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Background
The word atherosclerosis is of Greek origin and literally means focal accumulation of lipid (ie, athere [gruel]) and
thickening of arterial intima (ie, sclerosis [hardening])
Atherosclerosis is a disease of large and medium-sized muscular arteries and is characterized by the following:
Endothelial dysfunction
Vascular inflammation
Buildup of lipids, cholesterol, calcium, and cellular debris within the intima of the vessel wall
Plaque formation
Vascular remodeling
Acute and chronic luminal obstruction
Abnormalities of blood flow
Diminished oxygen supply to target organs
By impairing or obstructing normal blood flow, atherosclerotic buildup causes myocardial ischemia.
Silent Ischemia
In most cases, a temporary blood shortage to the heart causes the pain of angina pectoris. But in other cases, there is
no pain. These cases are called silent ischemia.
Silent ischemia may also disturb the heart’s rhythm. Abnormal rhythms such as ventricular tachycardia or
ventricular fibrillation can interfere with the heart’s pumping ability and can cause fainting or even sudden cardiac
death.
Chest pain
Shortness of breath
Weakness, tiredness, reduced exertional capacity
Dizziness, palpitations
Leg swelling
Weight gain
Diaphoresis
Stable angina pectoris
Intermittent claudication
Mesenteric angina
Tachycardia: Common in persons with acute coronary syndrome (ACS) and acute myocardial infarction (AMI)
High or low blood pressure
S4 gallop: A common early finding
S3 gallop: An indication of reduced left ventricular function
Heart murmurs
Tachypnea
Xanthelasmas
Risk Factors
Age
o Simply getting older increases your risk of damaged and narrowed arteries.
Sex
o Men are generally at greater risk of coronary artery disease.
o The risk for women increases after menopause.
Family history
o A family history of heart disease is associated with a higher risk of coronary artery disease,
especially if a close relative developed heart disease at an early age.
o Your risk is highest if your father or a brother was diagnosed with heart disease before age 55 or if
your mother or a sister developed it before age 65.
Smoking
o People who smoke have a significantly increased risk of heart disease.
o Exposing others to your secondhand smoke also increases their risk of coronary artery disease.
High blood pressure
o Uncontrolled high blood pressure can result in hardening and thickening of your arteries,
narrowing the channel through which blood can flow.
High blood cholesterol levels
o High levels of cholesterol in your blood can increase the risk of formation of plaque and
atherosclerosis.
o High cholesterol can be caused by a high level of low-density lipoprotein (LDL) cholesterol, known
as the "bad" cholesterol.
o A low level of high-density lipoprotein (HDL) cholesterol, known as the "good" cholesterol, can
also contribute to the development of atherosclerosis.
Diabetes
o Diabetes is associated with an increased risk of coronary artery disease.
Overweight or obesity
o Excess weight typically worsens other risk factors.
Physical inactivity
o Lack of exercise also is associated with coronary artery disease
High stress
o Unrelieved stress in your life may damage your arteries as well as worsen other risk factors for
coronary artery disease.
Unhealthy diet
o Eating too much food that has high amounts of saturated fat, trans fat, salt and sugar can increase
your risk of coronary artery disease.
Sleep apnea
o This disorder causes you to repeatedly stop and start breathing while you're sleeping.
o Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and
strain the cardiovascular system, possibly leading to coronary artery disease.
Preeclampsia
o This condition that can develop in women during pregnancy causes high blood pressure and a
higher amount of protein in urine.
o It can lead to a higher risk of heart disease later in life.
Alcohol use
o Heavy alcohol use can lead to heart muscle damage.
o It can also worsen other risk factors of coronary artery disease.
Autoimmune diseases
o Conditions such as rheumatoid arthritis and lupus (and other inflammatory rheumatologic
conditions) have an increased risk of atherosclerosis.
Diagnostics/Approach
Routine blood tests include complete blood count (CBC), chemistry panel, lipid profile, and thyroid function
tests
Routine measurement of blood glucose and hemoglobin A1C is appropriate in patients with DMII
Fasting lipid profile
o Triglyceride level
o VLDL-C level
o Apoprotein profile
Troponin I
CKMB
High sensitivity C-reactive protein
o High sensitivity C-reactive protein (hs-CRP) is a normal protein that appears in higher amounts
when there's inflammation somewhere in your body.
o High hs-CRP levels may be a risk factor for heart disease.
o It's thought that as coronary arteries narrow, you'll have more hs-CRP in your blood.
