CORONARY ARTERY DISEASE
A Roadmap for Patients with
C
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A
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
TABLE OF CONTENTS
Your Stress Test Results 3
Your Healthcare Journey 6
What You Can Expect 5
Low Risk 7
High Risk 9
Intermediate Risk 8
Types of Stress Test Results
Reducing Your Risk of Heart Attack 10
Myths vs. Facts 11
What is Your Approach? 12
Glossary of Terms
Medical Therapy and Angiogram 14
Stents and Bypass Surgery 15
Summary 13
#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
So, you had an
abnormal stress test...
!
A positive stress test does not necessarily mean you have
Coronary Artery Disease (CAD). Receiving this document is
not a diagnosis. You and your doctor will discuss what this
test result means for you.
This roadmap is not meant for patients who are having a
heart attack. If you think you are having a heart attack,
seek immediate medical attention.
What does this mean?
What will happen next?
What are my options?
What does this mean for my long-term health?
You probably have some questions:
The purpose of this booklet is to answer these questions and to
support you on your healthcare journey.
We call this booklet a ”Roadmap” because it will tell you what to
expect in the coming weeks, months and years. There are different
paths that you can take and decisions where you can participate!
This roadmap is not meant to replace conversations with your doctor.
It is meant to provide more information to help you talk to your
doctor and ask questions about your care options.
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
WHAT DOES AN ABNORMAL
STRESS TEST MEAN?
An abnormal stress test
result means that you may
have coronary artery disease
(CAD). CAD is the narrowing
or blockage of the arteries
that carry blood to the heart.
CAD is a chronic, but
treatable disease.
What are the symptoms of CAD?
Common symptoms include chest pain (angina) that worsens with exercise
and improves with rest, shortness of breath, and fatigue. Some people with
CAD do not have any symptoms at all.
Does this mean I’m at high risk of dying?
Not necessarily. CAD is a chronic but treatable disease. Lots of people
with CAD live a long time with the right treatments.
Does this mean I’m going to have a heart attack?
Not necessarily. People with CAD usually have a higher risk of heart attacks
than people without CAD. However, with the right treatment, people with
CAD may never experience a heart attack.
Does a positive stress test mean I definitely have CAD?
Not necessarily. Follow-up testing may show that you do not have CAD.
Now that I have had an abnormal stress test, what will happen next?
Continue reading this roadmap to learn more…
WHAT CAN YOU EXPECT IN THE
NEXT COUPLE OF WEEKS?
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
The immediate next step is to make an appointment with your doctor.
Your doctor will interpret your test result and determine if your results are
low, intermediate, or high risk, or if your results are unclear.
LOW-RISK RESULT
This means that you have a lower chance of major
complications—such as a heart attack or death—from
a blockage. Your doctor will probably recommend medications
and lifestyle changes.
!
INTERMEDIATE-RISK RESULT
This means that you have a medium chance of major
complications—such as a heart attack or death—from
a blockage. You and your doctor will decide whether more
intensive or less intensive treatment is best for you
!
HIGH-RISK RESULT
This means that you have a higher chance of major
complications—such as heart attack or death—from a blockage.
Your doctor will probably recommend more intensive treatment in
addition to discussing medications and lifestyle changes.
!
UNCLEAR RESULT
It is possible that your test result will be unclear.
If this happens you may receive more tests, and potentially
another type of stress test.
Stents
No Stent
or Surgery
Bypass
Surgery
!
Low Risk
Go to page 6
Intermediate Risk
Go to page 7
! !
High Risk
Go to page 8
Exit
No CAD
(False positive
stress test)
Abnormal stress test result
START
Medical Therapy &
Lifestyle Changes
Angiogram
Test
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
YOUR
HEALTHCARE
JOURNEY
In the next weeks,
months and years, you
may find yourself on
different points on
this map. All patients
end up at the same
place, which is long-term
management of CAD
with medications and
lifestyle changes like
diet and exercise.
!
Medications and lifestyle changes
are your main treatment: They will
reduce your chance of a heart attack
and to help you live a long life!
!
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
A low-risk stress test result means that
you take the path to medical therapy.
The main way to treat low risk Coronary Artery Disease (CAD) is
with lifelong medications. These medications will help you in two ways:
1. Reduce your chance of a heart attack
2. Reduce your symptoms such as chest pain
Your healthcare plan down the road:
Another important way to treat
your CAD is with diet and
exercise. Diet and exercise will
also help reduce your chance
of a heart attack and reduce
your symptoms.
