ATHEROSCLEROSIS

What Is Atherosclerosis?
Atherosclerosis is a hardening and narrowing of arteries caused by
cholesterol plaques lining the artery over time. It can put blood flow at risk
as arteries become blocked. It called arteriosclerosis also. At onset there are
usually no symptoms, but if they develop, symptoms generally begin around
middle age. When severe, it can result in coronary artery
disease, stroke, peripheral artery disease, or kidney problems, depending on
which arteries are affected.
What Causes Atherosclerosis?
Arteries are blood vessels that carry blood from your heart throughout the
body. They're lined by a thin layer of cells called the endothelium. It keeps
the inside of the arteries in shape and smooth, which keeps blood flowing.
Atherosclerosis begins with damage to the endothelium. Common causes
include:
 High cholesterol
 High blood pressure
 Inflammation, like from arthritis or lupus
 Obesity or diabetes
 Smoking
 family history
 Unhealthy diet

That damage causes plaque to build up along the walls of the arteries. When
bad cholesterol, or LDL, crosses a damaged endothelium, it enters the wall of
artery. White blood cells stream in to digest the LDL. Over the years,
cholesterol and cells become plaque in the wall of the artery.
Plaque creates a bump on artery wall. As atherosclerosis gets worse, that
bump gets bigger. When it gets big enough, it can create a blockage.
That process goes on throughout the entire body. It’s not only the heart at
risk, but there is risk for stroke and other health problems also.
Atherosclerosis usually doesn’t cause symptoms until you’re middle-age or
older. As the narrowing becomes severe, it can choke off blood flow
and cause pain. Blockages can also rupture suddenly. That causes blood to
clot inside an artery at the site of the rupture.

What Are the Risk Factors for Atherosclerosis?

Atherosclerosis starts when a person is young. Research has found that even
teenagers can have signs. If you’re 40 and generally healthy, you have about
a 50% chance of getting serious atherosclerosis in your lifetime. The risk
goes up as the person gets older. Most adults older than 60 have some
atherosclerosis, but most don’t have noticeable symptoms.
These risk factors are behind more than 90% of all heart attacks:

A. Modifiable
 Diabetes mellitus. Diabetes makes a person 2 to 6 times more likely
to develop atherosclerosis. This condition puts younger women (pre-
menopausal) at risk.
 High blood pressure (hypertension). High blood pressure that
persists for a long time can damage the artery wall. If the blood
pressure is higher than 110/75 mm Hg, you face a greater risk. And
that risk goes up the more the blood pressure goes up.
 High cholesterol. High levels of LDL, or “bad cholesterol,” can be
especially dangerous.
 Obesity. Obesity raises the blood pressure, blood sugar and
cholesterol levels. It also causes inflammation throughout the body.
Lifestyle factors also play a role. These factors include:
 Smoking.
 Lack of physical activity.
 A diet high in saturated fat, and trans fat, cholesterol, sodium (salt)
and sugar.

B. Non-modifiable
 South Asian descent
 Advanced age
 Genetic abnormalities
 Family history
 Coronary anatomy and branch pattern

Rates of death from atherosclerosis have fallen 25% in the past 3 decades.
This is because of better lifestyles and improved treatments.

PATHOPHYSIOLOGY: Development of the disease

Stage 1: Endothelial damage and immune response

Atherosclerosis begins when damage occurs to the inner layer of artery wall.
This layer is called the intima. The surface of the intima is lined with
endothelial cells. This thin lining, called the endothelium, is the barrier
between blood and artery wall.
Many things can harm this endothelium. The most common culprits include:
 High levels of LDL (“bad”) cholesterol circulating in the blood.
 Toxins, like those from cigarette smoke.
  High blood pressure that persists for a long time.
Once the endothelium is damaged, several things happen:
1. Cholesterol from the blood starts gathering at the site of injury.
2. These cholesterols become oxidized
3. This causes monocyte cells to travel to the area which lead to
inflammation within the artery.

Stage 2: Fatty streak

1. The monocytes that moved to the artery turn into cells called
macrophages. Macrophages consume the cholesterol and form “foam
cells.”
2. Foam cells consume more cholesterol and they die.
3. As this process continues, it damages the endothelium more.
4. All the dead foam cells form a bulge underneath the endothelium. This is
“fatty streak”.

Stage 3: Plaque growth

More dead foam cells and other debris continue building up at the site of the
fatty streak. The fatty streak slowly gets bigger and forms into a larger piece
of plaque. The plaque keeps growing. It gains calcium, which makes it
harder.
For a while, the blood still has enough room to pass through. As the plaque
gets too big, the opening of the artery becomes narrower and narrower.
There’s less room for the blood to flow through. Eventually, it can rupture.

Stage 4: Plaque rupture

In this final stage, the plaque ruptures and causes major problems in the
body.
This can trigger a blood clot to form. This blood clot (known as a “thrombus”)
blocks the blood flow and leads to a heart attack or stroke.

PREVENTION
Up to 90% of cardiovascular disease may be preventable if established risk
factors are avoided. Medical management of atherosclerosis first involves
modification to risk factors–for example, via smoking cessation and diet
restrictions. Prevention then is generally by eating a healthy diet, exercising,
not smoking, and maintaining a normal weight.
Diet
Changes in diet may help prevent the development of atherosclerosis.
Tentative evidence suggests that a diet containing dairy products do not
decreases the risk of cardiovascular disease.
A diet high in fruits and vegetables decreases the risk of cardiovascular
disease and death. Evidence suggests that a low-fat diet bring about long-
term changes to cardiovascular risk factors (e.g., lower cholesterol
level and blood pressure).
Exercise
Exercise is manage weight in patients who are obese, lower blood pressure,
and decrease cholesterol. Often lifestyle modification is combined with
medication therapy.