Diseases of the arteries

Atherosclerosis

Atherosclerosis, the most common form of arteriosclerosis, is a disease found in large and medium-sized arteries. It is characterized by the deposition of fatty substances, such as cholesterol, in the innermost layer of the artery (the intima). As the fat deposits become larger, inflammatory white blood cells called macrophages try to remove the lipid deposition from the wall of the artery. However, lipid-filled macrophages, called “foam cells,” grow increasingly inefficient at lipid removal and undergo cell death, accumulating at the site of lipid deposition. As these focal lipid deposits grow larger, they become known as atherosclerotic plaques and may be of variable distribution and thickness. Under most conditions the incorporation of cholesterol-rich lipoproteins is the predominant factor in determining whether or not plaques progressively develop. The endothelial injury that results (or that may occur independently) leads to the involvement of two cell types that circulate in the blood—platelets and monocytes (a type of white blood cell). Platelets adhere to areas of endothelial injury and to themselves. They trap fibrinogen, a plasma protein, leading to the development of platelet-fibrinogen thrombi. Platelets deposit pro-inflammatory factors, called chemokines, on the vessel walls. Observations of infants and young children suggest that atherosclerosis can begin at an early age as streaks of fat deposition (fatty streaks).

Distribution

Atherosclerotic lesions are frequently found in the aorta and in large aortic branches. They are also prevalent in the coronary arteries, where they cause coronary artery disease. The distribution of lesions is concentrated in points where arterial flow gives rise to abnormal shear stress or turbulence, such as at branch points in vessels. In general the distribution in most arteries tends to be closer to the origin of the vessel, with lesions found less frequently in more distal sites. Hemodynamic forces are particularly important in the system of coronary arteries, where there are unique pressure relationships. The flow of blood through the coronary system into the heart muscle takes place during the phase of ventricular relaxation (diastole) and virtually not at all during the phase of ventricular contraction (systole). During systole the external pressure on coronary arterioles is such that blood cannot flow forward. The external pressure exerted by the contracting myocardium on coronary arteries also influences the distribution of atheromatous obstructive lesions.

Epidemiology

The six principal risk factors for atherosclerosis include age, genetics, gender, serum cholesterol concentrations, smoking, and diabetes. The prevalence of atherosclerosis increases with age, and young children with evidence of fatty streaks are very likely to develop the disease when they are older. In addition, occurrence of atherosclerosis in some families is linked to a genetic component, and family history serves as a useful predictor for the course of development of the disease, particularly if it is evident at a young age. There are several important genetic defects of lipid metabolism, one of which involves a defect of lipoprotein receptors and constitutes an extreme form of familial propensity for atherosclerosis.

Men develop atherosclerosis more often then women, and complications generally appear at an earlier age. One reason for this difference has been ascribed to estrogen, a female hormone that induces high-density lipoproteins (HDL) which remove excess cholesterol from arterial cells, thus providing a protective effect against development of atherosclerosis in women. When estrogen levels decrease after menopause, the incidence of atherosclerosis and its complications rises. Though hormone replacement therapy was once considered an anti-atherosclerotic therapy for women, controversy surrounding the long-term effects of hormone therapy has greatly reduced their use for cardiovascular conditions.

Epidemiological observation has demonstrated that patients with high serum cholesterol and lipoprotein concentrations have a higher incidence of atherosclerosis. Increased cardiovascular risk lies mainly in cholesterol associated with low-density lipoproteins (LDL) and very low-density lipoproteins (VLDL) that contain large amounts of cholesterol relative to HDLs and deliver cholesterol directly to the cells of peripheral tissues, including arteries. There are also some qualitative abnormalities in lipoproteins that appear to control the risk of atherosclerosis and are also associated with familial propensity.

Smoking may increase the risk of developing atherosclerosis and its associated complications, with one pack of cigarettes a day doubling the risk and two packs a day tripling it. Smoking also increases the incidence of adverse coronary events in young women taking oral contraceptives. Complications of atherosclerosis are a significant cause of lowered life expectancy in smokers.

Incidence of atherosclerotic disease and its complications in patients with either type 1 (insulin-dependent) or type 2 (non-insulin-dependent) diabetes is significantly higher than in healthy individuals. This appears to be so even when accounting for abnormal blood lipids frequently associated with diabetes and poor diabetic control, suggesting that high blood sugar may potentially injure the artery and facilitate atherosclerosis. Patients with diabetes also frequently have high levels of triglycerides, which appear to be associated with diabetes and its complications.

In addition to these primary risk factors, there is substantial evidence that other factors, such as sedentary lifestyle, environmental stress, and obesity, increase risk. Atherosclerosis and its complications have also been associated with elevated levels of the blood amino acid homocysteine; however, this is unlikely to account for many cases of the disease. Great attention has been placed on the reduction of risk factors as therapeutic strategy for treatment and prevention of atherosclerosis.