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ARTHEROSCLEROSIS

Definition

Atherosclerosis is the build up of a waxy plaque on the inside of


blood vessels. In Greek, athere means gruel, and skleros means hard.
Atherosclerosis is often called arteriosclerosis. Arteriosclerosis (from the
Greek arteria, meaning artery) is a general term for hardening of the
arteries. Arteriosclerosis can occur in several forms, including
atherosclerosis.

Description

 Atherosclerosis, a progressive process responsible for most heart


disease, is a type of arteriosclerosis or hardening of the arteries.
 An artery is made up of several layers: an inner lining called the
endothelium, an elastic membrane that allows the artery to expand
and contract, a layer of smooth muscle, and a layer of connective
tissue.
 Arteriosclerosis is a broad term that includes a hardening of the inner
and middle layers of the artery. It can be caused by normal aging, by
high blood pressure, and by diseases such as diabetes. It is
characterized by plaque deposits that block the flow of blood.
 Plaque is made of fatty substances, cholesterol, waste products from
the cells, calcium, and fibrin, a stringy material that helps clot blood.
 The plaque formation process stimulates the cells of the artery wall to
produce substances that accumulate in the inner layer.
 Fat builds up within these cells and around them, and they form
connective tissue and calcium.
 The inner layer of the artery wall thickens, the artery's diameter is
reduced, and blood flow and oxygen delivery are decreased. Plaques
can rupture or crack open, causing the sudden formation of a blood
clot (thrombosis).
 Atherosclerosis can cause a heart attack if it completely blocks the
blood flow in the heart (coronary) arteries. It can cause a stroke if it
completely blocks the brain (carotid) arteries.
 Atherosclerosis can also occur in the arteries of the neck, kidneys,
thighs, and arms, causing kidney failure or gangrene and
amputation.

Causes and symptoms

 Atherosclerosis can begin in the late teens, but it usually takes


decades to cause symptoms.
 Some people experience rapidly progressing atherosclerosis during
their thirties, others during their fifties or sixties.
 Atherosclerosis is complex. Its exact cause is still unknown. It is
thought that atherosclerosis is caused by a response to damage to the
endothelium from high cholesterol, high blood pressure, and
cigarette smoking.
 A person who has all three of these risk factors is eight times more
likely to develop atherosclerosis than is a person who has none.
 Physical inactivity, diabetes, and obesity are also risk factors for
atherosclerosis.
 High levels of the amino acid homocysteine and abnormal levels of
protein-coated fats called lipoproteins also raise the risk of coronary
artery disease.
 These substances are the targets of much current research. The role
of triglycerides, another fat that circulates in the blood, in forming
atherosclerotic plaques is unclear. High levels of triglycerides are
often associated with diabetes, obesity, and low levels of high-density
lipoproteins (HDL cholesterol). The more HDL ("good") cholesterol, in
the blood, the less likely is coronary artery disease. These risk factors
are all modifiable. Non-modifiable risk factors are heredity, sex, and
age.

Risk factors that can be changed:

• Cigarette/tobacco smoke--Smoking increases both the chance of


developing atherosclerosis and the chance of dying from coronary
heart disease. Second hand smoke may also increase risk.
• High blood cholesterol--Cholesterol, a soft, waxy substance, comes
from foods such as meat, eggs, and other animal products and is
produced in the liver. Age, sex, heredity, and diet affect cholesterol.
Total blood cholesterol is considered high at levels above 240 mg/dL
and borderline at 200-239 mg/dL. High-risk levels of low-density
lipoprotein (LDL cholesterol) begin at 130-159 mg/dL.
• High triglycerides--Most fat in food and in the body takes the form of
triglycerides. Blood triglyceride levels above 400 mg/dL have been
linked to coronary artery disease in some people. Triglycerides,
however, are not nearly as harmful as LDL cholesterol.
• High blood pressure--Blood pressure of 140 over 90 or higher makes
the heart work harder, and over time, both weakens the heart and
harms the arteries.
• Physical inactivity--Lack of exercise increases the risk of
atherosclerosis.
• Diabetes mellitus--The risk of developing atherosclerosis is seriously
increased for diabetics and can be lowered by keeping diabetes under
control. Most diabetics die from heart attacks caused by
atherosclerosis.
• Obesity--Excess weight increases the strain on the heart and
increases the risk of developing atherosclerosis even if no other risk
factors are present.

Risk factors that cannot be changed:

• Heredity--People whose parents have coronary artery disease,


atherosclerosis, or stroke at an early age are at increased risk. The
high rate of severe hypertension among African-Americans puts them
at increased risk.
• Sex--Before age 60, men are more likely to have heart attacks than
women are. After age 60, the risk is equal among men and women.
• Age--Risk is higher in men who are 45 years of age and older and
women who are 55 years of age and older.
Symptoms differ depending upon the location of the atherosclerosis.

