In coronary artery disease, the coronary arteries become narrowed or blocked by a gradual buildup of fat (cholesterol) within the artery wall, which reduces the blood flow to the heart muscle. This buildup is called "atherosclerotic plaque" or simply "plaque," and may start slowly progressing in childhood.

If the plaque narrows the channel of the artery, it may make it difficult for adequate quantities of blood to flow to the heart. Basically, there are three main coronary arteries in your heart. These arteries are located in the front of the heart (LAD), in the back of the heart (CIRC), and on the right side of the heart (RCA). One, two, or all three of these coronary arteries or their branches may be involved in the process of narrowing or blockage. The blockage may be partial or complete (see figures below ). Your doctor will mark the sites of your blockage on the enclosed illustration. Then, after surgery, he will mark the course of your bypass graphs. When a coronary artery becomes partially or completely blocked, the part of the heart muscle supplied by the blood vessel does not get its required blood supply.

The first symptom generally is chest pain or chest discomfort which may be described as a pressure or heaviness beneath the breastbone (sternum) with associated neck, jaw or arm discomfort. The pattern varies from patient to patient and may have associated symptoms of sweating, shortness of breath, or nausea. This group of symptoms is referred to as angina. Angina is commonly brought on by physical work, mental work or stress, but may come on at rest or even while sleeping at night. Angina may be improved with the use of NTG (nitroglycerine), which helps the heart cope with these partial blockages.

If the blood supply to the blockage is not corrected rapidly, you may develop a "heart attack" (myocardial infarction). The area of the, heart muscle not receiving the blood supply will become scar tissue and will lose its ability to pump.

If your cardiologist or primary care physician has found coronary artery blockages during your catheterization, they have recommended coronary artery bypass surgery to protect your heart muscle from these threatening blockages.


What is coronary artery disease?



Heart Attack - What Causes It?

There are two main causes of clogged coronary arteries:

Coronary Artery Disease: also referred to as atherosclerosis, is a gradual process in which fatty layers (plaque) build up on the inside of the arterial walls. As the plaque continues to build up and the artery narrows, there is less room for adequate blood flow.

Coronary Thrombosis: is a blood clot that lodges inside a coronary artery and prevents the flow of blood.

Angina vs. Heart Attack

Angina (chest pain) is not a heart attack, but may be a warning of an impending heart attack. Angina also occurs when the heart muscle is not receiving enough oxygen. With angina, however, no permanent damage is done to the heart muscle. Angina is most commonly experienced with an activity such as shoveling snow, walking upstairs or uphill, consuming a large meal, or a stressful event.

The symptoms of angina are similar to those of a heart attack.

They are most commonly described as squeezing, burning, tightness, fullness, or pressure across the

chest. This discomfort may radiate to the shoulder, arms (especially the left), neck, jaw, teeth, earlobes,

as well as the upper back between the shoulder blades. Numbness or tingling in the arms or hands may

occur. Angina can be mistaken for indigestion. Unlike a heart attack, angina may be relieved by rest and/

or nitroglycerin within 15 minutes.

How is a Heart Attack Diagnosed?

Your physician has several tests at his/her disposal when determining whether or not you have had a heart attack.

  1. Medical History and Physician Exam
    Your physician will need to obtain your medical history and perform a complete physical examination. There will be questions asked regarding your present state of health, including specific symptoms you are experiencing. Questions concerning your lifestyle also need to be answered, i.e. dietary habits, exercise routine, stress, smoking history, alcohol consumption, and medications. It is important for your physician to know your family's medical history as well.

  2. 12 Lead Electrocardiogram (EKG)
    An electrocardiogram records the electrical activity of your heart. A series of EKGs are taken during your hospitalization to observe the gradual changes which are indicative of a heart attack.

  3. Blood Tests
    Cardiac enzymes are normally stored in the cells of the heart muscle. When the heart is injured, cardiac enzymes are released into the blood stream. A series of blood tests are drawn in order to observe changes of each specific enzyme.

