Atherosclerosis

Atherosclerosis (or arteriosclerotic vascular disease) is a condition where the arteries

become narrowed and hardened due to an excessive build-up of plaque around the artery
wall. The disease disrupts the flow of blood around the body, posing serious cardiovascular
complications.

Arteries contain what is called an endothelium, a thin layer of cells that keeps the artery
smooth and allows blood to flow easily. Atherosclerosis starts when the endothelium
becomes damaged, allowing LDL cholesterol to accumulate in the artery wall. The body
sends macrophage white blood cells to clean up the cholesterol, but sometimes the cells get
stuck there at the affected site. Over time this results in plaque being built up, consisting of
bad cholesterol (LDL cholesterol) and macrophage white blood cells.
The plaque clogs up the artery, disrupting the flow of blood around the body. This potentially
causes blood clots that can result in life-threatening conditions such as heart
attack, stroke and other cardiovascular diseases.
The condition can affect the entire artery tree, but mainly affects the larger high-pressure
arteries.

Arteriosclerosis and atherosclerosis

Arteriosclerosis and atherosclerosis are different conditions:

 Arteriosclerosis is the stiffening or hardening of the artery walls.

 Atherosclerosis is the narrowing of the artery because of plaque build-up.

Atherosclerosis is a specific type of arteriosclerosis.
All patients with atherosclerosis have arteriosclerosis, but those with arteriosclerosis might
not necessarily have atherosclerosis. However, the two terms are frequently used with the
same meaning.

Causes of atherosclerosis
Atherosclerosis is caused by
macrophage white blood cells and fat that
accumulate in arteries - the white blood
cells are originally sent by the body's
immune system to clean up LDL
cholesterol pockets.
When they stick to an artery they secrete
a molecule called netrin-1, this stops
normal migration of the macrophages out
of the arteries. As a result, what you have
left is a mixture of clumped up cholesterol
pockets and white blood cells, this is the
plaque that can disrupt blood flow.
 A study carried out by researchers at NYU Langone Medical Center is said to have been the
first of its kind to explain why macrophages stick to artery walls.
Certain factors that can damage the inner area of the artery (endothelium) and can trigger
atherosclerosis include:

 High Blood Pressure

 High levels of cholesterol
 Smoking
 High levels of sugar in the blood
Areas of the artery that are damaged are likely to have plaque build-up which can eventually
break open. When the plaque breaks open, blood cell fragments called thrombocytes (or
platelets) accumulate at the affected area. These fragments can then stick together, forming
blood clots.

Diabetes - patients with poorly-controlled diabetes, who frequently have excess blood

glucose levels, are much more likely to develop atherosclerosis.

Genetics - people with a parent or sibling who has/had atherosclerosis and cardiovascular
disease have a much higher risk of developing atherosclerosis than others.

Air pollution - in 2007, researchers from the University of California in Los Angeles linked
exposure to diesel exhaust particles in air pollution to a higher risk of bad cholesterol build-up
in the arteries.

Symptoms of atherosclerosis
A symptom is something the patient feels and describes, such as pain, while a sign can be
detected by other people, such as a rash.
The first signs of atherosclerosis can begin to develop during adolescence, with streaks of
white blood cells appearing on the artery wall. The symptoms of the disease depend on which
arteries are affected:
Carotid Arteries
Carotid arteries provide blood to the brain, when the blood supply is limited patients can
suffer stroke and may experience:
 Weakness
 Difficulty breathing
 Headache
 Facial numbness
 Paralysis

Coronary Arteries
Coronary arteries provide blood to the heart, when the blood supply to the heart is limited it
can cause angina and heart attack, symptoms include:
 Vomiting
 Extreme anxiety
 Chest pain
 Coughing
 Feeling faint
Renal Arteries
Renal arteries supply blood to the kidneys; if the blood supply becomes limited, there is a
serious risk of developing chronic kidney disease, and the patient may experience:
 Loss of appetite
 Swelling of the hands and feet
 Difficulty concentrating
Peripheral arterial disease
The arteries to the limbs, usually the legs, are blocked. The most common symptom is leg
pain, either in one or both legs, usually in the calves, thighs or hips. The pain may be
described as one of heaviness, cramp, or dullness in the leg muscles. Other symptoms may
include:

