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Coronary artery disease starts silently, often early in life. In fact, there’s a good chance that you’ve got at least the beginnings of it — and might not know it.

Heart disease is a leading cause of death for U.S. men and women. It usually involves coronary artery disease (CAD). The coronary arteries deliver blood to heart muscle. If fatty plaques in those arteries restrict blood flow, that’s coronary artery disease.

It doesn’t happen all at once. But it’s “silent” in early stages.

“CAD is a lifelong process. It progresses over time,” says Jeffrey Berger, MD, director of the Center for the Prevention of Cardiovascular Disease at NYU Langone Health. “It starts probably in your late teenage or early adult years. You start developing fatty streaks in arteries that subsequently develop into plaque.”

“Even when you are 18 years old, you can start to form blockages in your arteries,” says Leslie Cho, MD, section head of preventive cardiology and rehabilitation and director of the Women’s Cardiovascular Center at the Cleveland Clinic.

When Coronary Artery Disease Starts

CAD is usually full blown by the time men are in their 50s and 60s and women are in their 60s and 70s. But it starts decades earlier.

Both Berger and Cho point to a 1953 study  of people, mostly men, who died in the Korean War.  Autopsies showed that more than 75% of their hearts had plaque lining the coronary arteries. They didn’t necessarily die of heart disease — but they had at least some of its signs.

That study was one of the first to help doctors understand that CAD starts early, without any signs, and unfolds over time.

Other studies found the same thing, including one of people who died after trauma (like car accidents) before they turned 35. Even at that young age, 78% of their hearts showed signs of CAD. In 1 in 5 of those hearts, the coronary arteries were narrowed by more than half. And in almost 1 in 10, that narrowing was even more severe.

This work also points to something else: “Most people do not know that they have coronary artery disease, that they have plaque,” Berger says.

Do You Have Coronary Artery Disease?

In most cases, people find out they have coronary artery disease only after they have symptoms including fatigue, chest pressure, tightness, or a general feeling of discomfort, known as angina. Symptoms usually worsen with exercise and get better with rest.

“They are functionally limited,” Cho says. “This is how the majority of people get diagnosed. Some get diagnosed only after a heart attack or stroke. That’s the unfortunate way to find out.”

Besides age, some of the things that put you at risk are high blood pressure, high levels of “bad” cholesterol, smoking, diabetes, and not being physically active.

There are several ways to diagnose CAD. Doctors can measure electrical signals in your heart or check that it’s pumping normally. An exercise stress test can help, too. Doctors can also use imaging tests.

“Really, plaque is almost always there,” Berger says. “It’s a matter of figuring out how much there is, quantifying it.”

And all plaque may not carry the same risk.

Put Coronary Artery Disease in Check

What doctors and patients really want to know, Berger says, is which plaques are most likely to burst open and trigger a life-threatening problem.

“When plaques rupture, that’s what causes a heart attack,” Berger says. He notes that some people who have heart attacks have relatively little plaque. “The Holy Grail is predicting which plaques will rupture. There’s a lot of data to help, but we aren’t there yet.”

These days, Berger says, doctors usually don’t use stents or do other “invasive” procedures to open up coronary arteries unless someone has a blockage and symptoms. The key to preventing CAD, or at least slowing it down, is to take strong action to tame your risk factors. This  includes making healthy lifestyle changes.

“There’s a lot you can do,” Berger says. Lifestyle changes, such as being active, managing stress, eating a heart-friendly diet, and not smoking, matter so much. “People need to take an active role in their own heart health.”

Medications to control blood pressure, lower high levels of LDL (bad) cholesterol, and prevent clots can help a lot, too.

Your First Step

Ask your primary care doctor for a risk-factor assessment, Cho says. This should include a physical exam in which your doctor:

  • Checks your blood pressure
  • Collects samples of blood for lab tests that check your cholesterol levels and  fasting glucose
  • Asks about your family’s health history, including heart problems

You and your doctor can also review any lifestyle habits that would help, such as exercising, changing your diet, managing stress, getting enough sleep, and not smoking. Also discuss any conditions you have that might affect your heart’s health. Managing those risks is key.

Even if you have early signs of CAD already developing, there’s plenty of hope.

“The beauty of cardiovascular disease is it’s preventable,” Cho says. “Even if you have the worst family history, you can prevent it with the right medicine and the right lifestyle modifications. That’s the good news of prevention.”

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