Atherosclerotic heart disease - Clinicals, Diagnosis, and Management

Cardiovascular

Clinicals - History

Fact Explanation
Chest pain The coronary arteries supply oxygen-rich blood to heart. If plaque narrows or blocks these arteries, angina (chest pain or discomfort) occurs as the heart muscle doesn't get enough oxygen-rich blood Chest pain
The coronary arteries supply oxygen-rich blood to heart. If plaque narrows or blocks these arteries, angina (chest pain or discomfort) occurs as the heart muscle doesn't get enough oxygen-rich blood
Shortness of breath Reduced blood supply leading to less oxygen to tissues due to narrowing of vessels by the plaques. Shortness of breath
Reduced blood supply leading to less oxygen to tissues due to narrowing of vessels by the plaques.
Fatigue Reduced blood supply leading to less oxygen to tissues due to narrowing of vessels by the plaques Fatigue
Reduced blood supply leading to less oxygen to tissues due to narrowing of vessels by the plaques
Sudden weakness of limbs Carotid arteries supply oxygen-rich blood to brain. If plaque narrows or blocks these arteries (carotid artery disease), patients may have symptoms of a stroke Sudden weakness of limbs
Carotid arteries supply oxygen-rich blood to brain. If plaque narrows or blocks these arteries (carotid artery disease), patients may have symptoms of a stroke
Loss of consciousness Carotid arteries supply oxygen-rich blood to brain. If plaque narrows or blocks these arteries (carotid artery disease), patients may have symptoms of a stroke Loss of consciousness
Carotid arteries supply oxygen-rich blood to brain. If plaque narrows or blocks these arteries (carotid artery disease), patients may have symptoms of a stroke
Sudden and severe headache Carotid arteries supply oxygen-rich blood to brain. If plaque narrows or blocks these arteries (carotid artery disease), patients may have symptoms of a stroke Sudden and severe headache
Carotid arteries supply oxygen-rich blood to brain. If plaque narrows or blocks these arteries (carotid artery disease), patients may have symptoms of a stroke
Numbness of limbs/ pain in limbs Plaque also can build up in the major arteries that supply oxygen-rich blood to the legs, arms, and pelvis.Narrowing of these vessels can give rise to numbness , pain in limbs Numbness of limbs/ pain in limbs
Plaque also can build up in the major arteries that supply oxygen-rich blood to the legs, arms, and pelvis.Narrowing of these vessels can give rise to numbness , pain in limbs
Symptoms of kidney failure (loss of appetite, nausea, swelling in the hands or feet, itchiness or numbness, and trouble concentrating etc.) The renal arteries supply oxygen-rich blood to kidneys. If plaque builds up in these arteries, patients may develop chronic kidney disease. Over time, chronic kidney disease causes a slow loss of kidney function.Early kidney disease often has no signs or symptoms. As the disease gets worse it can cause tiredness, changes in urination (more often or less often), loss of appetite, nausea, swelling in the hands or feet, itching or numbness, and trouble concentrating Symptoms of kidney failure (loss of appetite, nausea, swelling in the hands or feet, itchiness or numbness, and trouble concentrating etc.)
The renal arteries supply oxygen-rich blood to kidneys. If plaque builds up in these arteries, patients may develop chronic kidney disease. Over time, chronic kidney disease causes a slow loss of kidney function.Early kidney disease often has no signs or symptoms. As the disease gets worse it can cause tiredness, changes in urination (more often or less often), loss of appetite, nausea, swelling in the hands or feet, itching or numbness, and trouble concentrating
Smoking Damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries Smoking
Damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries
High cholesterol levels in blood Damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries High cholesterol levels in blood
Damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries
High blood pressure Damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries High blood pressure
Damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries
History of diabetes High levels of sugar in blood, damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries History of diabetes
High levels of sugar in blood, damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries
Obesity / lack of physical activity Risk factor for atherosclerosis Obesity / lack of physical activity
Risk factor for atherosclerosis
Older age Risk for atherosclerosis increases with age. Genetic or lifestyle factors cause plaque to build up in arteries with age.In men, the risk increases after age 45. In women, the risk increases after age 55 Older age
Risk for atherosclerosis increases with age. Genetic or lifestyle factors cause plaque to build up in arteries with age.In men, the risk increases after age 45. In women, the risk increases after age 55
Family history of early heart disease Risk for atherosclerosis increases if there’s a family history. (If a 1st degree male relative was diagnosed with heart disease before 55 years of age, or if a 1st degree female relative was diagnosed with heart disease before 65 years of age) Family history of early heart disease
Risk for atherosclerosis increases if there’s a family history. (If a 1st degree male relative was diagnosed with heart disease before 55 years of age, or if a 1st degree female relative was diagnosed with heart disease before 65 years of age)
Heavy alcohol drinking Heavy drinking can damage the heart muscle and worsen other risk factors for atherosclerosis Heavy alcohol drinking
Heavy drinking can damage the heart muscle and worsen other risk factors for atherosclerosis
Intermittent claudication Cramping pain in muscles ( most of the times, calf muscles) which typically occurs with walking and goes away with rest.Occur due to peripheral vascular disease.Can be present in patients with athersclerotic heart disease as they are likely to have peripheral vascular disease. Intermittent claudication
Cramping pain in muscles ( most of the times, calf muscles) which typically occurs with walking and goes away with rest.Occur due to peripheral vascular disease.Can be present in patients with athersclerotic heart disease as they are likely to have peripheral vascular disease.

