---
title: Coronary heart disease and myocardial infarction
description: What coronary heart disease and myocardial infarction (heart attack) are, why they happen, how they are recognised, which treatment approaches exist and when to call an ambulance.
type: disease
preset: stemi
aliases:
  - CHD
  - coronary artery disease
  - CAD
  - heart attack
  - MI
  - angina
sources:
  - tier: guideline
    org: esc
    title: 2024 ESC Guidelines for the management of chronic coronary syndromes
    year: 2024
    doi: 10.1093/eurheartj/ehae177
    url: https://doi.org/10.1093/eurheartj/ehae177
  - tier: guideline
    org: esc
    title: 2023 ESC Guidelines for the management of acute coronary syndromes
    year: 2023
    doi: 10.1093/eurheartj/ehad191
    url: https://doi.org/10.1093/eurheartj/ehad191
  - tier: guideline
    org: minzdrav-rf
    title: Стабильная ишемическая болезнь сердца
    year: 2024
    doi: 10.15829/1560-4071-2024-6110
    url: https://cr.minzdrav.gov.ru/view-cr/155_2
  - tier: guideline
    org: nice
    title: Acute coronary syndromes (NG185)
    year: 2020
    url: https://www.nice.org.uk/guidance/ng185
  - tier: reference
    org: statpearls
    title: Acute Coronary Syndrome
    year: 2026
    url: https://www.ncbi.nlm.nih.gov/books/NBK459157/
sources_checked: 2026-10-11
review: null
---

Coronary heart disease (CHD) is damage to the heart muscle caused by impaired blood flow through the coronary arteries, the arteries that supply the heart.<Cite n={3} /> Acute coronary syndrome is a group of life-threatening conditions caused by a sudden lack of blood supply to the heart muscle; it includes unstable angina and [myocardial infarction](../myocardial-infarction/).<Cite n={[2, 5]} /> Myocardial infarction (a heart attack) is the death of heart muscle cells caused by a sudden lack of blood supply.<Cite n={2} />

<Diagram name="coronary-heart-disease">
  <p slot="normal">
    Normally blood flows through the coronary arteries, the arteries that supply the heart
    muscle.<Cite n={3} />
  </p>
  <p slot="disease">
    In CHD, plaques build up in the walls of the coronary arteries.<Cite n={[1, 3]} /> A plaque can
    narrow the artery and reduce blood flow through it.<Cite n={3} /> If a plaque is damaged, a
    blood clot forms on it and can block the artery completely.<Cite n={5} /> The heart muscle
    beyond the blockage loses its blood supply.<Cite n={5} /> The death of heart muscle cells caused
    by a sudden lack of blood supply is a myocardial infarction.<Cite n={2} />
  </p>
</Diagram>

## Why it happens

<Patient>

The main cause of CHD is atherosclerosis: plaques build up in the walls of the coronary arteries.<Cite n={[1, 3]} /> A plaque can narrow the artery and reduce blood flow through it.<Cite n={3} /> The risk goes up with abnormal blood fats (dyslipidaemia), high blood pressure, diabetes, smoking, too little physical activity, excess weight, stress and poor sleep.<Cite n={3} /> Some risk factors cannot be changed: being male, age, and heart disease in close relatives.<Cite n={3} />

A heart attack usually happens when a plaque is damaged and a blood clot forms on it, partly or completely blocking the artery.<Cite n={5} />

</Patient>

<Student>

The main cause of structural (organic) coronary artery disease is atherosclerosis; functional changes include spasm and intravascular thrombosis.<Cite n={3} /> The ESC describes chronic coronary syndromes as structural and/or functional alterations of the coronary arteries and/or the microcirculation; coronary microvascular dysfunction is common, including in patients with non-obstructive arteries.<Cite n={1} /> Modifiable risk factors are dyslipoproteinaemia, arterial hypertension, diabetes mellitus, smoking, low physical activity, obesity, stress, anxiety and sleep disturbance; non-modifiable ones are male sex, age and a family history of cardiovascular disease.<Cite n={3} />

The most common mechanism of acute coronary syndrome is disruption of an atherosclerotic plaque by rupture or erosion: thrombogenic subendothelial material is exposed to circulating blood, which triggers platelet activation, aggregation and thrombus formation.<Cite n={5} /> Complete occlusion of the artery causes transmural ischaemia with ST-segment elevation on the ECG (STEMI), while partial or transient occlusion causes subendocardial ischaemia, which presents as NSTEMI or unstable angina.<Cite n={5} />

</Student>

## Symptoms

<Patient>

The typical sign of CHD is angina: pain or discomfort behind the breastbone that may spread to the left arm, the back or the lower jaw.<Cite n={3} /> This pain comes on with physical effort or strong emotion and settles quickly once the effort stops.<Cite n={3} /> Many people, however, have less classic symptoms, such as breathlessness on exertion.<Cite n={1} />

The main symptom of a heart attack and other forms of acute coronary syndrome is sudden chest discomfort, described as pain, pressure, tightness, heaviness or burning.<Cite n={2} /> Women, older people and people with diabetes are more likely than others to have atypical symptoms without chest pain: only breathlessness, pain in the upper abdomen, or tiredness.<Cite n={5} />

