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Atherosclerosis

Atherosclerosis is a disease affecting arterial blood vessel. It is commonly referred to as a "hardening" or "furring" of the arteries. It is caused by the formation of multiple plaques within the arteries. Pathologically, the atheromatous plaque is divided into three distinct components: more...

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The atheroma ("lump of porridge", from Athera, porridge in Greek,) is the nodular accumulation of a soft, flaky, yellowish material at the center of large plaques, composed of macrophages nearest the lumen of the artery, sometimes with underlying areas of cholesterol crystals and possibly also calcification at the base of older/more advanced lesions.

Arteriosclerosis ("hardening of the artery") results from a deposition of tough, rigid collagen inside the vessel wall and around the atheroma. This increases the stiffness, decreases the elasticity of the artery wall. Arteriolosclerosis (hardening of small arteries, the arterioles) is the result of collagen deposition, but also muscle wall thickening and deposition of hyaline cartilage.

Calcification, sometimes even ossification (formation of complete bone tissue) occurs in the thickest parts of sclerosed vessel wall.

Some sources draw a distinction between "Arteriosclerosis", "Atherosclerosis," and "Arteriolosclerosis". In these contexts, "Atherosclerosis" is used when referring to larger arteries, and "Arteriolosclerosis" is used when referring to arterioles, with "Arteriosclerosis" used as a parent of both terms. Atherosclerosis causes two main problems. First, the atheromatous plaques causes stenosis (narrowing) of the artery and, therefore, an insufficient blood supply to the organ it feeds. This complication is chronic, slowly progressing. A common scenario is claudication from insufficient blood supply to the legs. Second, the soft plaque may suddenly rupture (see vulnerable plaque), causing the formation of a blood clot (thrombus) that will rapidly stop blood flow, leading to death of the tissues fed by the artery. This catastrophic event is called an infarction. The most common scenario is a thrombosis of a coronary artery causing myocardial infarction (a heart attack).

Symptoms

Atherosclerosis typically begins in later childhood, is usually found in most major arteries, yet is asymptomatic and not detected by most diagnostic methods during life. It most commonly becomes seriously symptomatic when interfering with the coronary circulation supplying the heart or cerebral circulation supplying the brain, and is considered the most important underlying cause of strokes, heart attacks, various heart diseases including congestive heart failure and most cardiovascular diseases in general. Atheroma in arm or more often leg arteries and producing decreased blood flow is called Peripheral artery occlusive disease (PAOD).

According to United States data for the year 2004, for about 65% of men and 47% of women, the first symptom of atherosclerotic cardiovascular disease is heart attack or sudden cardiac death (death within one hour of symptom onset).

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Screening for atherosclerosis: initiating secondary prevention for high-risk young to middle-aged adults
From CHEST, 10/1/05 by Ana M. Schaper

PURPOSE: The Framingham risk score is recommended for identifying individuals at high risk for a future event. However, the burden of cardiovascular disease resides in patients stratified as low and intermediate risk simply because of the large number of people receiving this classification. We propose the need to move beyond risk stratification for cardiovascular disease to identifying the presence of atherosclerosis in young to middle-aged adults who are truly at risk. The purpose of this analysis is to compare and contrast the role of Framingham risk stratification in the identification of atherosclerosis and risk for future events in a young to middle-aged population.

METHODS: Men ([less than or equal to] 55 years) and women ([less than or equal to] 65 years) without prior coronary heart disease scheduled for elective cardiac catheterization were studied. Subjects underwent coronary angiogram, carotid ultrasound and fasting lipid testing on the same day. Framingham risk scores were calculated. Endpoints included the presences of atherosclerosis (carotid or coronary disease) and one-year outcomes (hard events and future revascularization).

RESULTS: Men (n = 110) and women (n = 136) were studied. Atherosclerosis was present in 170 subjects (carotid disease n = 149, coronary disease n = 124). Per Framingham risk classification, 73%, 8%, 19% of subjects presented as low, intermediate and high risk, respectively. Median follow-up was 19 months. 25 subjects developed 35 events that included death (n = 2), stroke (n = 5), MI (n = 5), and revascularization (n = 23). Neither lipid testing nor Framingham risk scores predicted the presence of atherosclerosis or future events. Overall, 16% of subjects with atherosclerosis who were classified as low or intermediate risk had events compared to 14% of those at high risk. No future events occurred in subjects without documented atherosclerosis.

CONCLUSION: Many young to middle-aged adults classified as low or intermediate-risk have atherosclerosis and develop cardiovascular events. Framingham risk scores were not predictive of either.

CLINICAL IMPLICATIONS: By shifting to a focus on identifying and aggressively treating atherosclerosis, screening can easily be accomplished using non-invasive strategies, such as carotid ultrasound to reduce the overall burden of disease.

DISCLOSURE: Ana Schaper, None.

Ana M. Schaper PhD * Vicki L. McHugh MS Sharon I. Barnhart RN Michelle A. Mathiason MS Kwame O. Akosah MD Gundersen Lutheran Health Systems, La Crosse, WI

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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