Clinicals - Examination

Fact Explanation
Patient in pain / dyspnoic The coronary arteries supply oxygen-rich blood to heart. If plaque narrows or blocks these arteries, angina (chest pain or discomfort) occurs as the heart muscle doesn't get enough oxygen-rich blood Patient in pain / dyspnoic
The coronary arteries supply oxygen-rich blood to heart. If plaque narrows or blocks these arteries, angina (chest pain or discomfort) occurs as the heart muscle doesn't get enough oxygen-rich blood
Loss of consciousness Patients will have other complications of atherosclerosis such as strokes.
Carotid arteries supply oxygen-rich blood to brain. If plaque narrows or blocks these arteries (carotid artery disease), patients may have symptoms of a stroke
Loss of consciousness
Patients will have other complications of atherosclerosis such as strokes.
Carotid arteries supply oxygen-rich blood to brain. If plaque narrows or blocks these arteries (carotid artery disease), patients may have symptoms of a stroke
Weakness of limbs Patients will have other complications of atherosclerosis such as strokes.
Carotid arteries supply oxygen-rich blood to brain. If plaque narrows or blocks these arteries (carotid artery disease), patients may have symptoms of a stroke
Weakness of limbs
Patients will have other complications of atherosclerosis such as strokes.
Carotid arteries supply oxygen-rich blood to brain. If plaque narrows or blocks these arteries (carotid artery disease), patients may have symptoms of a stroke
Poor peripheral pulses Patients will have other complications of atherosclerosis such as peripheral vascular disease.Plaque can build up in the major arteries that supply oxygen-rich blood to the legs, arms, and pelvis Poor peripheral pulses
Patients will have other complications of atherosclerosis such as peripheral vascular disease.Plaque can build up in the major arteries that supply oxygen-rich blood to the legs, arms, and pelvis
Signs of chronic renal failure (pallor,ankle odema, scratch marks etc) The renal arteries supply oxygen-rich blood to kidneys. If plaque builds up in these arteries, patients may develop chronic kidney disease. Over time, chronic kidney disease causes a slow loss of kidney function.Early kidney disease often has no signs or symptoms. As the disease gets worse it can cause tiredness, changes in urination (more often or less often), loss of appetite, nausea, swelling in the hands or feet, itching or numbness, and trouble concentrating Signs of chronic renal failure (pallor,ankle odema, scratch marks etc)
The renal arteries supply oxygen-rich blood to kidneys. If plaque builds up in these arteries, patients may develop chronic kidney disease. Over time, chronic kidney disease causes a slow loss of kidney function.Early kidney disease often has no signs or symptoms. As the disease gets worse it can cause tiredness, changes in urination (more often or less often), loss of appetite, nausea, swelling in the hands or feet, itching or numbness, and trouble concentrating
High blood pressure Damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries
Can also occur due to renal failure
High blood pressure
Damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries
Can also occur due to renal failure
Nicotine stains Smoking can damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries Nicotine stains
Smoking can damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries
Signs of diabetes ( retinopathy changes, dermopathy changes) High blood sugar levels can damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries Signs of diabetes ( retinopathy changes, dermopathy changes)
High blood sugar levels can damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries
High BMI Obesity (BMI >30) is a risk factor for atherosclerotic heart disease High BMI
Obesity (BMI >30) is a risk factor for atherosclerotic heart disease
Carotid bruit Caused by turbulent blood flow in the narrowed carotid artery Carotid bruit
Caused by turbulent blood flow in the narrowed carotid artery

