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Chronic Care

What is a chronic disease?

Chronic diseases are conditions that last for more than a year and require ongoing medical attention or limit the activities of daily life.

According to the Centers for Disease Control and Prevention (CDC), six in ten adults in the US have a chronic disease and four in ten adults have two or more. The top three chronic conditions - heart disease, cancer, and diabetes - are the leading cause of death and disability in the US.

What are the most common chronic diseases in older adults?

The most common chronic diseases in older adults includes:

  • Hypertension (high blood pressure)
  • High Cholesterol
  • Arthritis
  • Coronary Heart Disease
  • Diabetes
  • Chronic Kidney Disease
  • Heart Failure
  • Depression
  • Alzheimer's Disease/Dementia
  • Chronic Obstructive Pulmonary Disease (COPD)

Don't let chronic conditions get you down keep you down. Save up to 60% when you book an appointment through Sesame today. Get your wellness journey started today with convenient and affordable care on Sesame.

What causes chronic illnesses?

Many chronic diseases are brought on by factors under our control. These include:

Tobacco use: Tobacco is the leading cause of preventable disease, disability, and death in the US. Each year 480,000 people die from smoking cigarettes with an additional 41,000 dying from secondhand smoke exposure.

Poor nutrition: Diets in the United States tend to be high in added sugars, sodium, and saturated fats, which can lead to high blood pressure, heart disease, heart attacks, and stroke. Fewer than 1 in 10 adults and adolescents living in the US meet their requirements for fruits and vegetables.

Lack of physical activity: Only 1 in 4 adults and 1 in 5 high school students in the US get the recommended levels of physical activity. Lack of activity combined with poor nutrition can lead to obesity. 40% of US adults have obesity, which puts them at increased risk for cardiovascular disease, heart failure, type 2 diabetes, and some cancers (primarily endometrial, colorectal, and breast cancer). Additionally, obesity costs the US health care system $147 billion each year.

Excessive alcohol consumption: Excessive use of alcohol can lead to serious health problems such as alcohol use disorder and problems with learning, memory, and mental health. Chronic health conditions linked to excessive alcohol consumption include high blood pressure, heart disease, stroke, liver disease, and cancer.

How can I prevent chronic diseases?

Making a few positive lifestyle changes and practicing some self-care can not only help to prevent chronic diseases but also enhance your overall quality of life. Some suggestions from the CDC include:

  • Quit smoking
  • Eat a healthy diet
  • Get regular physical activity
  • Avoid excessive alcohol use
  • Get regular screenings
  • Get enough sleep
  • Know your family history (so that you can take steps to catch conditions early or possibly even prevent them)

What is the best way to treat chronic diseases?

Treatment plans are as diverse and varied as the chronic conditions they fight.

However, for many chronic conditions, there are a few actionable steps that can help a great deal with chronic disease management. Here a just a few:

- Take time to learn about your disease. It will be helpful to know what you can expect, what is happening, and why.

- Build a team. Your doctor is a great resource, but may not be as helpful to you for making key changes to your diet as a dietician might be or to an exercise regimen as a physical therapist.

- Make healthy choices. If you smoke, quit. If you drink, stop. Not getting enough exercise or proper nutrition? Fix that too! Small steps can affect big change.

- Get better at stress management. Meditate, do yoga, find a support group, get a message or book an acupuncture session.

- Recruit your family. Changes to ease a chronic condition such as high cholesterol, hypertension, or heart disease are generally good for everyone. Making healthy changes will not only help to hold you accountable, but it might keep them from getting a chronic illness as well.

Can I refill any medication over video?

Doctors on Sesame can refill most prescriptions for simple things like medication for diabetes and high blood pressure, antidepressants, birth control, and more. Doctors can't refill controlled substances over video. Yep, even if you've taken it for years.

How do healthcare professionals manage pain?

Chronic conditions are responsible for 7 out of every 10 deaths in the United States. Chronic pain management and treatment is a growing medical field, and new treatment options are being developed to help you live pain-free. Here are a few ways that doctors manage patients' chronic pain:

Drug Therapy: For some patients, pain management specialists may recommend or prescribe pain medication. Over-the-counter drugs like Tylenol, aspirin, ibuprofen, and naproxen have proven effective in managing many types of pain. NSAIDs have also been shown to help combat inflammation and swelling. If necessary, your doctor may prescribe additional pain medicine. All prescriptions are at the sole discretion of your doctor.

