Coronary Artery Disease (CAD)

Issue

Vol. 1 No. 1 (2024)

Date Log

Submitted
May 23, 2024
Accepted
July 4, 2024
Published
July 20, 2024

Coronary Artery Disease (CAD) Demystified - Causes, Symptoms & Treatment

https://doi.org/10.69512/ajphi.v1i01.37
Bidhusi Pokharel, MD
University of Kansas Medical Center, Kansas City, KS, USA
Binaya Dhakal, MD
Nepalese Army Institute of Health Sciences-College of Medicine, Kathmandu, Nepal

Corresponding Author(s) : Bidhusi Pokharel, MD

pbidushi@gmail.com

The American Journal of Patient Health Info, Vol. 1 No. 1 (2024)

Abstract


  1. Coronary artery disease (CAD) stems from risk factors like high blood pressure, cholesterol, and smoking.

  2. Atherosclerosis, plaque buildup in arteries, restricts blood flow to the heart, causing symptoms such as chest pain.

  3. Diagnosis involves tests like ECGs and angiograms to evaluate blockages and heart function.

  4. Treatment focuses on symptom relief and risk reduction through lifestyle changes, medications, and procedures like stent placement or bypass surgery.

  5. CAD management requires ongoing medical care and lifestyle adjustments to improve heart health and prevent complications like heart attacks.

Keywords

Atherosclerosis Angina Angiogram Cardiac Catheterization Angioplasty
Pokharel, MD, B., & Dhakal, MD, B. (2024). Coronary Artery Disease (CAD) Demystified - Causes, Symptoms & Treatment. The American Journal of Patient Health Info, 1(1). https://doi.org/10.69512/ajphi.v1i01.37
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References
  1. Stark B, Johnson C, Roth GA. GLOBAL PREVALENCE OF CORONARY ARTERY DISEASE: AN UPDATE FROM THE GLOBAL BURDEN OF DISEASE STUDY. J Am Coll Cardiol 2024;83(13):2320
  2. Hafeez Y, Varghese V. Chronic Total Occlusion Of The Coronary Artery. PubMed. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560507/
  3. Gul Z, Makaryus AN. Silent Myocardial Ischemia. PubMed. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536915/
  4. Khera AV, Kathiresan S. Genetics of Coronary Artery disease: discovery, Biology and Clinical Translation. Nature Reviews Genetics. 2017 Mar 13;18(6):331–44. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5935119/
  5. Yilmaz A, Yalta K, Turgut OO, Yilmaz MB, Ozyol A, Kendirlioglu O, et al. Clinical importance of elevated CK-MB and troponin I levels in congestive heart failure. Advances in Therapy. 2006 Nov;23(6):1060–7.
  6. Adam. Coronary Artery Calcium (CAC) Test. www.heart.org. 2023. Available from: https://www.heart.org/en/health-topics/heart-attack/diagnosing-a-heart-attack/cac-test
  7. Holmes DR, Williams DO. Catheter-Based Treatment of Coronary Artery Disease. Circulation: Cardiovascular Interventions. 2008 Aug;1(1):60–73.
  8. Ghosh GC, Ghosh RK, Bandyopadhyay D, Chatterjee K, Aneja A. Ranolazine: Multifaceted Role beyond Coronary Artery Disease, a Recent Perspective. Heart Views : The Official Journal of the Gulf Heart Association. 2018 [cited 2022 Feb 12];19(3):88–98. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6448470/
  9. Malik I, Berger A. Coronary angioplasty and stenting. BMJ : British Medical Journal. 2002 Sep 7;325(7363):519. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC121332/
  10. Bachar BJ, Manna B. Coronary Artery Bypass Graft. PubMed. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507836/
  11. Dong Z, Zheng J. Anticoagulation after coronary stenting: a systemic review. British Medical Bulletin. 2017 Jul 1;123(1):79–89.
  12. Bush M, Kucharska-Newton A, Simpson RJ, Fang G, Stürmer T, Brookhart MA. Effect of Initiating Cardiac Rehabilitation After Myocardial Infarction on Subsequent Hospitalization in Older Adults. Journal of Cardiopulmonary Rehabilitation and Prevention. 2020 Mar;40(2):87–93.
  13. Sofi F, Macchi C, Abbate R, Gensini GF, Casini A. Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score. Public Health Nutr 2014;17(12):2769–82.
  14. Winzer EB, Woitek F, Linke A. Physical Activity in the Prevention and Treatment of Coronary Artery Disease. J Am Heart Assoc 2018;7(4).
  15. De Hert M, Detraux J, Vancampfort D. The intriguing relationship between coronary heart disease and mental disorders. Dialogues Clin Neurosci 2018;20(1):31–40.
  16. Gundugurti P, Bhattacharyya R, Koneru A. Management of psychiatric disorders in patients with cardiovascular diseases. Indian J Psychiatry 2022;64(8):355.
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Bidhusi Pokharela, Binaya Dhakalb