Test & Procedures

Thromblytic Therapy: In thrombolytic therapy, medication is given intravenously to dissolve the blood clot causing the heart attack. Once the blood clot is dissolved, blood flow can be restored to the affected area of the heart. Activase (t-PA) or Streptokinase are the most common medications used for dissolving a blood clot.

Cardiac Catheterization (coronary angiography): A cardiac catheterization is an invasive procedure performed in a special lab under a local anesthetic and sterile conditions. A catheter is introduced into the heart via an artery and/or vein located in the groin or arm. Dye is injected through the catheter into the coronary arteries and/or heart's chambers, while an x-ray is taken and recorded on film. This procedure allows the physician to visualize the coronary arteries, as well as the function of the heart and its valves.

Echocardiogram: An echocardiogram is a non-invasive procedure using ultrasound waves to visualize the structures of the heart on the screen with the use of a probe. The hand-held probe is moved across the chest to visualize the movements of the heart's valves and chambers.

Transesophageal Echocardiogram: A transesophageal echocardiogram is the same as a standard echocardiogram, except a miniaturized transducer (the probe) is passed down the esophagus by means of a flexible scope to visualize the heart.

Graded Exercise Stress Test: A graded exercise stress test involves exercising on a treadmill or bike at increased degrees of difficulty while the heart's response is recorded on an electrocardiogram (EKG). The level of exercise tolerance is measured by changes on the EKG, reported symptoms, as well as blood pressure and heart rate response. It also allows the physician to evaluate the effectiveness of your medical treatment. Patients recovering from a heart attack are usually given a low level exercise stress test prior to discharge.

Thallium Stress Test: A thallium stress test may be done at rest, or follow the same procedure as a graded exercise test, with an intravenous injection of a low dose of radioactive material at peak exercise. This is immediately followed by a scan of the heart to visualize areas of the heart that do not receive sufficient blood supply. A comparative scan will be done four hours later to note any changes at rest.

MUGA Scan: A MUGA scan uses low dose radioactive material given intravenously to visualize the heart's pumping action (ejection fraction).

Persantine Stress Test: A persantine stress test is similar to the graded exercise stress test except that a medication called persantine is used to elevate the heart rate instead of exercise.

Stress Echocardiogram: A stress echocardiogram is similar to a graded exercise stress test, except that an echocardiogram is performed prior to the stress test and immediately following the stress test. A stress echocardiogram allows the physician to visualize changes in the pumping action of the heart between rest and exercise.

24 Hour Holter Monitor: With a 24 hour Holter monitor, electrodes are placed on the chest wall and connected to a small tape recorder which records the heart rhythm for a 24 hour period. The patient resumes his/her normal lifestyle while being monitored. The patient maintains a log of activity and symptoms over the same time period. The physician then correlates the activities and symptoms to any changes in the heart rhythm.

Angioplasty (PTCA): An angioplasty is a procedure performed on patients with blocked or clogged coronary arteries. The technique is similar to a catheterization except that a special catheter with a small balloon is inserted into the blockage and inflated in order to compress the plaque and open the artery. A balloon catheter is advanced to the area of your blockage. The balloon is then inflated and deflated several times until the blockage is compressed and the artery is widened.

Directional Coronary Atherectomy (DCA): A directional coronary atherectomy is similar to an angioplasty except that the blockage is decreased by mechanically removing the plaque.

Stents: During an angioplasty, your physician may need to insert a wire coil tube (stent) into the coronary artery. This stent will remain permanently in place to keep the artery open.

Coronary Artery Bypass Surgery (CABG): A CABG is a surgical procedure that involves the removal of a portion of vein from the leg or the internal mammary artery (located in the chest) and using it to "bypass" the blockage(s) in the coronary artery

Heart Murmur - What is it?