TENS: TENS, or transcutaneous electrical nerve stimulation therapy, uses low-voltage electrical currents to help alleviate pain. This stimulates nerves, sending signals to the brain that disrupt - and temporarily alleviate - your pain. TENS has been shown to be an effective treatment for neuropathy.

Spinal Cord Stimulation: For some chronic pain, doctors may recommend implanting a spinal cord stimulator into your spinal cord. This device directly stimulates your spinal cord with low levels of electricity, which can help reduce certain pains. Spinal cord stimulators, which require two implantation procedures, have been shown to improve patients' quality of life and reduce their reliance on pain killers.

Nerve Blocks: Nerve blocks are another neurological defense against pain. Nerve blocks are a shot that board-certified doctors use to effectively "turn off" certain nerves that are causing you pain.

Physical Therapy: Chronic pain isn't always the result of a serious condition like cancer or diabetes. Sometimes, pain can be caused by a lack of strength or mobility. Physical therapists work with patients to enhance and restore both. Whether you're suffering from herniated discs or a torn ACL, physical therapists can rehab you back into shape. Physical medicine specialists, doctors who focus on enhancing the quality of life of people with chronic disabilities, can also help provide strategies to keep pain at bay.

What causes back pain?

Back pain can be caused by any number of problems. According to the ACA, back pain is the third most common reason for doctor’s office visits although not usually caused by serious conditions such as arthritis, infection, or cancer. Some common causes of back pain are:

Muscle or ligament strain: Heavy lifting, sudden movement, or awkward sleeping positions have been known to cause strain on muscles and ligaments in the back. Pulled muscles, tendons, and ligaments can lead to tightness in the back and painful spasms.

Bulging discs: The back has 24 spinal discs, which are spongy cushions that separate the individual vertebrae in the spinal cord and up through the neck. These discs act as shock absorption and allow for pivot points (movement) in the back. When inflammation occurs around the tough membrane surrounding the vertebral disc without rupturing it, the disc is referred to as bulging. Bulging discs can lead to numbness, pain, and difficulty walking (among other symptoms).

Herniated discs: Herniated discs, or slipped discs, are often confused for bulging discs. A herniated disc, though, has ruptured the tough membrane surrounding the spongy tissue, causing the soft material to push through the rupture and irritate nerves around the area. Herniated discs can cause arm or leg pain, numbness, tingling, and muscle weakness. Herniated discs can cause inflammation leading to pinched nerves which can affect limbs and mobility.

Arthritis (or osteoarthritis): According to the Arthritis Foundation, arthritis is not a single disease, but a way to refer to joint pain or joint disease. Osteoarthritis is the most common form of arthritis; characterized by swelling and tenderness in the joints, usually caused by the deterioration of cartilage between bones in joints. This causes bones to rub up against each other during movement, which leads to swelling, stiffness, and pain. Arthritis usually worsens with age, as cartilage continues to break down. Obesity and medical history can also contribute to risk factors associated with arthritis.

Osteoporosis: Osteoporosis is a disease that causes bones to lose mass, thereby becoming weak and brittle. When the body loses too much bone mass without making enough replacement bone, bones can be fractured more easily. In severe cases, osteoporosis can lead to bone fractures from small occurrences like sneezing or bending over. When left untreated, osteoporosis leads to back pain, loss of height, and easy bone breakage.

Stress: Poor posture, excess weight, or inadequate exercise can lead to pressure in the muscles on the back. If the body is constantly hunched over, or muscles are left tight without stretching, the muscles in the back have to work extra hard to maintain mechanical mobility. This can lead to aching and soreness in the back.

Fibromyalgia: Fibromyalgia is a chronic disorder that causes fatigue, pain in muscles and bones, tenderness, and cognitive disturbances (like lack of sleep). Fibromyalgia causes regions of pain that produce a constant dull aching. Because the nerves of the body are constantly being stimulated due to pain, the brain develops an abnormal nervous system response to pain, causing the pain receptors in the brain to overreact to pain and non-painful stimuli. Illness, trauma, stress, and genetic inheritance (family history of the disease) can cause fibromyalgia.

