When cholesterol and other debris collect in the walls of your arteries, they harden, reducing blood flow to the heart.  When this series of events occurs in the coronary artery, doctors call the plaque accumulation coronary atherosclerosis, or coronary artery disease. Atherosclerosis can become a serious condition: the heart may weaken because of a lack of oxygen, and the cholesterol buildup can rupture, damaging the walls of the artery.

However, treatment options can vary and it's important to find a doctor who understands how to treat atherosclerosis at the root of the problem. Surgical treatment does not permanently solve a patient’s cardiac problems, even if the surgery is completely successful says Michael Cleman, MD, director of the Interventional Cardiology Program at Yale Medicine. Dr. Cleman says he always refers patients for cardiac rehabilitation.

“It gets you in with a supervised exercise program,” he says. “The majority of people weren’t exercising before the condition.” At rehab, he says, they go over diet and weight loss techniques. “It’s motivating for people,” he says, “and just as important, you’re with other people who have a similar problem so you’re not isolated."

Chest pain and shortness of breath while walking are the signature symptoms of coronary atherosclerosis. Unfortunately, in early stages of buildup, patients may not exhibit any symptoms at all, making atherosclerosis difficult to catch.

Patients, particularly those with other risk factors, should be aware of any new symptoms, especially any pain or shortness of breath that either awakens them from sleep or occurs while they are at rest. More gradual onset can be harder to notice, but people should always mention anything resembling these symptoms to a general practitioner or cardiologist.

It’s important to note that women’s symptoms can be quite different from men’s. These might include nausea, abdominal pain, and lightheadedness. Because these vary from the typical, male indications, they can end up overlooked.

“If you’re not feeling well you should be insistent about being carefully checked out,” says Dr. Cleman. 

The factors that put people at risk are smoking, high blood pressure, high cholesterol and a family history of heart disease. Obesity is another risk factor and one that’s increasingly problematic.

“I’ve been seeing people younger and younger,” says Dr. Cleman.

First, a patient will come in for a stress test. Normally, this involves walking on a treadmill while wearing sticky electrode patches that are connected to an electrocardiogram machine. If a patient’s health prevents walking, doctors instead use a chemical test, which relies on medication to get the heart rate up. The goal of the test is to get the rate to reach about 85 percent of what’s normal for the patient’s age group.

While the patient exercises, doctors look for changes in the electrocardiogram. “If you walk, and you’re not getting enough blood to that muscle, it starts contracting,” says Dr. Cleman.

If the heart’s activity is irregular, doctors then perform follow-up testing to isolate the problem. They may do myocardial perfusion imaging (MPI), which allows them to watch the blood flow in the area near the heart. They may also do a computerized tomography (CT) scan with dye—another way of revealing spots where there is blockage.

If any of these tests suggest coronary atherosclerosis, doctors might have the patient undergo an angiography, an imaging technique that reveals plaque buildups causing obstruction.

If the stress test shows blockage in the arteries but the patient is not at high risk for complications, doctors prescribe medication as a first step. If a patient doesn’t respond to medicine, doctors begin discussions about more invasive procedures.

One common option, a stent, is simply a small tube placed inside an artery that keeps it open to blood flow. This procedure is called an angioplasty. Newer stents can include drugs that prevent the cholesterol buildup. After angioplasty, patients can usually go home the next day.

Coronary bypass is surgery that reroutes blood flow around the blocked arteries to veins where the blood can flow freely. During the three-to-six-hour surgery, a doctor may use a bypass machine to do the work of the heart, or he or she may perform the surgery on a beating heart. Bypass requires general anesthesia, and recovery in the hospital takes about three or four days.

Figuring out the best treatment for a specific patient requires measurements and conversation. Doctors look at the details of a patient’s disease and health, weighing the risks—such as diabetes, high blood pressure, and the amount of plaque— against the odds of a healthy recovery. “We have the discussion about the pros and cons of different treatments,” says Dr. Cleman.

The patient isn’t dictated to, Dr. Cleman says. “You’re still the boss."

Still, when it comes to atherosclerosis, reducing all possible risk factors is better than treating the condition itself. “You want to not smoke, keep your blood pressure and cholesterol controlled, and exercise,” he says.

Stents in particular have come a long way.

“Though bypass surgery was the treatment of choice 25 years ago,” Dr. Cleman says, these days, angioplasty has surpassed it.

Newer stents use a thin polymer coating on the outside of the metal tube, which reduces the likelihood of inflammation. The polymer can release drugs, which helps with preventing the symptoms of atherosclerosis. And doctors can now put the stents in harder-to-reach places than ever before, both because of improved materials and new techniques for insertion.

Yale Medicine is currently involved in a clinical trial of a biodegradable stent that opens the artery, then dissolves, leaving the artery open.

Yale Medicine is one of the leading investigating centers for new devices, including the latest stents. “When a patient comes here, there’s the possibility you could come here to be in a trial,” says Dr. Cleman. Even if there’s not a current trial when a new treatment is approved, it’s likely that “We have the most experience doing it,” he says.