
The plaque can often be stabilised and may modestly shrink with intensive cholesterol lowering and lifestyle change, which reduces the risk of heart attack. The disease cannot usually be cured completely, but it can be well controlled.
Do I need a stent or bypass?
Not everyone does. Many people are managed well with medicines and lifestyle change. A stent or bypass is considered if symptoms persist despite medicines or if tests show high-risk disease. Your cardiologist will discuss the options.
What is the best test for coronary artery disease?
It depends on the person. CT coronary angiography is often the first choice because it shows the arteries directly without a catheter. Stress echo and exercise ECG show how the heart responds to effort. Angiography is used if intervention is likely.
How can I lower my risk of a heart attack?
Do not smoke, take your statin and other preventive medicines, keep blood pressure, cholesterol and blood sugar controlled, exercise regularly, eat a Mediterranean-style diet and keep a healthy weight.
Can I have a private assessment for chest pain or coronary disease?
Yes. A telephone, video or face-to-face consultation in Peterborough or Corby can assess your symptoms and risk, and tests such as ECG, echocardiography, CT coronary angiography and stress echo can be arranged.
- Do I have coronary artery disease, and how severe is it?
- Which test is best for me, and what will it show?
- Which medicines do I need, and what are the side effects?
- What are my cholesterol and blood pressure targets?
- Do I need a stent or bypass, and what are the benefits and risks?
- How much exercise is safe, and can I attend cardiac rehabilitation?
- What symptoms should make me seek urgent help?
- Should my relatives be checked?
- How often will I be reviewed?
- What should I do if I get chest pain, and should I carry a GTN spray?
Coronary artery disease: plaque narrows the arteries that supply the heart muscle.
Image: Blausen.com staff (BruceBlaus), Blausen 0259 CoronaryArteryDisease 02, Wikimedia Commons. Licensed under CC BY 3.0.
How plaque narrows an artery (atherosclerosis).
Image: National Heart, Lung, and Blood Institute (NHLBI), Atherosclerosis diagram, Wikimedia Commons. Public domain.
How a coronary artery narrows
Healthy artery: smooth lining and wide channel, so blood flows freely to the heart muscle.
Early plaque: cholesterol and inflammatory cells build up within the artery wall, often with no symptoms.
Significant narrowing: the channel narrows so that blood flow falls short during exertion, causing angina.
Plaque rupture and clot: a plaque can crack, a clot forms and blocks the artery, causing a heart attack. This is an emergency.
If you have chest tightness, breathlessness on effort or risk factors for heart disease, you may benefit from a telephone consultation or video consultation to discuss your symptoms and risk, or a face-to-face consultation in Peterborough or Corby for a more comprehensive assessment.
Investigations such as ECG, echocardiography, CT coronary angiography and stress echo may be recommended.
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Medically reviewed by Dr Salam Salloum, Consultant Cardiologist. Last updated: . This page is for general information and does not replace personal medical advice.