Whether or not you've felt symptoms,  your doctor has probably heard your heart make a sound called a murmur. A murmur is usually present when you have a heart valve problem. To find out what kind of valve problem you have, your doctor may have ordered various tests, including an echocardiogram, an electrocardiogram, a chest x-ray, or cardiac catheterization. You may have taken medications to help treat your valve problem. If you have been referred to us, your doctor is recommending heart valve surgery. During this surgery, problem heart valves will either be repaired or replaced.

What are Heart Valves?

Your heart is a pumping muscle that works nonstop to keep your body supplied with oxygen rich blood. Four heart valves act like one-way doors to keep blood moving in one direction through the heart. Problems with one or more valves may mean that the heart has to work harder to get blood out to the body.

How Normal Heart Valves Work

The heart is divided into four chambers. The upper chambers are called atria and the lower chambers are called ventricles. The heart muscle squeezes blood from chamber to chamber. At each squeeze, the valves open to let blood through to the next chamber. 'Then the valves close to stop blood from moving backward. In this way, the valves keep blood moving as efficiently as possible through the heart and out to the body.

Heart Valve Problems

Valve disease occurs when a valve doesn't work the way it should. If a valve doesn't open all the way, less blood can move through the smaller opening. If a valve doesn't close tightly, blood may leak backward. These problems may mean the heart has to work harder to pump the same amount of blood. Or blood may back up in the lungs or body because it's not moving efficiently through the heart.

Problems Opening:  Stenosis occurs when a valve doesn't open completely. The valve may have become hardened or stiff with calcium deposits or scarring, so it's hard to push open. Blood has to flow through a smaller opening, so less blood gets through the valve into the next chamber.

Problems Closing:  Insufficiency (also called regurgitation) results when the valve doesn't close tightly. The valve's supportive structures may be loose or torn. Or the valve itself may have stretched or thinned. Blood then may leak back in the wrong direction through the valve.


What Causes Valve Disease?

Valve disease can have several causes. You may be born with a problem valve. Rheumatic fever or a bacterial infection can damage heart valves. Coronary artery disease (blocked blood vessels in the heart) can sometimes cause heart valve problems. Or your valves may simply wear out as you grow older.

Atrial Fibrillation

Atrial fibrillation (AF) is a type of tachycardia, or fast, irregular heart rhythm. AF affects about 2 million Americans. It is not usually life threatening. However, it can lead to stroke or heart muscle damage. People with AF are about five times more likely to have a stroke.

The heart beats between 300 and 600 times per minute during AF. The result is that the atria, or upper chambers of the heart, quiver and no longer pump efficiently. Some blood might stay in the atria with each heartbeat. The pooled blood can clot, increasing the risk of stroke.


High blood pressure, coronary artery disease, and other heart and lung conditions are associated with AF. Alcohol, stress, caffeine, severe infections, and some drugs may cause a normal heart to go into AF. Sometimes no underlying cause is found. The risk of AF seems to increase after age 60.


Symptoms of AF vary. Some people have palpitations, a sudden fluttering or pounding in the chest. Others feel dizzy, faint, or short of breath.


To diagnose atrial tachycardia, your doctor will typically use an electrocardiogram (ECG) test. This is a painless test using electrode patches on your skin. It shows how electrical signals travel through your heart and then prints them on paper. The printed pattern of your heartbeat indicates what kind of rhythm you have.

If you don't have AF constantly, your doctor may have you wear a small monitor over several days in an effort to record an AF episode. Your doctor will explain what type of testing is best for you.


To treat AF doctors may prescribe medications, a pacemaker, cardioversion, surgery, or a combination of these therapies. Generally, treatment involves helping control your heart rate and reducing the risk of blood clots.

Blood thinners such as aspirin or warfarin are commonly prescribed. Antiarrhythmic medications that help control episodes of rapid heart rhythms are also available. Most of the medications work some of the time but not all of the time. For that reason, your doctor may try other medications if you continue to experience symptoms or unwanted side effects.