You will meet with your doctor regularly to discuss your
symptoms and medications. These conversations can be
driven by you, and how you feel about your symptoms.
If your symptoms are negatively affecting your daily life, then
you and your doctor can consider more intensive treatment
paths, like getting an angiogram and possibly a stent.
LOW-RISK
How will you know what path to choose?
Which path will you take?
You and your doctor will discuss what is the best path for you,
based on your preferences and your doctor’s recommendations.
Do you want to take the
less intensive path and try
just medicines and lifestyle
changes first? Or do you want
to take the more intensive
treatment path and get a test
to look for blockages?
An intermediate risk stress test result
means that you have a choice.
!
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
INTERMEDIATE-RISK
Low
Intensity
Take the less
intensive
path, and try
medicines
first
High
Intensity
Take the more
intensive path,
and get an
angiogram test
and possibly
a stent
High Intensity Path
• You don’t mind
getting more
intensive testing or
treatment, like an
angiogram or stents,
even if these
treatments might
not help more than
medications.
Low Intensity Path
• You want to avoid
tests and treatments
that are invasive or
burdensome.
• Since medications
are proven to help with
symptoms and reduce
your chance of a heart
attack, you’re okay
with taking
medications and not
doing more.
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
A high-risk stress test result means that
you will probably take the path
to an angiogram.
HIGH-RISK
How will you know
what path to choose?
Your doctor will probably
want to look for blockages
inside your heart (coronary)
arteries using an angiogram.
What is an angiogram?
An angiogram is a test where doctors
can see exactly where blockages
are in the heart arteries.
A long flexible tube is inserted through
the blood stream to deliver dye into
the arteries making them visible on
the x-ray.
What happens if the angiogram
shows I have blockages?
Depending on the extent of the
blockages, your doctor may recommend
trying medications only, give you
a stent or recommend bypass surgery.
To learn more about stents and
bypass surgery, turn to the Glossary.
What happens if the angiogram
shows I don’t have any
blockages?
If this happens it is good news!
This means that you will be treated
with medications, which will reduce
your chance of a heart attack and help
with your symptoms.
Angiogram
Test
Stents
No Stent
or Surgery
Bypass
Surgery
!
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
ALL ROADS LEAD TO
THE SAME PLACE:
MEDICATIONS AND
LIFESTYLE CHANGES
These 4 things are the
BEST
way to reduce
your risk of a future heart attack:
TAKE
MEDICATIONS
1
Medications to lower cholesterol
are very effective at preventing heart
attacks. Statins and PCSK9 inhibitors
are commonly-prescribed
cholesterol-lowering medications.
Blood thinners like as
pirin help prevent
clots in the arteries in your heart.
If you have diabetes or high blood
pressure, getting these under control
with medications is very important too.
QUIT
SMOKING
3
Smoking greatly increases your
risk of having a heart attack.
The good news is if you quit smoking
your risk quickly becomes the same
as people who have NEVER smoked!
Medications and counseling are
both effective in helping you to stop
smoking. Talk to your doctor to
determine the best way for you to
stop smoking.
GET
MOVING
2
Any activity is benecial.
You can get the most benefit from
activities that make you breathe faster
and your heart beat faster than normal.
For example, brisk walking, jogging,
dancing, tennis, and biking. Moderate
exercise 30 minutes per day, 5 days
per week is optimal. Discuss with your
doctor what level of activity is safe
for you.
EAT A HEART-
HEALTHY DIET
4
A healthy diet, along with exercise
and medications, can help.
General principles of a heart healthy
diet include eating more fruits and
vegetables and selecting whole
grain foods.
For information on a heart healthy diet
and recipes, see
https://www.heart.org/en/healthy-
living/healthy-eating/eatsmart/
nutrition-basics
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
TREATMENT
MYTHS VS. FACTS
1. Can CAD be cured?
Unfortunately, there is no “cure” for CAD.
CAD is a chronic condition. Build up of plaque will continue to narrow your
coronary arteries and no treatment will make this go away completely.
Medications and lifestyle changes are the main way to treat CAD and lower
your risk of a heart attack. You may also need more intensive treatment like a
stent or bypass surgery at some points in the journey.
With these treatments, people with CAD can live long lives.
2. Do stents reduce the chance of a heart attack?
It depends.