Back pain is one of the most persistent and widespread conditions affecting Americans today, Sesame offers a range of care options such as chronic care visits, chiropractic visits, and physical therapy visits.

How can I treat chronic low back pain?

Chronic low back pain is characterized by low back pain that persists for 12 weeks or longer. According to the NIH, roughly 20 percent of people who experience low back pain develop chronic back pain within the year. Most underlying causes of low back pain do not require serious medical attention and treatment plans may vary based on the patient’s risk factors.

Chronic low back pain may require an x-ray, magnetic resonance imaging (MRI), or computed tomography (CT) scan to examine soft tissue and check for any internal injuries or growths. Conditions such as kidney stones can cause acute low back pain, and a physical examination might be required to help diagnose any underlying causes of low back pain. Chronic low back pain can be treated by a doctor using treatment options such as:

Chiropractic adjustments: Doctors can use spinal manipulation to adjust or stimulate the spine and the soft tissues surrounding the spinal cord. This can help relieve pain and increase mobility but is not recommended for people with underlying causes of low back pain, such as osteoarthritis, osteoporosis, or spondylosis.

Steroid injections: In some severe cases, a doctor may prescribe an epidural or corticosteroid injection to help relax muscles and relieve pain. Steroid injections can have adverse effects if used frequently, and provide only temporary relief.

Surgery: Back surgery may be required for severe chronic low back pain, or low back pain that is caused by degenerative diseases such as spondylolisthesis or arthritis. The exact surgical procedure varies based on the patient’s need, and back surgeries are not always successful. Surgery is often performed as a last resort to help relieve pain and regain some mechanical functionality in the back.

Whether you are experiencing acute low back pain, or have been dealing with chronic low back pain for several weeks, Sesame offers care from real, quality doctors near you. Don’t let low back pain control your life. Connect directly with a doctor on Sesame today to discuss treatment options that will work for you.

What is the best treatment for back pain?

If you're dealing with persistent low back pain, there are several treatment options to help with pain relief and muscle tension. Over-the-counter pain relievers, cold packs, and heating pads - along with old-fashioned bed rest - are among the most commonly prescribed treatments for lower back pain. Chronic low back pain can be complicated, though, and additional back pain treatment may be needed. Some of the best treatments for back pain include:

Hot/ Cold Therapies: Bed rest and a steady dose of heating pads and ice packs can help stimulate blood flow to the ligaments and muscles in the back. This can help reduce inflammation of the soft tissues in the back and speed up recovery time, especially when complemented with over-the-counter pain relievers.

Over-the-counter (OTC) pain relievers: Nonsteroidal anti-inflammatory drugs (NSAIDs) can help with back pain relief. Drugs such as ibuprofen (Advil), acetaminophen (Tylenol), or naproxen (Aleve) will reduce inflammation and reduce pain symptoms.

Muscle relaxants: Muscle relaxants are used to treat acute, rather than chronic, low back pain. These drugs are usually used if NSAIDs are unable to help with pain management. Muscle relaxers will release muscle tension in the back, which can help reduce muscle spasms and back pain.

Physical therapy/ chiropractic care: A physical therapist can offer medical advice, acupuncture therapy, and stretching exercises to increase physical activity and strengthen the abdominal muscles that can help support the back. Weak abdominal muscles are one of the most common causes of low back pain. Strengthening these muscles can help with the stability and support of the lumbar vertebrae. Physical therapy can help restore mobility affected by:

  • Herniated disk
  • Back sprains
  • Compression fractures
  • Spondylitis (inflammatory arthritis in the back)
  • Sciatica
  • Osteoporosis/ Osteoarthritis
  • Lumbar spinal stenosis

Chiropractors can also help with pain management and injury prevention by providing hands-on health care like spinal manipulation. Spinal manipulation thrusts joints in the spine into their proper place, helping take pressure off certain areas of the spine and improve posture.

Back pain is one of the most common causes of disability in America, with nearly 60-70% of adults experiencing some form of lower back pain every year. Chronic low back pain can lead to missed work, high health care costs, and reduced quality of life. Fed up with a constant ache in your back? Get in touch with a real, quality doctor on Sesame to book a convenient and affordable back pain consultation. Doctors on Sesame will address your symptoms, recommend treatment options, and offer referrals if needed. Don't wait to treat your low back pain. Save up to 60% when you book an in-person or video visit on Sesame - no insurance needed.