In many AF patients medications cannot control the arrhythmia or may cause serious side effects. A surgical procedure called the MAZE or a catheter ablation is sometimes considered for these patients. We can help you with surgical MAZE procedure, including the new Endoscopic Micro-MAZE procedure.

Warning Signs - What Your Heart Is Telling You

Heart problems can take you by surprise. Suddenly, you're hunched over with chest pressure, pain, or even a heart attack. These are frightening symptoms of coronary artery disease (sometimes called atherosclerosis or hardening of the arteries). This disease means that your heart isn't getting enough blood. The good news is that surgery and basic lifestyle changes can give your heart another chance.

Warning Signs of Coronary Artery Disease

First you must be aware that most patients with heart disease usually do not have symptoms with ordinary activities until their disease is fairly advanced. When they first sense something is wrong, it may not be signaled by chest pain. In fact, many patients insist that they do not have pain. They experience a tightness, heaviness, or an uncomfortable feeling in their chest. Sometimes the discomfort will radiate to the neck, jaw, left shoulder, or down the inner side of the left arm and forearm.


You're probably familiar with angina, one of the most common symptoms of coronary artery disease. Angina is a feeling that can range from numbness or pressure to severe pain in your chest, arms, jaw, throat, or upper back. You might even confuse angina with heartburn. Sometimes you have no symptoms of coronary artery disease at all until you're struck by a heart attack. In any case, it's time to do something about your heart problem.

As the individual becomes familiar with the conditions which elicit these feelings, he subconsciously avoids the situations that bring them on. Consequently, when asked if he has any symptoms, the customary answer is "No." It is advisable not to wait until chest pain or discomfort becomes severe before you consult a physician concerning these symptoms.


Another set of symptoms associated with coronary artery disease may be caused by a condition called ischemia. Ischemia occurs when the narrowed coronary artery may reach a point where it cannot supply enough oxygen-rich blood to meet your heart's needs. Your heart muscle begins to become "starved" for oxygen. Symptoms associated ischemia include:

  1. shortness of breath - when doing normal daily activities or lying down flat in bed. You may need to sleep propped up on a few pillows to breathe easier

  2. palpitations - skipped beats or a flip-flop feeling in your chest

  3. weakness or dizziness - feels like passing out

  4. chest discomfort - a pain or pressure lasting a few seconds or for a few hours

  5. tachycardia - a faster heart beat at rest (over 100 beats/minute)

  6. dizziness

  7. nausea

  8. extreme weakness

Symptoms caused by a Ischemia is more likely to occur when the heart demands extra oxygen. These conditions known as the Four E's occur most commonly during Exertion (activity), Eating, Excitement and Exposure to cold. . However, coronary artery disease can progress to a point where ischemia occurs even while you rest. Ischemia may be present without any warning symptoms. This is called "silent ischemia."

Warning Signs of Heart Valve Disease

Your heart valves are doorways that open and close to let blood move between the chambers of your heart. Problems with your heart valves can mean that blood doesn't flow through your heart and to your body the way it should. This can keep you from feeling your best. Fortunately, valve surgery may help fix a heart valve problem so your heart can work better.

If you have heart valve trouble, you may experience one or more of the following:

  1. shortness of breath - when doing normal daily activities or lying down flat in bed. You may need to sleep propped up on a few pillows to breathe easier

  2. palpitations - skipped beats or a flip-flop feeling in your chest

  3. weakness or dizziness - feels like passing out

  4. quick weight gain - three pounds in one day is possible

  5. edema - swelling in your ankles, feet or abdomen

  6. chest discomfort - a pain or pressure lasting a few seconds or for a few hours

Symptoms can occur quickly if your valve disease is severe and comes on suddenly. If your disease develops slowly and your heart has time to adjust, you may barely notice your symptoms. The exception is mitral valve prolapse (MVP), where symptoms are common, but may not reflect the severity of your valve disease.