a University of Kansas Medical Center, Kansas City, KS, USA

b Nepalese Army Institute of Health Sciences-College of Medicine, Kathmandu, Nepal

Background

Coronary Artery Disease (CAD) is a prevalent and potentially life-threatening cardiovascular condition affecting millions worldwide. About 315 million people suffer from coronary artery disease globally, with the highest prevalence seen in Central Europe, Eastern Europe, and Central Asia. 1It is the leading cause of heart-related morbidity and mortality in the US, imposing a significant burden on public health systems and individuals alike. CAD develops when the coronary arteries, the blood vessels responsible for supplying oxygen and nutrients to the heart muscle, become narrowed or blocked due to atherosclerosis, characterized by the accumulation of fatty deposits and plaque on the arterial walls.

Forms of Coronary Artery Disease

CAD can present in various forms, each with distinct characteristics and implications for heart health. It is essential to recognize and diagnose each individual's specific form of CAD, as treatment strategies and management approaches may vary. The different forms of CAD include:

Figure 1.

  • Stable Angina: Stable angina is the most common form of CAD. It occurs when there is a partial blockage or narrowing of the coronary arteries, leading to chest pain or discomfort during physical exertion or emotional stress. The pain is predictable and tends to subside with rest or medication.
  • Unstable Angina: Unstable angina is a more severe and unpredictable form of CAD. It happens when a plaque in the coronary artery ruptures, causing a sudden and severe reduction in blood flow. Unstable angina can occur at rest or with minimal exertion and requires immediate medical attention, as it may lead to a heart attack.
  • Acute Myocardial Infarction (Heart Attack): A heart attack occurs when a coronary artery becomes completely blocked by a blood clot, cutting off blood flow to a portion of the heart muscle. This leads to the death of heart tissue. Heart attacks are medical emergencies that require urgent treatment to restore blood flow and prevent further damage.
  • Chronic Total Occlusion (CTO): CTO refers to a complete blockage of a coronary artery that persists for an extended period, often over three months. People with CTO may experience chronic chest pain, reduced exercise tolerance, and, in severe cases, heart failure. 2
  • Silent Ischemia: Some individuals with CAD may not experience typical symptoms like chest pain or discomfort. Instead, they may have "silent ischemia," where the heart muscle does not receive enough blood and oxygen without noticeable symptoms. Most common in patients with other comorbidities like diabetes. 3

Risk factors of coronary artery disease

Figure 2.

1. Non-Modifiable Risk Factors

  • Age and Gender: The risk of coronary artery disease increases with age, and men are generally at higher risk than premenopausal women. However, the risk for women increases after menopause, equalizing with that of men by around age 65.
  • Genetic Predisposition: Individuals with a family history of coronary artery disease are at increased risk, as genetic factors can predispose them to develop the condition. 4

2. Modifiable Risk Factors

  • High Blood Pressure (Hypertension): Elevated blood pressure puts strain on the arteries, increasing the risk of damage and atherosclerosis.
  • High Cholesterol Levels: Elevated  LDL cholesterol ("bad cholesterol") can lead to plaque buildup in the arteries, narrowing them and reducing blood flow to the heart.
  • Smoking: Tobacco smoke contains chemicals that damage blood vessels and accelerate the development of atherosclerosis.
  • Diabetes: Individuals with diabetes are at increased risk of developing coronary artery disease due to factors such as insulin resistance and inflammation.
  • Obesity: Excess body weight, particularly around the waist, is associated with high blood pressure, high cholesterol levels, and diabetes, all of which increase the risk of coronary artery disease.
  • Physical Inactivity: Lack of regular exercise contributes to obesity, high blood pressure, and abnormal cholesterol levels, all risk factors for coronary artery disease.
  • Unhealthy Diet: Diets high in saturated and trans fats, cholesterol, sodium, and refined sugars increase the risk of coronary artery disease by promoting atherosclerosis and contributing to obesity and other risk factors.
  • Stress: Chronic stress can contribute to high blood pressure, unhealthy coping behaviors like overeating or smoking, and overall cardiovascular risk.