How can I relieve back pain at home?

Dealing with an aching back? Back pain affects millions of Americans every year - leading to over $100 billion in health care costs per year. The good news? Many cases of low back pain can be managed with simple, affordable, at-home remedies such as:

Stretching and exercise: Physical therapy and exercise can help prevent further injury and reduce low back pain. Building the back and abdominal muscles through light strength training and mobility exercises helps stabilize the spine and take the pressure off the bones and joints in the back. Additionally, a stretching routine can loosen muscles in the back and stimulate blood flow to the posterior chain, helping speed up recovery.

Over-the-counter (OTC) medication: NSAID pain relievers can reduce inflammation and relieve pain. These drugs are inexpensive and can be found in most major drugstores.

Hot/cold therapy: Rest, along with a steady diet of cold packs and heating pads, can help lessen swelling and stimulate blood flow. By reducing inflammation and improving circulation, blood can help soft tissues and muscles in the back recover quicker.

Maintain a healthy weight: Obesity is one of the common causes of back pain, as excess weight can put pressure on the spine. Physical activity and a healthy diet can help minimize undue stress on the back, reducing the risk of injury and low back pain.

How can I prevent back pain?

The American Chiropractic Association states that at least one-half of working Americans experience back pain symptoms every year. Back pain isn't just a health issue - it's an economic one. Back pain is the leading cause of disability in America, and is responsible for nearly $100 billion in health care costs, lost pay, and decreased productivity. There are several tips and strategies to help prevent or manage low back pain including:

Maintaining a healthy weight: Being overweight or obese can cause strain on back muscles, which can lead to tightness and strain. A healthy diet and exercise can help you maintain a healthy weight and put less stress on the musculoskeletal structures in your back.

Exercise: A low-impact exercise program that doesn’t strain the back can help improve mobility and build strength. Physical activities that use the back muscles and abdominal muscles help to condition those areas and build core strength, preventing back injury. The Mayo Clinic recommends frequent walking and swimming as low-impact activities that can help build strength and endurance in the core and back. Exercise, along with a healthy diet, can help with weight loss, and general wellness.

Quit smoking: Smoking leads to loss of blood flow, which keeps much-needed oxygen and nutrients from reaching spinal tissues. Smoking increases your risk of lower back pain and may cause an increase in the amount you smoke during the day. Quitting smoking can help prevent lower back pain, among a wide range of other health benefits.

Maintain proper posture: Slouching and improper posture can put a strain on back muscles. If you are able, sit in chairs that feature lumbar support and change your position frequently. Try to stand and walk around every half-hour or so to prevent from back muscles tightening.

Lift properly: Lift heavy objects with your legs, keep your back straight, and refrain from twisting while lifting. Hold the object you are lifting close to your body, and get help if the object seems too heavy. Lifting with improper technique, or lifting objects that are too heavy, can cause herniated discs and lower back pain.

As with any medical condition, the cause of your back pain may be different. That's why it's best to connect directly with a qualified doctor to assess your symptoms and craft a treatment plan that's right for you, your back, and your health.

What is chronic kidney disease?

Chronic kidney disease (CKD), sometimes referred to as chronic renal failure (CRF), encompasses all 5 stages of decreased kidney function. The job of the kidneys is to filter extra water and waste products out of your blood and to make urine.

The National Kidney Foundation defines kidney disease as "either kidney damage or a decreased glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2." Translation: Your kidneys are too damaged and can't filter blood the way they should.

You may be at increased risk of developing kidney disease if you have high blood pressure, heart disease, a family history of kidney failure, or are a diabetic. If you have any of these risk factors, it is a good idea to get tested for kidney disease and to protect your kidneys by making healthy food choices, getting plenty of physical activity, maintaining a healthy weight, and managing any conditions that might cause kidney damage.

If you're looking to get tested and don't know where to start, book a visit with a real, quality primary care physician on Sesame and save up to 60% on your first appointment - no insurance needed.

What are the causes of chronic kidney disease?

Chronic kidney disease can be caused by many different factors.