 Hair loss on legs or feet

 Male impotence (erectile dysfunction)
 Numbness in the legs
 The color of the skin on the legs change
 The toenails get thicker
 Weakness in the legs

Treatments for atherosclerosis

Those who are at risk of developing atherosclerosis will likely be told by their doctor to
change their lifestyle and maintain a healthy weight. In some cases treatment may include
medication or surgery.

Lifestyle Changes- The changes will focus on weight management, physical activity and a
healthy diet. Your doctor may recommend eating foods high in soluble fibre and limiting your
intake of saturated fats, sodium and alcohol. You can read more information about what a
healthy diet is here.

Medication - The doctor may prescribe medications to prevent the build-up of plaque or to
help prevent blood clots (anteplatelets). Other medications such as statins may be prescribed
to lower cholesterol, and Angiotensin-converting enzyme (ACE) inhibitors to lower blood
pressure.

Surgery - Severe cases of atherosclerosis may be treated by surgical procedures, such as

angioplasty or coronary artery bypass grafting (CABG).
Angioplasty involves expanding the artery and opening the blockage, so that the blood can
flow through properly again. CABG is another form of surgery that can improve blood flow to
the heart by using arteries from other parts of the body to bypass a narrowed coronary artery.

Dilated Cardiomyopathy
Dilated cardiomyopathy (DCM) is the most common type of nonischemic cardiomyopathy. In
dilated cardiomyopathy, the heart's ability to pump blood is decreased because the heart's
main pumping chamber, the left ventricle, is enlarged, dilated and weak. At first, the
chambers of the heart respond by stretching to hold more blood to pump through the body.
This helps to strengthen the heart's contraction and keep the blood moving for a short while.
With time, the heart muscle walls weaken and are not able to pump as strongly. The kidneys
often respond by retaining fluid (water) and sodium. If fluid builds up in the legs, ankles, feet,
lungs or other organs, the body becomes congested, and congestive heart failure is the term
used to describe this condition.

Symptoms of DCM
Many people with dilated cardiomyopathy have no symptoms or only minor symptoms.
Other people develop symptoms, which may progress as heart function worsens.

Symptoms of dilated cardiomyopathy can occur at any age and may include:

 Shortness of breath
 Swelling of the legs and feet
 Fatigue (feeling overly tired), inability to exercise, or carry out activities as usual
 Weight gain, cough and congestion related to fluid retention
 Palpitations or fluttering in the chest due to abnormal heart rhythms (arrhythmia)
 Dizziness or light-headedness
 Fainting (caused by irregular heart rhythms, abnormal responses of the blood
vessels during exercise, without apparent cause)
 Blood clots due to blood flowing more slowly through the body. If a blood clot
breaks off, it can be carried to the lungs (pulmonary emboli), kidney (renal
emboli), brain (cerebral emboli or stroke), or limbs (peripheral emboli).

Causes of DCM
 Most cases of dilated cardiomyopathy are idiopathic (an exact cause is not
known)
 Sometimes a viral illness may be responsible
 Occasionally it may be inherited (familial cardiomyopathy)
 Heart valve disease (valvular cardiomyopathy)
 Alcoholism (heavy drinking, alcoholic cardiomyopathy)
  Drug abuse or taking d rugs that are toxic to the heart
 Thyroid disease
 Diabetes
 Women after childbirth (peripartum cardiomyopathy).