Investigations - Diagnosis

Fact Explanation
Lipid profile - cholesterol levels Optimal/near-optimal
serum concentration (mg/dl) :
-Total cholesterol <200
-High-Density Lipoprotein Cholesterol ≥60
-Low-Density Lipoprotein Cholesterol <100 optimal
(100-129 near-optimal)

Borderline serum
concentration (mg/dl):
-Total cholesterol 200-239
-High-Density Lipoprotein Cholesterol 40-59 (men)
50-59 (women)
-Low-Density Lipoprotein Cholesterol 130-159

High-risk/very
high-risk serum
concentration (mg/dl) :
-Total cholesterol ≥240
-High-Density Lipoprotein Cholesterol <40 men
<50 women
-Low-Density Lipoprotein Cholesterol 160-189 high
≥190 very high
Lipid profile - cholesterol levels
Optimal/near-optimal
serum concentration (mg/dl) :
-Total cholesterol <200
-High-Density Lipoprotein Cholesterol ≥60
-Low-Density Lipoprotein Cholesterol <100 optimal
(100-129 near-optimal)

Borderline serum
concentration (mg/dl):
-Total cholesterol 200-239
-High-Density Lipoprotein Cholesterol 40-59 (men)
50-59 (women)
-Low-Density Lipoprotein Cholesterol 130-159

High-risk/very
high-risk serum
concentration (mg/dl) :
-Total cholesterol ≥240
-High-Density Lipoprotein Cholesterol <40 men
<50 women
-Low-Density Lipoprotein Cholesterol 160-189 high
≥190 very high
Lipid profile - Triglycerides Optimal/near-optimal
serum concentration (mg/dl) : <150
Borderline serum
concentration (mg/dl): 150-199
High-risk/very
high-risk serum
concentration (mg/dl) : 200-499 high
≥500 very high
Lipid profile - Triglycerides
Optimal/near-optimal
serum concentration (mg/dl) : <150
Borderline serum
concentration (mg/dl): 150-199
High-risk/very
high-risk serum
concentration (mg/dl) : 200-499 high
≥500 very high
Electrocardiogram (ECG) Will show ST segment changes according to the areas which are supplied by the blocked coronary arteries Electrocardiogram (ECG)
Will show ST segment changes according to the areas which are supplied by the blocked coronary arteries
Exercise ECG Patient will not be able to complete, as the blood requirement is high during physical activity and the blocked vessels are unable to reach the demand.
A stress test can show possible signs and symptoms of coronary heart disease, such as, abnormal changes in your heart rate or blood pressure
Shortness of breath or chest pain
Abnormal changes in your heart rhythm or your heart's electrical activity
Exercise ECG
Patient will not be able to complete, as the blood requirement is high during physical activity and the blocked vessels are unable to reach the demand.
A stress test can show possible signs and symptoms of coronary heart disease, such as, abnormal changes in your heart rate or blood pressure
Shortness of breath or chest pain
Abnormal changes in your heart rhythm or your heart's electrical activity
Echocardiogram Can identify areas of poor blood flow to the heart, areas of heart muscle that aren't contracting normally Echocardiogram
Can identify areas of poor blood flow to the heart, areas of heart muscle that aren't contracting normally
Angiogram Can show whether plaque is blocking the arteries and how severe the blockage is Angiogram
Can show whether plaque is blocking the arteries and how severe the blockage is