Clinical Presentation of Coronary Artery Disease

The symptoms of CAD may not be immediately apparent, as it is a chronic condition that progresses slowly over many years, possibly even decades. However, as the arteries narrow due to plaque accumulation, mild symptoms may emerge, indicating that the heart is working harder to supply oxygen-rich blood to the body. Common symptoms of chronic CAD include:

Figure 3.

  • Chest Discomfort: One of the most common and characteristic symptoms of CAD is chest discomfort, often described as a feeling of pressure, tightness, squeezing, or heaviness in the chest. This discomfort may be mistaken for indigestion or heartburn, but it typically occurs during physical exertion or emotional stress and eases with rest. Such kind of pain is seen with stable angina. It is essential not to ignore persistent or recurrent chest discomfort that does not go away with rest or nitroglycerine then, it might be more severe conditions like unstable angina or myocardial infarction.
  • Shortness of Breath: People with CAD may experience shortness of breath, especially during activities that once seemed effortless. As the coronary arteries become narrowed, the heart may struggle to pump blood efficiently, leading to reduced oxygen supply to the body. Shortness of breath can occur even during mild physical exertion or at rest in more advanced stages of the disease.
  • Fatigue: Persistent fatigue is another common symptom of CAD. As the heart's blood supply diminishes, the heart muscle may not receive enough oxygen, leading to a feeling of constant tiredness and reduced stamina. Fatigue may be particularly pronounced after physical activity or during stressful situations.
  • Unexplained Pain in Other Areas: In some cases, the pain or discomfort associated with CAD may radiate to other body parts. Pain may be felt in the arms (usually the left arm), shoulders, neck, jaw, or back. This referred pain can vary in intensity and may come and go, making it important to recognize these unusual symptoms.
  • Dizziness and Lightheadedness: Insufficient blood flow to the brain due to narrowed coronary arteries can cause dizziness or lightheadedness. People with CAD may experience fainting spells or suddenly feel dizzy when standing up.
  • Palpitations: CAD can disrupt the heart's rhythm, leading to palpitations or a sensation of irregular heartbeats.

Diagnosis of Coronary Artery Disease

Tests play a crucial role in diagnosing CAD and evaluating heart function. Besides a thorough medical assessment, your healthcare provider may recommend the following tests to aid the diagnosis:

Figure 4.

  • Electrocardiogram (EKG/ECG): By recording your heart's electrical activity, an EKG/ECG can detect previous or current heart attacks, ischemia (reduced blood flow to the heart), and irregular heart rhythms that might be associated with CAD.
  • Blood Tests: These tests analyze specific substances in your blood that may indicate artery damage or an increased risk of developing CAD. Elevated levels of specific biomarkers like Troponin and CK-MB are used as parameters for assessment. 5
  • Echocardiogram: Utilizing sound waves, an echocardiogram evaluates the structure and function of your heart. It provides valuable information about heart chamber sizes, pumping capacity, and any abnormalities in heart valves, contributing to diagnosing CAD.
  • Stress Test: This test assesses how your heart responds to physical exertion. It helps detect angina (chest pain) and can identify potential blockages in the coronary arteries by monitoring the heart's performance during exercise.
  • Cardiac Catheterization: Considered the gold standard for diagnosing CAD, this procedure involves inserting thin tubes (catheters) into the coronary arteries to evaluate their condition. It can confirm the presence and severity of blockages, guiding further treatment decisions.
  • Computed Tomography Coronary Angiogram: Using advanced imaging technology and contrast dye, a CT coronary angiogram generates detailed 3D images of your heart's movement. This non-invasive test allows the detection of blockages in the coronary arteries, aiding in CAD diagnosis.
  • Coronary Calcium Scan: This test measures the amount of calcium in your coronary arteries' walls, indicating atherosclerosis. The CT machine takes detailed heart images during the scan, focusing on the coronary arteries. The presence and quantity of calcium deposits in the arterial walls are measured and scored using a numerical scale called the Agatston score. Though it does not directly determine significant blockages, it helps assess your risk for developing CAD. 6

Cardiac Catheterization Explained

Coronary catheterization, also known as cardiac catheterization or coronary angiography, is a widely used and minimally invasive medical procedure that plays a crucial role in assessing the condition of the coronary arteries—the blood vessels responsible for supplying oxygen-rich blood to the heart muscle.