When there is no known cause, the condition is called idiopathic dilated

cardiomyopathy. About 1/3 of patients with idiopathic DCM have a family history, called
familial dilated cardiomyopathy. Familial DCM is a genetic condition. In rare autosomal
dominant inheritance patterns (at least two family member have idiopathic DCM), first
degree relatives (parents, siblings, children) have a 50 percent chance of inheriting the
condition, and may benefit from risk screening or follow-up by a physician.

How is DCM diagnosed?

DCM is diagnosed based on your medical history, physical exam, and other tests.
Specific tests may include blood tests, electrocardiogram (ECG), chest X-
ray, echocardiogram, exercise stress test, cardiac catheterization, CT scan, MRI scan,
and radionuclide studies.

Occasionally, a myocardial biopsy may be performed to determine the cause of

cardiomyopathy. During a myocardial biopsy, small tissue samples are taken from the
heart and examined under a microscope to determine the cause of the cardiomyopathy.

Family members with familial idiopathic DCM should be screened for DCM. Testing
would be the same as mentioned above (medical history, physical exam, ECG,
echocardiogram, etc.). Genetic testing is available to identify abnormal genes;
researchers are looking into identifying abnormal genes. You should speak to your
doctor about family screening.

Treatments for DCM

Treatment of cardiomyopathy is aimed at treating the cause of heart failure whenever
possible. Once diagnosed, the primary goal is to improve cardiac function and reduce
symptoms. Patients usually take several medications to treat DCM. Doctors also
recommend lifestyle changes that decrease symptoms and hospitalizations, and
improve quality of life.

Medications

Medications are used for two reasons:

1. To improve cardiac function

2. To treat symptoms and prevent complications

To manage heart failure, most people improve by taking a beta-blocker and ACE

inhibitor even when not having symptoms. If symptoms occur and/or worsen,
digoxin, diuretics, and aldosterone inhibitors may be added. Other medications will be
added as needed. For example, if you have an arrhythmia, your doctor may give you a
medication to control your heart rate or lessen the occurrence of arrhythmia. Or, blood
thinners may be used to prevent blood clots from occurring. Your doctor will discuss
what medications are best for you.

Lifestyle Changes

 Diet. Once you develop symptoms such as shortness of breath or fatigue, you

should restrict your intake of salt (sodium) to 2,000 to 3,000 mg per day. Follow
this low-sodium diet even when your symptoms seem to have subsided. Most
salt ingested comes from processed food. In addition to removing the salt shaker
from the table and when cooking, read all food labels for sodium content and
serving size so you can keep track of your sodium intake. Learn more about
nutrition guidelines for heart failure.

 Exercise. Your doctor will tell you if you may exercise or not. Most people with
cardiomyopathy are encouraged to do non-competitive aerobic exercise. Heavy
weight lifting may not be recommended.

Implantable Devices

 Cardiac Resynchronization Therapy (CRT, such as biventricular pacing): In some

patients with advanced heart failure, biventricular pacing (a pacemaker that
senses and initiates heartbeats in the right and left ventricle) improves survival,
reduces symptoms and increases exercise capacity or tolerance. For people with
heart block or some bradycardias (slow heart rates), this pacemaker will also
serve to maintain an adequate heart rate.

 Implantable Cardioverter Defibrillators (ICD) : ICDs are suggested for people at

risk for life-threatening ventricular arrhythmias or sudden cardiac death. The ICD
constantly monitors the heart rhythm. When it detects a very fast, abnormal heart
rhythm, it delivers energy (shock) to the heart muscle to cause the heart to beat
in a normal rhythm again.

Both devices may be combined in a single unit, usually labelled CRT-D.

Surgery

 Surgery may be advised to treat valve disease; scarred, thin heart muscle after

heart attack; or congenital malformations. In addition, some patients may benefit
from left ventricular assist device insertion. This procedure requires the patient to
meet strict criteria and have advanced, end-stage heart failure.

 Heart transplant or other heart failure surgical options

 Get information about ischemic cardiomyopathy