Investigations - Management

Fact Explanation
Lipid profile - cholesterol levels Optimal/near-optimal
serum concentration (mg/dl) :
-Total cholesterol <200
-High-Density Lipoprotein Cholesterol ≥60
-Low-Density Lipoprotein Cholesterol <100 optimal
(100-129 near-optimal)

Borderline serum
concentration (mg/dl):
-Total cholesterol 200-239
-High-Density Lipoprotein Cholesterol 40-59 (men)
50-59 (women)
-Low-Density Lipoprotein Cholesterol 130-159

High-risk/very
high-risk serum
concentration (mg/dl) :
-Total cholesterol ≥240
-High-Density Lipoprotein Cholesterol <40 men
<50 women
-Low-Density Lipoprotein Cholesterol 160-189 high
≥190 very high
Lipid profile - cholesterol levels
Optimal/near-optimal
serum concentration (mg/dl) :
-Total cholesterol <200
-High-Density Lipoprotein Cholesterol ≥60
-Low-Density Lipoprotein Cholesterol <100 optimal
(100-129 near-optimal)

Borderline serum
concentration (mg/dl):
-Total cholesterol 200-239
-High-Density Lipoprotein Cholesterol 40-59 (men)
50-59 (women)
-Low-Density Lipoprotein Cholesterol 130-159

High-risk/very
high-risk serum
concentration (mg/dl) :
-Total cholesterol ≥240
-High-Density Lipoprotein Cholesterol <40 men
<50 women
-Low-Density Lipoprotein Cholesterol 160-189 high
≥190 very high
Lipid profile - Triglycerides Optimal/near-optimal
serum concentration (mg/dl) : <150
Borderline serum
concentration (mg/dl): 150-199
High-risk/very
high-risk serum
concentration (mg/dl) : 200-499 high
≥500 very high
Lipid profile - Triglycerides
Optimal/near-optimal
serum concentration (mg/dl) : <150
Borderline serum
concentration (mg/dl): 150-199
High-risk/very
high-risk serum
concentration (mg/dl) : 200-499 high
≥500 very high
Electrocardiogram (ECG) Will show ST segment changes according to the areas which are supplied by the blocked coronary arteries Electrocardiogram (ECG)
Will show ST segment changes according to the areas which are supplied by the blocked coronary arteries
Exercise ECG Patient will not be able to complete, as the blood requirement is high during physical activity and the blocked vessels are unable to reach the demand.
A stress test can show possible signs and symptoms of coronary heart disease, such as, abnormal changes in your heart rate or blood pressure
Shortness of breath or chest pain
Abnormal changes in your heart rhythm or your heart's electrical activity
Exercise ECG
Patient will not be able to complete, as the blood requirement is high during physical activity and the blocked vessels are unable to reach the demand.
A stress test can show possible signs and symptoms of coronary heart disease, such as, abnormal changes in your heart rate or blood pressure
Shortness of breath or chest pain
Abnormal changes in your heart rhythm or your heart's electrical activity
Echocardiogram Can identify areas of poor blood flow to the heart, areas of heart muscle that aren't contracting normally Echocardiogram
Can identify areas of poor blood flow to the heart, areas of heart muscle that aren't contracting normally
Angiogram Can show whether plaque is blocking the arteries and how severe the blockage is Angiogram
Can show whether plaque is blocking the arteries and how severe the blockage is
Ankle/Brachial Index Compares the blood pressure in ankle with the blood pressure in arm to see how well blood is flowing. This test can help diagnose peripheral vascular disease Ankle/Brachial Index
Compares the blood pressure in ankle with the blood pressure in arm to see how well blood is flowing. This test can help diagnose peripheral vascular disease
Fasting blood sugar High blood sugar levels can damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries Fasting blood sugar
High blood sugar levels can damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries

Management - Supportive

Fact Explanation
Regular exercise At least 30 minutes of moderate intensity physical activity (consuming 4-7
kcal/min) 4 to 6 times weekly, with an expenditure of at least 200 kcal/day. Suggested activities include brisk walking, riding a stationary bike,
water aerobics, cleaning/scrubbing, mowing the
lawn, and sporting activities.

Target heart rate:
Moderate exercise intensity: 50 to 70 percent of the maximum heart rate
Vigorous exercise intensity: 70 to 85 percent of the maximum heart rate
(maximum heart rate: subtract age from 220)
Regular exercise
At least 30 minutes of moderate intensity physical activity (consuming 4-7
kcal/min) 4 to 6 times weekly, with an expenditure of at least 200 kcal/day. Suggested activities include brisk walking, riding a stationary bike,
water aerobics, cleaning/scrubbing, mowing the
lawn, and sporting activities.

Target heart rate:
Moderate exercise intensity: 50 to 70 percent of the maximum heart rate
Vigorous exercise intensity: 70 to 85 percent of the maximum heart rate
(maximum heart rate: subtract age from 220)
Patient education (precautions) regarding exercise Always perform a proper warm-up and cool-down activity, such as walking slowly (e.g., two miles per hour) five to seven minutes before and after exercise.
Never exercise to the point of chest pain or angina.
Exercise with a friend and/or always carry a cell phone to ensure emergency personnel can be contacted quickly if necessary.
If prescribed, always carry nitroglycerin, especially when exercising.
Exercise should be stopped immediately if dizziness, nausea, unusual shortness of breath or irregular heart beats occur during or immediately after exercise. A physician should be contacted immediately.
Do not exceed the target heart rate
Patient education (precautions) regarding exercise
Always perform a proper warm-up and cool-down activity, such as walking slowly (e.g., two miles per hour) five to seven minutes before and after exercise.
Never exercise to the point of chest pain or angina.
Exercise with a friend and/or always carry a cell phone to ensure emergency personnel can be contacted quickly if necessary.
If prescribed, always carry nitroglycerin, especially when exercising.
Exercise should be stopped immediately if dizziness, nausea, unusual shortness of breath or irregular heart beats occur during or immediately after exercise. A physician should be contacted immediately.
Do not exceed the target heart rate
Cessation of cigarette smoking Smoking damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries Cessation of cigarette smoking
Smoking damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries
Control other co morbid factors - hypertension, diabetes High blood sugar levels and high blood pressure damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries Control other co morbid factors - hypertension, diabetes
High blood sugar levels and high blood pressure damage the inner layers of the arteries and plaque may begin to build up where the arteries are damaged. Over time, plaque hardens and narrows the arteries
Diet Avoid food with high lipids. Avoid :
Poultry with skin, fried chicken,Fried fish, fried shellfish,Egg yolks,Coconut oil, palm oil,Butter,Commercially baked biscuits, pastries, muffins containing whole milk, saturated oils.
Eat healthy foods, such as fruits, vegetables, and whole grains that are low in saturated fat and high in fiber
Diet
Avoid food with high lipids. Avoid :
Poultry with skin, fried chicken,Fried fish, fried shellfish,Egg yolks,Coconut oil, palm oil,Butter,Commercially baked biscuits, pastries, muffins containing whole milk, saturated oils.
Eat healthy foods, such as fruits, vegetables, and whole grains that are low in saturated fat and high in fiber

