Coronary Artery Disease: Causes, Diagnosis and Treatment

Coronary artery disease (CAD) is the single most common cause of death in adults worldwide, responsible for approximately one-third of all deaths in high-income countries. It results from the progressive narrowing of the arteries that supply blood to the heart muscle — a process driven primarily by the accumulation of cholesterol-laden plaques in the artery walls.

What Are the Coronary Arteries?

The heart muscle works continuously, beating around 100,000 times a day. Like any organ, it requires a constant supply of oxygen-rich blood. This is delivered by the coronary arteries, which branch off from the aorta immediately above the heart.

• The left main coronary artery divides into two major branches: the left anterior descending (LAD) artery (supplying the front and septum of the heart) and the left circumflex artery (supplying the lateral wall)
• The right coronary artery (RCA) supplies the right ventricle and, in most people, the posterior wall

Disease in any of these arteries — particularly the LAD, sometimes called the "widow maker" — reduces blood flow to the corresponding region of heart muscle.

How Coronary Artery Disease Develops

Atherosclerosis

The underlying process is atherosclerosis — the gradual build-up of plaques within artery walls. A plaque consists of cholesterol, inflammatory cells, calcium deposits and fibrous tissue. Over years to decades, plaques enlarge, harden, and protrude into the artery lumen, restricting blood flow.

Atherosclerosis is not unique to the coronary arteries — it affects vessels throughout the body, including the carotid arteries (raising stroke risk) and peripheral arteries (causing leg pain on walking).

Plaque Rupture and Heart Attack

A stable plaque that narrows an artery by 50–70% may cause angina (chest pain on exertion) but not complete blockage. However, even a smaller plaque can rupture suddenly, exposing its interior to the blood and triggering an immediate clot. This clot can completely block the artery within minutes, cutting off blood supply to a region of heart muscle — a heart attack (myocardial infarction). The affected muscle dies if blood flow is not restored urgently.

Risk Factors

Non-Modifiable

• Age — risk increases progressively; men above 45, women above 55
• Sex — men develop CAD earlier than women; the gap narrows after menopause
• Family history — a first-degree male relative with CAD before age 55, or female relative before 65, substantially raises risk
• Genetic cholesterol disorders — familial hypercholesterolaemia causes very high LDL from birth

Modifiable

Symptoms

Stable Angina

Stable angina is chest pain or pressure that occurs predictably with physical exertion or emotional stress, and resolves with rest within a few minutes. It results from temporarily inadequate blood flow to the heart muscle (ischaemia) when demand exceeds what the narrowed artery can supply.

Typical features:

• Location: central or left-sided chest, often described as tightening, heaviness or pressure
• Radiation: may spread to the left arm, jaw, neck, or shoulder
• Duration: 2–10 minutes; resolves with rest or sublingual nitrate
• Triggers: walking uphill, cold weather, large meals, emotional upset

Atypical presentations — particularly in women, older adults and diabetic patients — may involve breathlessness, nausea, jaw pain or fatigue without chest pain.

Unstable Angina and Heart Attack

Unstable angina occurs at rest, with minimal exertion, or in a new, severe, or worsening pattern — signs that a plaque has become unstable. It requires urgent medical assessment.

A heart attack (myocardial infarction) presents with:

• Severe, crushing chest pain lasting more than 20 minutes
• Not relieved by rest or nitrates
• Sweating, nausea, shortness of breath
• In some cases (particularly women and diabetics), atypical symptoms: jaw pain, back pain, extreme fatigue, epigastric discomfort

A heart attack is a medical emergency. Treatment within the first 90 minutes dramatically reduces heart muscle loss. Call emergency services immediately.

Silent Ischaemia

In some people — particularly those with diabetes or older adults — significant coronary artery disease causes no symptoms at all. The condition may be discovered only during routine testing or after a silent heart attack detected on an ECG.