Some of the common causes of CKD include:

  • Type 1 or 2 diabetes
  • High blood pressure (hypertension)
  • Glomerulonephritis
  • Vesicoureteral reflux
  • Recurrent kidney infection (pyelonephritis)
  • Interstitial nephritis
  • Polycystic kidney disease
  • Prolonged obstruction of the urinary tract

Some other risk factors include:

  • High blood pressure
  • Heart and blood vessel (cardiovascular) disease
  • Ethnicities such as African-Americans, Native Americans, and Asian-Americans
  • Abnormal kidney structure

How is chronic kidney disease diagnosed?

A doctor can use two simple tests to diagnose chronic kidney disease - a blood test and a urine test.

The doctor will be testing to get an idea of your ACR or Albumin to Creatinine ratio.

An excess amount of protein (albumin) in your urine may mean that your kidney's filtering units (glomeruli) have been damaged by disease.

The blood test will show the level of waste products, such as urea and creatinine, in your blood.

The doctor will then use these results along with your age, race, gender, and other factors to calculate your glomerular filtration rate (which shows how much kidney function you have).

What are the symptoms of chronic kidney disease?

It is possible to have no signs or symptoms in the early stages of CKD. The kidneys have a tremendous capacity to keep us healthy, and slight decreases in function can often go unnoticed.

As kidney disease worsens, a person may experience swelling (called edema) as the kidneys struggle to get rid of extra fluid and salt.

Some symptoms of advanced chronic kidney disease include:

  • Chest pain
  • Sleep problems
  • Trouble concentrating
  • Itching or numbness
  • Weight loss
  • Feeling tired
  • Headaches
  • Vomiting
  • Increase or decreased urination
  • Loss of appetite
  • Muscle cramps
  • Nausea
  • Shortness of breath

What complications can chronic kidney disease cause?

In many ways, we are as healthy as our kidneys. The kidneys drive a significant number of bodily functions, and loss of kidney capacity can cause side effects like:

  • Fluid retention, which causes swelling in your arms and legs, also known as pulmonary edema
  • A sudden rise in potassium levels in your blood. This can impair your heart's ability to function and may be life-threatening
  • Cardiovascular disease (Heart and blood vessel)
  • Weak bones
  • Anemia
  • Negative impacts on sexual health
  • Decreased immune system function
  • Potential pregnancy complications
  • Irreversible damage to your kidneys (end-stage renal disease), eventually requiring either dialysis or a kidney transplant for survival

What is diabetes?

Diabetes is a chronic condition in which the body does not properly process food into energy. When we eat food (particularly carbs) the body turns it into glucose (sugar), the substance our body uses as energy. Central to this process is insulin, a hormone made by the pancreas to help cells absorb glucose. In people with diabetes, the body either does not produce enough insulin or uses it inefficiently. This causes the blood sugar, or blood glucose levels, to either get too high (hyperglycemia) or too low (hypoglycemia).

What are the four types of diabetes?

There are four main kinds of diabetes. They are:

Prediabetes: This is when your blood sugar is too high, but not high enough for your doctor to diagnose it as diabetes. It can, however, make you more likely to get type 2 diabetes and heart disease. More than a third of all people in the United States have prediabetes, though most are unaware of it. Exercising more and losing weight can lower the risk of it progressing.

Type 1 diabetes: Also known as insulin-dependent diabetes, type 1 diabetes is an autoimmune condition. It occurs when your body attacks your pancreas with antibodies causing the organ to stop producing insulin.

Type 2 diabetes: With type 2 diabetes, the pancreas usually produces some insulin, but it either doesn't produce enough, or the body doesn't use it correctly. About 90% of people who have diabetes have type 2. People who are obese (more than 20% over their target body weight) are at higher risk of type 2 diabetes.

Gestational diabetes: Pregnancy often causes some amount of insulin resistance. When it gets bad enough to become diabetes it is known as gestational. Gestational diabetes occurs in about 2%-10% of pregnancies and it usually goes away after birth. However, about 10% of women who have gestational diabetes get type 2 later on.

What are the risk factors for diabetes?

The exact cause of type 1 is unknown, though risk factors may include: family history, environment, presence of autoantibodies, and geography. Risk factors for type 2 diabetes may include:

  • Being overweight
  • Inactivity
  • Family history
  • Race/ethnicity
  • Age
  • High blood pressure
  • Low HDL ("good cholesterol") or high triglyceride levels

What are the possible complications of diabetes?