During this diagnostic test, a skilled medical team performs the procedure in a specialized area called the catheterization laboratory or "cath lab." The patient is usually awake during the procedure, as it involves only local anesthesia to numb the catheter's insertion area.

To begin the process, a small incision is made in the wrist or groin area, where a thin, flexible tube called a catheter is carefully inserted into the blood vessels. The choice of insertion site depends on various factors, such as the patient's medical history and the preference of the medical team.

Once the catheter is in place, a special dye known as contrast is injected through the catheter and into the coronary arteries. This dye is visible on X-ray images, creating an "angiogram." As the contrast moves through the arteries, the medical team can visualize the blood flow and identify potential blockages, narrowings, or abnormalities in the coronary arteries. The X-ray images obtained during the procedure provide valuable information about the condition of the heart's blood vessels, helping doctors diagnose conditions such as CAD or other heart-related issues. 7

Treatment of Coronary Artery Disease

CAD is a chronic condition that requires comprehensive management to prevent progression and reduce the risk of complications. The treatment approach for CAD typically involves a combination of medications and, in some cases, surgical procedures followed by cardiac rehabilitation.

Figure 5.

1. Medications

  • Antiplatelet Drugs: Medications like aspirin and clopidogrel help prevent blood clots from forming by inhibiting platelet aggregation. They are often prescribed to individuals with CAD or those who have undergone coronary stent placement.
  • Cholesterol-Lowering Drugs: Statins are the most commonly prescribed medications to lower LDL cholesterol levels, reducing the risk of plaque buildup in the arteries. Other lipid-lowering drugs, such as ezetimibe or PCSK9 inhibitors, may also be used with statins.
  • Beta-blockers: These drugs help reduce the heart's workload by slowing the heart rate and reducing blood pressure. They can also alleviate angina symptoms and improve heart function. These drugs help prevent changes in the heart muscle, which is called remodeling.
  • Angiotensin-converting enzyme (ACE) Inhibitors and Angiotensin II Receptor Blockers (ARBs): These medications lower blood pressure and reduce strain on the heart. They are often prescribed to individuals with CAD and heart failure.
  • Nitroglycerin: Nitroglycerin relieves angina symptoms by relaxing and dilating the coronary arteries, increasing blood flow to the heart.
  • Calcium Channel Blockers: These medications help widen blood vessels, improve blood flow, and reduce blood pressure. They are sometimes prescribed as an alternative to beta-blockers for angina management.
  • Antianginal Medications: Ranolazine is a newer antianginal drug that can manage chronic angina when other medications are insufficient. 8

2. Surgical Procedures

  • Angioplasty and Stent Placement: Percutaneous Coronary Intervention (PCI) involves inserting a catheter with a balloon at the tip into the narrowed coronary artery. The balloon is inflated to widen the artery, and a stent (a mesh-like tube) is placed to keep the artery open and improve blood flow. 9
  • Coronary Artery Bypass Grafting (CABG): In this surgical procedure, a healthy blood vessel from another body is grafted to the blocked coronary artery, bypassing the blocked segment and restoring blood flow to the heart muscle. 10
  • Enhanced External Counterpulsation (EECP): EECP is a non-invasive treatment option for individuals with refractory angina. It involves applying external pressure cuffs to the legs to improve blood flow to the heart.
  • Transmyocardial Laser Revascularization (TMR): This procedure involves using a laser to create tiny channels in the heart muscle to improve blood flow to areas with reduced blood supply.