• In the coronary (heart) arteries: Chest pain, heart attack, or sudden


death.
• In the carotid (brain) arteries: Sudden dizziness, weakness, loss of
speech, or blindness.
• In the femoral (leg) arteries: Disease of the blood vessels in the outer
parts of the body (peripheral vascular disease) causes cramping and
fatigue in the calves when walking.
• In the renal (kidney) arteries: High blood pressure that is difficult to
treat.

Diagnosis
 Physicians may be able to make a diagnosis of atherosclerosis during
a physical exam by means of a stethoscope and gentle probing of the
arteries with the hand (palpation). More definite tests are
electrocardiography, echocardiography or ultrasonography of the
arteries (for example, the carotids), radionuclide scans, and
angiography.
 An electrocardiogram shows the heart's activity. Electrodes covered
with conducting jelly are placed on the patient's body. They send
impulses of the heart to a recorder. The test takes about 10 minutes
and is performed in a physician's office.
 Exercise electrocardiography (stress test) is conducted while the
patient exercises on a treadmill or a stationary bike. It is performed in
a physician's office or an exercise laboratory and takes 15-30
minutes.
 Echocardiography, cardiac ultrasound, uses sound waves to create an
image of the heart's chambers and valves. A technician applies gel to
a hand-held transducer, presses it against the patient's chest, and
images are displayed on a monitor. This technique cannot evaluate
the coronary arteries directly. They are too small and are in motion
with the heart. Severe coronary artery disease, however, may cause
abnormal heart motion that is detected by echocardiography.
 Performed in a cardiology outpatient diagnostic laboratory, the test
takes 30-60 minutes. Ultrasonography is also used to assess arteries
of the neck and thighs.
 Radionuclide angiography and thallium (or sestamibi) scanning
enable physicians to see the blood flow through the coronary arteries
and the heart chambers.
 Radioactive material is injected into the bloodstream. A device that
uses gamma rays to produce an image of the radioactive material
(gamma camera) records pictures of the heart. Radionuclide
angiography is usually performed in a hospital's nuclear medicine
department and takes 30-60 minutes. Thallium scanning is usually
done after an exercise stress test or after injection of a vasodilator, a
drug to enlarge the blood vessels, like dipyridamole (Persantine).
 Thallium is injected, and the scan is done then and again four hours
(and possibly 24 hours) later. Thallium scanning is usually performed
in a hospital's nuclear medicine department. Each scan takes 30-60
minutes.
 Coronary angiography is the most accurate diagnostic method and
the only one that requires entering the body (invasive procedure). A
cardiologist inserts a catheter equipped with a viewing device into a
blood vessel in the leg or arm and guides it into the heart.
 The patient has been given a contrast dye that makes the heart visible
to x rays. Motion pictures are taken of the contrast dye flowing
though the arteries. Plaques and blockages, if present, are well
defined. The patient is awake but has been given a sedative. Coronary
angiography is performed in a cardiac catheterization laboratory
and takes from 30 minutes to two hours.

Treatment
 Treatment includes lifestyle changes, lipid-lowering drugs,
percutaneous transluminal coronary angioplasty, and coronary
artery bypass surgery. Atherosclerosis requires lifelong care.
 Patients who have less severe atherosclerosis may achieve adequate
control through lifestyle changes and drug therapy. Many of the
lifestyle changes that prevent disease progression--a low-fat, low-
cholesterol diet, losing weight (if necessary), exercise, controlling
blood pressure, and not smoking--also help prevent the disease.
 Most of the drugs prescribed for atherosclerosis seek to lower
cholesterol. Many popular lipid-lowering drugs can reduce LDL-
cholesterol by an average of 25-30% when combined with a low-fat,
low-cholesterol diet. Lipid-lowering drugs include bile acid resins,
"statins" (drugs that effect HMG-CoA reductase, an enzyme that
controls the processing of cholesterol), niacin, and fibric acid
derivatives such as gemfibrozil (Lobid).
 Aspirin helps prevent thrombosis and a variety of other medications
can be used to treat the effects of atherosclerosis.
 Percutaneous transluminal coronary angioplasty and bypass surgery
are invasive procedures that improve blood flow in the coronary
arteries. Percutaneous transluminal coronary angioplasty (coronary
angioplasty) is a non-surgical procedure in which a catheter tipped
with a balloon is threaded from a blood vessel in the thigh into the
blocked artery. The balloon is inflated, compresses the plaque to
enlarge the blood vessel, and opens the blocked artery. Coronary
angioplasty is performed by a cardiologist in a hospital and generally
requires a hospital stay of one or two days. It is successful about 90%
of the time, but for one-third of patients the artery narrows again
within six months. It can be repeated and a "stent" may be placed in
the artery to help keep it open.
 In coronary artery bypass surgery (bypass surgery), a detour is built
around the blockage with a healthy vein or artery, which then
supplies oxygen-rich blood to the heart. It is major surgery
appropriate for patients with blockages in two or three major coronary
arteries or severely narrowed left main coronary arteries, and for
those who have not responded to other treatments. It is performed in
a hospital under general anesthesia and uses a heart-lung machine.
About 70% of patients experience full relief; about 20% partial relief.
 Three other semi-experimental surgical procedures may be used to
treat atherosclerosis. In atherectomy, a cardiologist shaves off and
removes strips of plaque from the blocked artery. In laser angioplasty,
a catheter with a laser tip is inserted to burn or break down the
plaque. A metal coil called a stent may be permanently implanted to
keep a blocked artery open.