Possible complications from diabetes include:

  • Cardiovascular disease
  • Kidney disease
  • Eye damage
  • Nerve damage
  • Foot problems
  • Skin conditions

How is diabetes treated?

Diabetes treatment involves keeping a close eye on your blood sugar levels and keeping them in the target range set by your doctor through a combination of diet, exercise, and medication.

Your doctor may recommend you check your blood glucose levels daily. An instrument called a glucometer is used to check the blood sugar by dabbing a sample of your blood on a strip of paper. A newer device, known as a continuous glucose monitor (CGM), can be attached to your body and can measure your blood sugar every few minutes for up to a week at a time.

Monitoring your glucose gives you and your doctor a better idea of your body's changing need for insulin. For some people with type 2 diabetes, diet and exercise may be enough to control your diabetes. Others will need medication, which may be either an oral drug or insulin. There are a variety of oral drugs that a doctor may choose to prescribe, that each works in different ways. Insulin may be administered either as a shot, an insulin pen, or have an insulin pump.

How can I reverse diabetes naturally?

Diabetes is a serious illness that you cannot treat on your own. You will want to see a doctor, and possibly build a team of health professionals, to help with your diabetes management. While there is no cure for diabetes, in some cases type 2 diabetes can be reversed. This means that the disease is in remission and your blood sugar levels can stay in a healthy range without needing medication. The key to this is often weight loss. Consult your health care team to figure out what method is best for you.

What is a diabetes care plan?

A diabetes care plan is a written document detailing the specific needs of diabetic students for the faculty and staff. It includes information such as what foods and medicines they take, when to take them, how much, and how the medicine is administered. Children and students with diabetes should have a care plan on file at their schools.

What is heart disease?

Heart disease (cardiovascular disease) is an umbrella term that describes many types of heart problems including atrial fibrillation and arrhythmias (irregular heartbeats), high blood pressure, and coronary artery disease. Heart conditions are treatable by a cardiologist, a doctor who specializes in heart and cardiovascular health care.

What are the symptoms of heart disease?

Heart disease symptoms can vary from patient to patient.

If you feel any chest pain, faint, or have shortness of breath call 911. These may be symptoms of a heart attack.

Common types of heart disease and their related symptoms include:

  • Heart disease in your blood vessels: Pain, pressure, tightness, or general discomfort in the chest.

  • Heart defect: Bluish or pale gray skin color, swollen legs, eyes, or abdomen.

  • Heart disease caused by abnormal heartbeats: Fainting, dizziness, chest pain or discomfort, fast heartbeat, slow heartbeat, feeling lightheaded, and/or a fluttering in your chest.

  • A diseased heart muscle (cardiomyopathy): Feeling breathless even at rest, swollen legs, ankles, and feet, fatigue, fluttering or pounding heartbeats, dizziness, fainting, and/or feeling lightheaded.

  • Heart infection: Fever, skin rash, changes in your heartbeat, shortness of breath, fatigue or weakness, swelling of the legs or abdomen, and/or a dry persistent cough.

  • Valvular heart disease: pain in the chest, fatigue, shortness of breath, unusual heartbeat, swollen feet or ankles, and/or fainting.

It is important to maintain your cardiovascular health. Speak today with a real, quality heart specialist on Sesame for one affordable, upfront price.

What are the risk factors for heart disease?

The risk of heart disease varies based on your family history, lifestyle, age, and race. Risk factors include:

Obesity: Those with a high body mass index (BMI) are at greater risk of developing heart disease.

High blood pressure (hypertension): This can often be treated with calcium channel blockers, beta-blockers, and diuretics.

High cholesterol: Treatment for high cholesterol includes statins.

Genetics: Heart disease can run in the family.

Alcohol and tobacco use: can raise blood pressure, and damage the heart and blood vessels

Poor diet: A diet rich in saturated fats, cholesterol, and trans fats is linked to heart disease.

Heart defects: congenital heart defects put you at a higher risk for coronary heart disease.

What are the symptoms of coronary artery disease?

The most common symptom of coronary artery disease (CAD) is angina, the medical term for chest pain. If this discomfort is joined by nausea, pain in the arm, or shortness of breath, you could be having a heart attack. You must act immediately if you believe you are suffering from a heart attack.

Coronary artery disease is a type of heart disease that is caused by a buildup of plaque in the wall of blood vessels (arteries)that directly supply blood to the heart.

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