Importance of Blood Thinners After Angioplasty

The importance of blood thinners after angioplasty cannot be overstated. These medications play a vital role in preventing complications and ensuring the success of the procedure. The procedure can damage the inner layer of the blood vessel, leading to the formation of blood clots. Blood thinners, also known as antiplatelet medications, such as Aspirin, Plavix, or Brilinta, are prescribed after angioplasty to prevent these clots from forming. Your cardiologist will recommend dual antiplatelet therapy like Aspirin and Plavix or Aspirin and Brilinta after angioplasty for at least one year. By inhibiting platelet aggregation and reducing the risk of clot formation, blood thinners help maintain the newly opened artery's patency and reduce the chance of restenosis (re-narrowing) at the stent site. Additionally, these medications lower the risk of heart attacks and other cardiovascular events, providing essential protection to individuals who have undergone angioplasty and contributing to improved heart health and overall well-being. 11

Cardiac Rehabilitation

Cardiac rehabilitation is a medically supervised program aimed at improving cardiovascular health for individuals who have undergone heart attack, heart failure, angioplasty, or heart surgery. It involves a collaborative effort, with doctors, nurses, pharmacists, family, and friends working together to manage lifestyle choices and habits affecting the heart. The program encompasses three essential components: exercise counseling and training to promote heart health through physical activity, education on heart-healthy living to manage risk factors and make nutritious choices, and counseling to address and reduce stress, which impacts heart health.

To get started, individuals must consult their doctor for eligibility, register for a cardiac rehabilitation program, set heart health goals with the medical team, and actively participate in their care to achieve the objectives. Consistent adherence to medication and promptly seeking medical attention for any new or worsening symptoms are also emphasized for a successful cardiac rehabilitation journey. 12

Prevention of Coronary Artery Disease

Preventing CAD is not always under our control, as some risk factors are beyond our influence. However, we can take numerous proactive steps to lower our risk and manage the condition effectively if diagnosed. To reduce the risk of CAD and slow its progression, consider the following strategies:

Figure 6.

  • Quit Smoking and Tobacco Use: Connect with resources and support groups to aid in the challenging process of quitting smoking. Seek recommendations from healthcare providers for assistance in your community.
  • Adopt a Heart-Healthy Diet: Avoid foods high in saturated and trans fats, sodium, and sugar. Go for whole grains over refined carbohydrates and learn about nutrition's impact on cholesterol levels. Adopting a Mediterranean diet, rich in fruits, vegetables, whole grains, and healthy fats, has reduced the risk of CAD by up to 30%. 13
  • Prioritize Quality Sleep: Strive for seven to nine hours of restful sleep per night. Discuss strategies with healthcare providers to ensure adequate sleep to support heart health.
  • Maintain a Healthy Weight: Work with healthcare providers to determine your ideal weight and set achievable goals. Avoid extreme diets and focus on lifestyle changes for long-term success.
  • Assess Heart Disease Risk: Starting around age 20, undergo regular risk screenings with healthcare providers. These screenings include blood pressure and BMI measurements, and risk calculators may be used to predict future heart disease risk.
  • Limit Alcohol Consumption: Be mindful of alcohol intake, aiming for no more than two drinks per day for men and people assigned male at birth (AMAB) and one drink per day for women and people assigned female at birth (AFAB).
  • Engage in Regular Exercise: Aim for 150 minutes of planned and intentional weekly exercise, such as 30 minutes, five days a week. Incorporate additional movement throughout the day, like parking farther away or walking around the house during daily activities. 14
  • Adhere to Prescribed Medications: Take medications as healthcare providers recommend to reduce CAD risk and prevent heart attacks if diagnosed. Understand their benefits and how they contribute to prolonging life.

Mental Health and Coronary Artery Disease

Mental health support is a critical component of comprehensive care for individuals with CAD, as the psychological impact of CAD can significantly affect patient outcomes and quality of life. Anxiety and depression are common among CAD patients, with many experiencing major depressive disorder or persistent anxiety due to the fear of recurrence and lifestyle changes.15 Effective mental health interventions, such as cognitive-behavioral therapy (CBT), support groups, mindfulness techniques, and pharmacotherapy, can improve adherence to treatment regimens, enhance emotional well-being, and reduce the risk of subsequent cardiac events. Healthcare providers play a crucial role in screening for psychological issues, educating patients about the mental health disease link, and involving family members in the care process. Integrated care models that combine mental health services with primary and cardiology care can ensure that psychological needs are addressed as part of routine cardiac care, leading to better-coordinated and continuous support. Despite challenges such as stigma and accessibility, providing individualized mental health support is essential for the holistic treatment and recovery of CAD patients, ultimately improving both clinical outcomes and overall well-being. 16

Questions To Ask Your Doctor

  1. How often should I have follow-up appointments?
  2. How can I make lifestyle changes to improve my condition and overall health?
  3. How do I know that chest pain is due to coronary artery disease, and what would be my first step?
  4. How does this condition affect my daily life or work?
  5. Are there any clinical trials or new treatment options?