</Patient>

<Student>

The Russian Ministry of Health guideline lists three features of typical angina that the doctor uses to assess chest pain: pain (or discomfort) in the sternal area, possibly radiating to the left arm, back or lower jaw; onset during physical exertion or marked emotional stress; and rapid relief once exertion stops or within 1–3 minutes of taking nitroglycerin.<Cite n={3} /> According to the ESC, only 10–25% of patients with suspected chronic coronary syndrome present with angina with classic aggravating and relieving factors.<Cite n={1} /> The ESC recommends a detailed description of symptoms instead of the labels "typical" and "atypical".<Cite n={1} />

In acute coronary syndrome the leading symptom is acute chest discomfort; chest pain-equivalent symptoms include dyspnoea, epigastric pain, and pain in the left or right arm or neck/jaw.<Cite n={2} /> Diaphoresis, nausea and lightheadedness may also occur.<Cite n={5} /> Atypical presentations (isolated dyspnoea, epigastric pain, fatigue without chest pain) are more common in women, older adults, and patients with diabetes or renal insufficiency.<Cite n={5} />

</Student>

## How it is diagnosed

<Patient>

If stable CHD is suspected, the doctor asks about your symptoms and arranges an ECG and an ultrasound scan of the heart (echocardiogram).<Cite n={[1, 3]} /> To see the heart's arteries or to check whether the heart gets enough blood during exertion, doctors use stress tests, a CT scan of the coronary arteries or coronary angiography.<Cite n={[1, 3]} />

If a heart attack is suspected, an ECG is recorded within the first minutes, and a blood test looks for troponin, a substance released into the blood when heart muscle is damaged.<Cite n={[2, 5]} />

</Patient>

<Student>

Work-up of stable CHD uses a resting 12-lead ECG, transthoracic echocardiography, stress testing (exercise ECG, stress echocardiography, stress SPECT), Holter monitoring (for rhythm disturbances or suspected vasospastic angina), coronary CT angiography and invasive coronary angiography.<Cite n={[1, 3]} />

In suspected ACS, an ECG should be performed within 10 minutes of first medical contact, and high-sensitivity cardiac troponin is recommended in all patients.<Cite n={2} /> Initial classification of ACS is based on the ECG: with persistent ST-segment elevation the working diagnosis is STEMI.<Cite n={2} /> NSTEMI is distinguished from unstable angina by elevated markers of myocardial necrosis; unstable angina is myocardial ischaemia at rest or on minimal exertion in the absence of acute cardiomyocyte injury.<Cite n={[2, 5]} />

</Student>

## How it is treated

<Patient>

Treatment of stable CHD starts with lifestyle changes and control of risk factors, with medicines added on top.<Cite n={1} /> If medicines do not control the symptoms or the risk of complications is high, the doctor may suggest restoring blood flow in the artery with a stent or bypass surgery.<Cite n={[1, 3]} />

In a heart attack with ST elevation on the ECG, doctors try to restore blood flow in the blocked artery as quickly as possible; the preferred way is coronary angiography followed by stenting.<Cite n={[4, 5]} /> After a heart attack, people are offered a cardiac rehabilitation programme.<Cite n={[4, 5]} /> The doctor and the patient decide together which treatment is right.

</Patient>

<Student>

In chronic coronary syndrome, the final step of ESC management combines lifestyle and risk-factor modification with disease-modifying medications; a combination of antianginal drugs is often needed, and revascularisation is considered if symptoms are refractory to medical treatment or high-risk coronary disease is present.<Cite n={1} /> Revascularisation (PCI or coronary artery bypass grafting) is performed to reduce symptoms and/or improve prognosis.<Cite n={3} />

In STEMI, reperfusion (primary PCI or fibrinolysis) is delivered as quickly as possible; the preferred strategy is coronary angiography with follow-on primary PCI if indicated.<Cite n={[4, 5]} /> NICE applies this to patients who present within 12 hours of symptom onset when primary PCI can be delivered within 120 minutes of the time fibrinolysis could have been given.<Cite n={4} /> Immediate coronary angiography is indicated in unstable angina or NSTEMI when the clinical condition is unstable.<Cite n={4} /> Referral to exercise-based cardiac rehabilitation is associated with reduced mortality and rehospitalisation.<Cite n={5} />

</Student>

## When to call an ambulance

Call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK) straight away if there are signs of a heart attack:<Cite n={2} />

- sudden pain, pressure, tightness, heaviness or burning in the chest, especially if it lasts more than 15 minutes or comes back within an hour;<Cite n={2} />
- the same sensations or pain in the arm, neck, lower jaw or upper abdomen, or sudden breathlessness, together with chest pain or instead of it;<Cite n={[2, 5]} />
- if this is accompanied by sweating, nausea, dizziness or feeling faint.<Cite n={5} />

Do not wait for it to pass, do not drive yourself, and do not make your own way to a hospital or GP surgery: call an ambulance.<Cite n={[2, 5]} /> In women, older people and people with diabetes, a heart attack may start without chest pain, with only breathlessness, pain in the upper abdomen or tiredness.<Cite n={5} />

<Quiz />