Management - Specific

Fact Explanation
Cholesterol Lowering Drugs - Statins (eg:Atorvastatin, simvastatin) HMG-CoA reductase inhibitors, or statins, inhibit cholesterol synthesis. To varying degrees, all of these agents lower total, LDL and triglyceride cholesterol components and slightly raise the HDL fraction. While these agents are generally well tolerated, a small percentage of patients (fewer than 1 percent) may develop elevated hepatic transaminase levels, which may necessitate discontinuation of the drug Cholesterol Lowering Drugs - Statins (eg:Atorvastatin, simvastatin)
HMG-CoA reductase inhibitors, or statins, inhibit cholesterol synthesis. To varying degrees, all of these agents lower total, LDL and triglyceride cholesterol components and slightly raise the HDL fraction. While these agents are generally well tolerated, a small percentage of patients (fewer than 1 percent) may develop elevated hepatic transaminase levels, which may necessitate discontinuation of the drug
Cholesterol Lowering Drugs- Bile acid sequestrants (eg:cholestyramine) bind cholesterol-containing bile acids in the intestines, producing an insoluble complex that prevents reabsorption Cholesterol Lowering Drugs- Bile acid sequestrants (eg:cholestyramine)
bind cholesterol-containing bile acids in the intestines, producing an insoluble complex that prevents reabsorption
Cholesterol Lowering Drugs- Nicotinic acid Decreases the synthesis of LDL cholesterol by reducing the hepatic synthesis of VLDL cholesterol, by increasing the synthesis of HDL cholesterol, by inhibiting lipolysis in adipose tissue and by increasing lipase activity Cholesterol Lowering Drugs- Nicotinic acid
Decreases the synthesis of LDL cholesterol by reducing the hepatic synthesis of VLDL cholesterol, by increasing the synthesis of HDL cholesterol, by inhibiting lipolysis in adipose tissue and by increasing lipase activity
Cholesterol Lowering Drugs- Fibric acid derivatives Increase the clearance of VLDL cholesterol by enhancing lipolysis and reducing hepatic cholesterol synthesis Cholesterol Lowering Drugs- Fibric acid derivatives
Increase the clearance of VLDL cholesterol by enhancing lipolysis and reducing hepatic cholesterol synthesis
Antiplatelet agents- Asprin Recommended for the secondary prevention of coronary artery disease.
Aspirin - irreversibly inhibits the enzyme COX, resulting in reduced platelet production of TXA2 (thromboxane - powerful vasoconstrictor that lowers cyclic AMP and initiates the platelet release reaction).
Reduces risk of transient ischemic attack (TIA), stroke, and heart attacks
Antiplatelet agents- Asprin
Recommended for the secondary prevention of coronary artery disease.
Aspirin - irreversibly inhibits the enzyme COX, resulting in reduced platelet production of TXA2 (thromboxane - powerful vasoconstrictor that lowers cyclic AMP and initiates the platelet release reaction).
Reduces risk of transient ischemic attack (TIA), stroke, and heart attacks
Antiplatelet agents- Clopidogrel Recommended for the secondary prevention of coronary artery disease.
Clopidogrel- affects the ADP-dependent activation of IIb/IIIa complex
Antiplatelet agents- Clopidogrel
Recommended for the secondary prevention of coronary artery disease.
Clopidogrel- affects the ADP-dependent activation of IIb/IIIa complex
Angioplasty Used to widen narrowed arteries.
Inserts a catheter with a deflated balloon into the narrowed part of the artery. The balloon is inflated, widening the blood vessel so blood can flow more easily. The balloon is then deflated, and the catheter is removed. A permanent stent (wire mesh) may be put in to hold the artery open and improve blood flow
Angioplasty
Used to widen narrowed arteries.
Inserts a catheter with a deflated balloon into the narrowed part of the artery. The balloon is inflated, widening the blood vessel so blood can flow more easily. The balloon is then deflated, and the catheter is removed. A permanent stent (wire mesh) may be put in to hold the artery open and improve blood flow
Surgical methods - Coronary Artery Bypass Grafting Uses a blood vessel from another part of body or an artificial tube to reroute blood around narrowed arteries Surgical methods - Coronary Artery Bypass Grafting
Uses a blood vessel from another part of body or an artificial tube to reroute blood around narrowed arteries

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