Stents are mainly done for symptom relief. Stenting smaller arteries will
NOT reduce your chance of a future heart attack and may be used as a last
resort for trying to help with your symptoms if medications are not working.
If your chest pain symptoms are well controlled with medications, you may
not benefit from stent.
Sometimes when there are blockages in larger, more central arteries, stents
are thought to reduce the chance of a heart attack. This is different from
stenting smaller arteries.
3. If I have a stent or bypass surgery, can I stop
taking medicines?
You will need to continue taking life long medications.
Medications are the best way to reduce your risk of having a future heart
attack. You may be able to stop taking the medicines that treat your
symptoms if your CAD symptoms improve. However, you should
continue to take medicines that reduce your risk of a heart attack.
On your care journey you may have a choice to get more invasive, high-intensity
treatments, like stents. Some people have a preference to get high-intensity
treatments, whereas other people prefer to avoid them when possible.
What do you prefer?
Do you prefer high or low intensity health care?
YOUR VALUES:
WHAT IS YOUR APPROACH?
• You don’t mind treatments
that are aggressive, invasive,
or burdensome.
• You tend to maximize tests
and procedures, especially if
benefits are uncertain.
• Your focus is “get that taken
care of” and ”I want to know”.
High IntensityLow Intensity
• You want to avoid treatments
that are aggressive, invasive,
or burdensome.
• You tend to minimize tests
and procedures, especially if
benefits are uncertain.
• Your focus is “less is more”
and ”I don’t need to know”.
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
QUESTIONS TO ASK YOUR DOCTOR
AT EACH VISIT
3
• What are the possible benets and harms of this treatment?
• How likely are those benets and harms to happen to me?
• What will happen if I do not do this treatment?
I lean toward
low intensity
treatments
I lean towards
high intensity
treatments
Neutral:
I lean toward neither
high nor low intensity
treatment approach
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
We hope that this booklet
helped to answer some of your
questions about your abnormal stress test result. You
can refer back to this booklet throughout your healthcare
journey, and use this information to help you talk to your
doctor and ask questions about your care options.
Remember:
Medications and lifestyle changes are your main
treatment: They will reduce your chance of a heart attack
and help you to live a long life!
MEDICAL THERAPY
Glossary of Terms
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
What kind of medication will I take?
There are two types of medications:
• Medications such as blood thinners (such
as aspirin), and cholesterol lowering
medications (such as statins) can help
reduce your risk of having a heart attack.
• Other medications such as beta
blockers and nitroglycerin are
prescribed to help manage symptoms.
The medication your doctor prescribes will
depend on your specific situation.
How long will I need to take medications?
Patients with CAD will usually need lifelong medical therapy.
What is medical therapy for Coronary Artery Disease?
The goals of medical therapy for CAD are to reduce your risk of dying from
CAD and from having a heart attack, and to manage your symptoms.
What is an angiogram?
An angiogram is a procedure where doctors can see exactly where blockages
are in the heart arteries. A long flexible tube (a catheter) is inserted through the
blood stream and to the heart, to deliver dye into the arteries making them visible
on the x-ray. The catheter might be started in an artery in the groin or wrist.
What happens if my doctor finds blockages?
If there are extensive blockages your doctor will probably recommend
bypass surgery. If there are less extensive blockages then your doctor
may put in one or more stents during the angiogram procedure.
ANGIOGRAM
STENT
BYPASS SURGERY
Glossary of Terms
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#20-2030 PI: Vinay Kini (v.2: 10-21-2020)
What is bypass surgery?
Bypass surgery is open heart surgery.
A healthy artery or vein from a different part of
your body will be used to bypass the blocked
artery, allowing blood to flow better. If your
doctor is recommending bypass surgery, he
or she will explain what you can expect for
preparation and recovery.
Why would my doctor recommend bypass surgery?
Bypass surgery may be recommended because it has been
shown to reduce the chance of heart attack and death when you have:
• Blockage in the left main artery, which is the largest artery
• Worrisome blockages in 2 or more heart arteries
• Certain other conditions such as diabetes or heart failure
What is a stent?
With the help of a thin tube, a small
balloon is inserted into the clogged artery
and inflated to open the blockage. Then
a small wire mesh tube (the stent) is left
inside that part of the artery to help keep
it open, allowing blood to flow better.
Why would I get a stent?
Stents can be used when patients have
one or two blockages in certain heart
arteries. With more extensive CAD (that
is, more blockages in bigger arteries),
bypass surgery is often recommended
instead of a stent.