Prognosis
 Atherosclerosis can be successfully treated but not cured. Recent
clinical studies have shown that atherosclerosis can be delayed,
stopped, and even reversed by aggressively lowering LDL cholesterol.
 New diagnostic techniques enable physicians to identify and treat
atherosclerosis in its earliest stages. New technologies and surgical
procedures have extended the lives of many patients who would
otherwise have died. Research continues.

Prevention
A healthy lifestyle--eating right, regular exercise, maintaining a
healthy weight, not smoking, and controlling hypertension--can reduce
the risk of developing atherosclerosis, help keep the disease from
progressing, and sometimes cause it to regress.

• Eat right-A healthy diet reduces excess levels of LDL cholesterol and
triglycerides. It includes a variety of foods that are low in fat and
cholesterol and high in fiber; plenty of fruits and vegetables; and
limited sodium. Fat should comprise no more than 30%, and
saturated fat no more than 8-10%, of total daily calories according to
the American Heart Association. Cholesterol should be limited to
about 300 milligrams per day and sodium to about 2,400 milligrams.
The "Food Guide" Pyramid developed by the U.S. Departments of
Agriculture and Health and Human Services provides daily guidelines:
6-11 servings of bread, cereal, rice, and pasta; 3-5 servings of
vegetables; 2-4 servings of fruit; 2-3 servings of milk, yogurt, and
cheese; and 2-3 servings of meat, poultry, fish, dry beans, eggs, and
nuts. Fats, oils, and sweets should be used sparingly. Mono-
unsaturated oils, like olive and rapeseed (Canola) are good
alternatives to use for cooking.
• Exercise regularly--Aerobic exercise can lower blood pressure, help
control weight, and increase HDL ("good") cholesterol. It may keep the
blood vessels more flexible. Moderate to intense aerobic exercise
lasting about 30 minutes (or three 10-minute exercise periods) four or
more times per week is recommended, according to the Centers for
Disease Control and Prevention and the American College of Sports
Medicine. Aerobic exercise includes walking, jogging, and cycling,
active gardening, climbing stairs, or brisk housework. A physician
should be consulted before exercise if a person has atherosclerosis or
is at increased risk for it.
• Maintain a desirable body weight--Losing weight can help reduce
total and LDL cholesterol, reduce triglycerides, and boost HDL
cholesterol. It may also reduce blood pressure. Eating right and
exercising are two key components in maintaining a desirable body
weight.
• Do not smoke or use tobacco--Smoking has many adverse effects on
the heart but quitting can repair damage. Ex-smokers face the same
risk of heart disease as non-smokers within five to 10 years of
quitting. Smoking is the worst thing a person can do to their heart
and lungs.
• Seek treatment for hypertension--High blood pressure can be
controlled through lifestyle changes--reducing sodium and fat,
exercising, managing stress, quitting smoking, and drinking alcohol
in moderation--and medication. Drugs that provide effective treatment
are: diuretics, beta-blockers, sympathetic nerve inhibitors,
vasodilators, angiotensin converting enzyme inhibitors, and calcium
antagonists. Hypertension usually has no symptoms so it must be
checked to be known. Like cholesterol, hypertension is called a "silent
killer".

SOME BASIC TERMINOLOGY IN ATHEROSCLEROSIS

Arteriosclerosis
Hardening of the arteries. It includes atherosclerosis, but the two terms
are often used synonymously.

Cholesterol
A fat-like substance that is made by the human body and eaten in
animal products. Cholesterol is used to form cell membranes and
process hormones and vitamin D. High cholesterol levels contribute to
the development of atherosclerosis.
HDL Cholesterol
About one-third or one-fourth of all cholesterol is high-density
lipoprotein cholesterol. High levels of HDL, nicknamed "good" cholesterol,
decrease the risk of atherosclerosis.
LDL Cholesterol
Low-density lipoprotein cholesterol is the primary cholesterol molecule.
High levels of LDL, nicknamed "bad" cholesterol, increase the risk of
atherosclerosis

Plaque
A deposit of fatty and other substances that accumulates in the lining of
the artery wall.

Triglyceride
A fat that comes from food or is made from other energy sources in the
body. Elevated triglyceride levels contribute to the development of
atherosclerosis.