# Symptoms and Phases of Coronary Artery Disease
Coronary artery disease usually progresses in different stages, from onset to acute events. Not everyone goes through all phases — some people have few symptoms for years, while others suddenly have a serious attack. The following describes how the disease usually develops and what that means for daily life.
Phase 1: Early Atherosclerosis (No Symptoms)
In this phase, fat deposits form in the arteries of the heart, but you usually don't notice them. The blockages are not yet severe enough to noticeably limit the blood supply. This can take years — sometimes ten years or more — before someone develops symptoms.
**What happens:**
- Fat deposits (plaques) grow slowly in the heart artery walls
- The body usually knows nothing about it
**Meaning for daily life:**
You feel normal, you have no symptoms, you can do anything. The disease is usually discovered by chance in this phase, for example via a heart exam for other reasons or because family members have heart problems.
**What is known about this stage:**
How long this phase lasts varies enormously from person to person. It depends on age, genetic predisposition, smoking, cholesterol, blood pressure, and diabetes risk. Someone may have no symptoms for ten years, another longer or shorter. There are no average numbers for this phase.
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Phase 2: Stable angina pectoris
This stage usually begins when the narrowing of at least one heart artery has become so severe (often more than 70% blocked) that the heart muscle does not receive enough oxygen during exercise.
**Symptoms:**
- Chest pain or pressure that occurs at predictable times (e.g. when climbing or walking fast)
- Pain that feels like heaviness, tightness, or chest pressure
- Pain can spread to the arm, neck, jaw, or lower back
- Shortness of breath, especially during exertion
- Tiredness or weakness
- Nausea (less common)
The pain usually occurs during physical exertion or emotional stress and disappears after a few minutes of rest or use of heart medication (nitrates).
**What the pain means: **
Your heart doesn't get enough oxygen in certain situations. As soon as you slow down (stop exercising, sit down), the heart beats normalize and pain goes away. So the pain is predictable and reversible.
**Meaning for daily life:**
Many people are adapting their activities. They slow down, avoid strenuous exercise or climactic situations, or take preventative medication. Some people feel anxious about pain and avoid a lot. Others learn their limits and can live relatively normally — they only know when to be careful. Sleep, concentration, and mood can be under pressure.
**What is known about this stage:**
Stable angina can last for many years without becoming more severe. Studies show that approximately 4— 5% of people with stable angina have a heart attack or sudden cardiac arrest each year, depending on how many arteries are clogged and what other risk factors are present (source: Framingham Heart Study and subsequent cohort studies). This means that most of those who have stable angina can live for many more years, but the risk of an acute event is real. Individual differences are significant.
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Phase 3: Unstable angina
This is a warning sign: the pain is becoming more unpredictable, worse, or occurs without a clear cause.
**Symptoms:**
- Chest pain/pressure that is stronger than before, lasts longer (more than 20 minutes)
- Pain also occurs during light activities or even at rest
- Pain responds less well or does not respond to heart medications
- Nocturnal facial changes (chest pain wakes you up)
- Sudden shortness of breath
- Nausea, sweat
**What this means:**
The plaque in a heartbeat vein has probably become unstable. This means that the beginning of the blood system can become loose or that a large blood clot can develop. The situation could turn into a complete myocardial infarction at any time.
**Meaning for daily life:**
This feels urgent and frightening. Many people cannot sleep well, are afraid to be alone at home, feel vulnerable. Normal activities have become difficult. This is a phase where hospitalization is needed.
**What is known about this stage:**
Unstable angina requires immediate medical attention. Approximately 10–20% of people with unstable angina experience a heart attack or serious event in the following months if they are not treated (source: NSTEMI studies). With hospital treatment, this risk decreases significantly. This is truly a critical phase.
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Phase 4: Acute myocardial infarction (heart attack)
This is the moment when one or more coronary arteries are completely or almost completely blocked by a blood clot. Heart muscle tissue dies from lack of oxygen.
**Symptoms:**
- Severe chest pain or pressure that does not go away with rest or medication
- Pain that lasts 30 minutes or longer (can last for hours)
- Pain can radiate to arm, neck, jaw, shoulder, abdomen
- Severe shortness of breath, sense of panic
- Cold sweat, paleness
- Nausea, vomiting
- Heart rhythm disturbances (feeling irregular heartbeat)
- Dizziness or fainting
- In some people less typical symptoms (especially women, elderly and diabetics): only fatigue, nausea, shortness of breath without clear chest pain
**What this means:**
Part of the heart muscle receives no oxygen and begins to die. This is a medical emergency: the faster the treatment, the more tissue can be saved. Risks of arrhythmias, heart failure or cardiogenic shock also increase.