Diagnosis

Non-Invasive Testing

• Resting ECG — may show signs of prior infarction or current ischaemia; normal in many patients with stable CAD
• Exercise stress test (ECG) — monitors the heart's electrical activity and symptoms during graded physical exercise; low cost and widely available
• Stress echocardiogram — detects regional wall motion abnormalities during stress, indicating reduced blood flow
• CT coronary angiogram (CTCA) — non-invasive visualisation of coronary artery anatomy; excellent sensitivity for ruling out CAD; can quantify stenosis and detect plaque before symptoms develop
• Cardiac MRI — assesses viability of heart muscle (alive vs. scarred) and detects ischaemia

Invasive Coronary Angiogram

Gold standard for diagnosis. A thin catheter is passed through the wrist or groin to inject contrast dye into the coronary arteries under X-ray guidance. This precisely maps the location and severity of narrowings and is performed when coronary intervention (stenting or surgery) is being considered. It can be combined with fractional flow reserve (FFR) measurement — a wire-based assessment of whether a blockage is severe enough to restrict blood flow at rest.

Treatment

Medications

All patients with coronary artery disease require:

• High-intensity statin (e.g. atorvastatin 40–80 mg, rosuvastatin 20–40 mg) — reduces LDL cholesterol and stabilises plaques; independently reduces cardiovascular events beyond cholesterol-lowering
• Antiplatelet therapy — aspirin (low-dose), plus a second agent (clopidogrel, ticagrelor, prasugrel) after stenting or heart attack
• Beta-blocker — reduces heart rate and oxygen demand; improves outcomes after heart attack and in angina
• ACE inhibitor or ARB — particularly beneficial in patients with diabetes, reduced ejection fraction or kidney disease
• Sublingual nitrates — for rapid relief of acute angina

Coronary Intervention (PCI — Stenting)

Percutaneous coronary intervention (PCI), commonly called angioplasty, involves inflating a small balloon inside the narrowed artery to restore blood flow, followed by placement of a drug-eluting stent (DES) to hold the artery open. PCI is performed through the radial artery (wrist), using local anaesthetic and mild sedation. The procedure typically takes 30–60 minutes and most patients are discharged within 24–48 hours.

In a heart attack, emergency PCI (primary PCI) performed within 90 minutes of symptom onset is the most effective treatment.

Coronary Artery Bypass Grafting (CABG)

Surgery is preferred for patients with:

• Disease in three major coronary arteries (triple vessel disease)
• Disease in the left main artery
• Severe narrowings in multiple vessels alongside poor heart function
• Diabetic patients with multivessel disease

In CABG, blood vessels taken from the chest (internal mammary artery — the gold standard) or leg (saphenous vein) are sewn in to bypass the blocked segments. It is a major operation requiring general anaesthesia, typically a 5–7 day hospital stay, and 6–12 weeks recovery — but it offers excellent long-term results and can restore normal life expectancy in appropriate patients.

Cardiac Rehabilitation

A structured programme of supervised exercise, dietary guidance and cardiovascular risk education dramatically reduces subsequent heart attacks and improves long-term quality of life. Enrolment is recommended after any coronary event.

Coronary Artery Disease Treatment in China

China's top-tier cardiac centres perform tens of thousands of coronary procedures annually and operate to international standards:

• CT coronary angiography available; provides a non-invasive assessment before any procedure decision
• Primary PCI for acute heart attacks: 24/7 catheterisation laboratories in major centres with door-to-balloon times at international benchmarks
• Complex multivessel PCI and left main stenting performed by interventional cardiologists with international fellowship training
• Off-pump CABG (beating-heart surgery) available, reducing complications in higher-risk surgical patients
• Cost: coronary intervention in China is typically 30–50% of the equivalent cost in private UK, US or Middle Eastern hospitals
• Full English coordination including pre-procedure consultation, in-hospital translation and post-procedure follow-up planning

Contact a ChinaMedicalTour care navigator to arrange a coronary artery assessment or surgical consultation.

Medical content based on MSD Manuals, authored by Ranya N. Sweis MD MS and Arif Jivan MD PhD (Northwestern University Feinberg School of Medicine), reviewed by Jonathan G. Howlett MD. Last reviewed February 2024, updated January 2026.