References

  1. Stark B, Johnson C, Roth GA. GLOBAL PREVALENCE OF CORONARY ARTERY DISEASE: AN UPDATE FROM THE GLOBAL BURDEN OF DISEASE STUDY. J Am Coll Cardiol 2024;83(13):2320. Available from: https://pubmed.ncbi.nlm.nih.gov/33309175/
  2. Hafeez Y, Varghese V. Chronic Total Occlusion Of The Coronary Artery. PubMed. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560507/
  3. Gul Z, Makaryus AN. Silent Myocardial Ischemia. PubMed. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536915/
  4. Khera AV, Kathiresan S. Genetics of Coronary Artery disease: discovery, Biology and Clinical Translation. Nature Reviews Genetics. 2017 Mar 13;18(6):331–44. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5935119/
  5. Yilmaz A, Yalta K, Turgut OO, Yilmaz MB, Ozyol A, Kendirlioglu O, et al. Clinical importance of elevated CK-MB and troponin I levels in congestive heart failure. Advances in Therapy. 2006 Nov;23(6):1060–7. Available from: https://pubmed.ncbi.nlm.nih.gov/17276973/
  6. Adam. Coronary Artery Calcium (CAC) Test. www.heart.org. 2023. Available from: https://www.heart.org/en/health-topics/heart-attack/diagnosing-a-heart-attack/cac-test
  7. Holmes DR, Williams DO. Catheter-Based Treatment of Coronary Artery Disease. Circulation: Cardiovascular Interventions. 2008 Aug;1(1):60–73. Available from: https://pubmed.ncbi.nlm.nih.gov/20031656/
  8. Ghosh GC, Ghosh RK, Bandyopadhyay D, Chatterjee K, Aneja A. Ranolazine: Multifaceted Role beyond Coronary Artery Disease, a Recent Perspective. Heart Views : The Official Journal of the Gulf Heart Association. 2018 [cited 2022 Feb 12];19(3):88–98. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6448470/
  9. Malik I, Berger A. Coronary angioplasty and stenting. BMJ : British Medical Journal. 2002 Sep 7;325(7363):519. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC121332/
  10. Bachar BJ, Manna B. Coronary Artery Bypass Graft. PubMed. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507836/
  11. Dong Z, Zheng J. Anticoagulation after coronary stenting: a systemic review. British Medical Bulletin. 2017 Jul 1;123(1):79–89. Available from: https://pubmed.ncbi.nlm.nih.gov/28910988/
  12. Bush M, Kucharska-Newton A, Simpson RJ, Fang G, Stürmer T, Brookhart MA. Effect of Initiating Cardiac Rehabilitation After Myocardial Infarction on Subsequent Hospitalization in Older Adults. Journal of Cardiopulmonary Rehabilitation and Prevention. 2020 Mar;40(2):87–93. Available from: https://pubmed.ncbi.nlm.nih.gov/31592930/
  13. Sofi F, Macchi C, Abbate R, Gensini GF, Casini A. Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score. Public Health Nutr 2014;17(12):2769–82. Available from: https://pubmed.ncbi.nlm.nih.gov/24476641/
  14. Winzer EB, Woitek F, Linke A. Physical Activity in the Prevention and Treatment of Coronary Artery Disease. J Am Heart Assoc 2018;7(4). Available from: https://pubmed.ncbi.nlm.nih.gov/29437600/
  15. De Hert M, Detraux J, Vancampfort D. The intriguing relationship between coronary heart disease and mental disorders. Dialogues Clin Neurosci 2018;20(1):31–40.
  16. Gundugurti P, Bhattacharyya R, Koneru A. Management of psychiatric disorders in patients with cardiovascular diseases. Indian J Psychiatry 2022;64(8):355.