**Meaning for daily life (during the event):**
This is life-threatening. You cannot function normally; you need immediate hospitalization and intensive care. The pain and anxiety are intense. Resuscitation may be needed.
**What is known about this stage:**
Approximately 5–10% of people with a heart attack die in or shortly after the acute phase, especially if treatment is delayed (sources: national heart attack registers, STEMI studies). Of those who survive, various degrees of heart muscle damage are possible. The first three days are most critical. After survival, rehabilitation and adjustment to life afterwards follows.
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Phase 5: Post-heart attack period (healing and rehabilitation)
After a heart attack, the body must recover. This takes weeks to months.
**What happens:**
- Damaged heart muscle tissue forms scars
- Remaining healthy heart muscle adapts
- Blood vessels can expand (collaterals) as compensation
- Medication helps the heart work more efficiently
**Symptoms in this phase: **
- Fatigue, sometimes severe
- Weakness and shortness of breath easily
- Possible lingering pain complaints (different from acute pain period)
- Fear of another heart attack
- Depressed mood, mood changes
- Insomnia
**Meaning for daily life:**
In the first weeks, careful activity is needed. Physical rehabilitation begins gradually. Many people feel psychologically damaged and afraid. Return to work and normal activities happens step by step. Sexuality, family and work stress often become difficult.
**What is known about this stage:**
After surviving a heart attack, recovery varies greatly. Some recover well within weeks, others remain weak. The severity of the infarction (amount of heart tissue that died) determines much. Survival in the first year after infarction: approximately 85–90% survive the first year, depending on infarction size, age and other illnesses (source: heart registers worldwide, recent years). In the longer term (5 years): approximately 70–75% survive, also depending on many factors (source: CASS, SYNTAX and later cohorts). **These numbers say nothing about one person** — individual recovery is very different.
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Phase 6: Chronic heart failure after infarction
If much heart muscle tissue is damaged, the heart can no longer pump enough blood. This can occur directly after infarction or years later.
**Symptoms:**
- Shortness of breath (especially with exertion, lying down or at night)
- Swollen feet/legs (edema)
- Extreme fatigue
- Night sweats
- Coughing (often dry)
- Weight gain (due to fluid retention)
- Heart palpitations, irregular heartbeat
- Concentration difficulties
**Meaning for daily life:**
Many limitations. Walking, stairs, lifting — everything causes shortness of breath. Nighttime bathroom visits. Appetite changes. Social contacts become more difficult. Work is hard. Anxiety and depression are frequent.
**What is known about this stage:**
With heart failure, the prognosis depends on how poor the pumping function is. On average: people with moderate heart failure: approximately 50% survive 5 years; severe heart failure: lower (source: NHFA registers, MERIT-HF study). These numbers are averages for large groups; individual prognosis varies greatly and depends on many factors (age, other illnesses, response to medication).
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Phase 7: Stable phase with repeated risks (years after infarction)
Many people who survive a heart attack continue relatively stably for years — with medication and adjusted living.
**Symptoms:**
- Few or no symptoms (with good medication)
- Sometimes occasional shortness of breath or tired muscles
- Fear of recurrence remains
**Meaning for daily life:**
With the right medication and adjustments (diet, exercise, stress management), much of normal life can return. However: the risk of a recurrent event (a new heart attack, sudden cardiac arrest, progressive heart failure) remains. This depends on how well risk factors are controlled.
**What is known about this stage:**
Of people with coronary heart disease who do not have another infarction, approximately 1–2% die per year from heart-related causes (source: long-term studies CASS, EuroHeart). For those with previous infarctions, the risk is higher. Much depends on age, number of damaged vessels, home circumstances, and medication adherence.
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When to contact your doctor
Call immediately (112/emergencies) or go to the hospital if you:
- Get sudden severe chest pain or pressure sensation lasting longer than a few minutes
- Have shortness of breath with chest pain
- Faint or feel severely dizzy
- Feel irregular or very fast heartbeat with pain or dizziness
- Have cold sweats, nausea, and pain at the same time
- Get severe symptoms again after a previous heart attack
Call your doctor urgently (same day) if:
- Chest pain changes in pattern (stronger, longer, or at unexpected times)
- Shortness of breath worsens
- Feet/legs suddenly swell
- Medication no longer seems to help
- You feel very anxious or depressed
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_This information never replaces a doctor's judgment.