Atherosclerosis

DEFINITION:Formation of atherosclerotic plaques affecting large- and medium-sized arteries

Risk factors: Increasing age. Male gender. Family history of early coronary heart disease (eg, in men Race - eg, many South Asian races are at higher risk. Lifestyle, social and environmental factors Cigarette smoking. Lack of regular physical exercise. Diet: Lack of fruit and vegetables. High-fat - the type of fat is important - eg trans fats increase CVD risk. Lower intake of omega-3 fatty acids  High alcohol intake (moderate alcohol intake may be protective). Psychosocial factors Hypertension. Diabetes mellitus (probably through mechanisms of hyperglycaemia, lipoprotein abnormalities, and inflammation) Hyperlipidaemia: Raised low-density lipoprotein (LDL) cholesterol. High-density lipoprotein (HDL) cholesterol and its apolipoproteins (apos) A-I and A-II are protective. Raised triglycerides (possibly). Obesity, particularly abdominal obesity (including metabolic syndrome). Systemic inflammation - eg, in systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, human immunodeficiency virus, systemic sclerosis, vasculitis and periodontitis.

Macrovascular: disease of the large blood vessels, including the  aorta, and the sizable arteries in the brain and in the limbs.Microvascular: retinopathy, nephropathy

Clinical consequences: Atherosclerosis in its early stages is silent. The clinical presentation is usually with complications Possible signs are: Xanthelasmata (from hyperlipidaemia). Bruits over large arteries (eg, carotid bruits). Aortic aneurysm. Poor peripheral pulses. Reduced ankle brachial index

Atherosclerotic plaques tend to occur in regions where vessels branch, curve or are irregular, where blood undergoes sudden changes in velocity and in direction of flow.

Complications: Coronary heart disease: Stable angina. Acute coronary syndromes - unstable angina and myocardial infarction. Cerebrovascular disease: Stroke. Transient ischaemic attack. Aortic aneurysm. Peripheral arterial disease: Claudication. Acute limb ischaemia. Visceral ischaemia: Renal artery stenosis. Mesenteric angina and mesenteric infarction. Atheroembolic disease: This is the release of cholesterol crystals into arteries, usually following vascular surgery, catheterisation or anticoagulation. It may affect various organs - the kidneys (atheroembolic renal disease), skin, gastrointestinal system, and brain.

Lifestyle modifications: Smoking cessation. Diet - increased fruit and vegetables, reduced fat intake, increased omega-3 fatty acid intake. Regular physical exercise. Avoiding excess alcohol. Treatment of a contributing disease - eg, diabetes, and hypertension; treat complications. Drug treatment: Statins - these have effects on both lipids and inflammation. There is some evidence that statins prevent progression and may even reverse coronary atherosclerosis.[3] Omega-3 fatty acids - these are currently prescribable as adjunct in secondary prevention for those with myocardial infarction in the previous three months, or for hypertriglyceridaemia.[21] They are also available as over-the-counter supplements. Antiplatelet drugs - aspirin and others, are used for those at greatest risk (eg, in the secondary prevention of CVD).

Atherosclerosis