Homocysteine
o Homocysteine is an amino acid your body uses to make protein and to build and maintain tissue.
o But high levels of homocysteine may increase your risk of coronary artery disease.
Electrocardiogram (ECG)
o Records electrical signals as they travel through your heart.
o Can often reveal evidence of a previous heart attack or one that's in progress.
Holter monitoring
Echocardiogram
o Uses sound waves to produce images of your heart.
o Determine whether all parts of the heart wall are contributing normally to your heart's pumping
activity.
o Parts that move weakly may have been damaged during a heart attack or be receiving too little
oxygen.
o May indicate coronary artery disease or various other conditions.
Stress test
o Exercise Tolerance Test
Walk on a treadmill or ride a stationary bike during an ECG
o Stress echocardiogram
Echocardiogram before and after you exercise on a treadmill or bike
o Pharmacologic nuclear stress test
Adenosine or Dobutamine
Measures blood flow to your heart muscle at rest and during stress.
Similar to a routine exercise stress test but with images in addition to an ECG
A tracer is injected into your bloodstream, and special cameras can detect areas in your
heart that receive less blood flow.
Cardiac catheterization and angiogram
o Dye is injected into the arteries of the heart through a long, thin, flexible tube (catheter) that is
threaded through an artery, usually in the leg, to the arteries in the heart.
o Dye outlines narrow spots and blockages on the X-ray images
If a blockage that requires treatment
a balloon can be pushed through the catheter and inflated to improve the blood
flow in the coronary arteries
a mesh tube (stent) may then be used to keep the dilated artery open.
Heart scan
o Computerized tomography (CT) technologies can help to see calcium deposits in your arteries that
can narrow the arteries
o A CT coronary angiogram, in which you receive a contrast dye injected intravenously during a CT
scan, also can generate images of your heart arteries.
Treatment of Angina
Beta-blockers
o Inhibit sympathetic stimulation of the heart
reducing heart rate and contractility
o Can decrease myocardial oxygen demand and thus prevent or relieve angina in patients with CAD.
o Since beta-blockers reduce the heart rate–blood pressure product during exercise, the onset of
angina or the ischemic threshold during exercise is delayed or avoided.
Calcium channel blockers
o Prevent calcium entry into vascular smooth muscle cells and myocytes
leads to coronary and peripheral vasodilatation, decreased atrioventricular (AV)
conduction, and reduced contractility
o These effects result in decreased coronary vascular resistance and increased coronary blood flow.
Nitrates
o effective in the treatment of acute anginal symptoms
o usually given sublingually
o primary anti-ischemic effect of nitrates is to decrease myocardial oxygen demand by producing
systemic vasodilation
o improves exercise tolerance, time to onset of angina, and ST-segment depression during exercise
testing
o particularly effective in combination with beta-blockers or calcium-channel blockers.
Ranolazine
o believed to relieve ischemia by reducing myocardial cellular sodium and calcium overload via
inhibition of the late sodium current of the cardiac action potential.
Surgical Revascularization
Coronary Artery Bypass Grafting (CABG)
o Better long-term patency rates and improved late survival were achieved by using the LIMA than
by using SVGs.
o Guidelines for CABG
Class I indications
Left main coronary artery disease (LMCAD) with 50% or greater narrowing
Anatomically equivalent LMCAD with 70% or greater narrowing in both the
proximal left anterior descending (LAD) coronary artery and the left circumflex
artery
Three-vessel coronary artery disease (CAD), particularly in the setting of an
impaired left ventricular ejection fraction (LVEF)
Class II indications
Proximal LAD coronary artery stenosis (impaired LVEF becomes a class I
indication)
One-vessel or two-vessel CAD that does not involve the proximal LAD coronary
artery if a moderate area of viable myocardium is at risk
Class III indications
One-vessel or two-vessel CAD that does not involve the proximal LAD coronary
artery
One-vessel or two-vessel CAD that does not involve the proximal LAD coronary
artery with only a small area of viable myocardium
Percutaneous Coronary Intervention (PCI)
o Balloon angioplasty
o Coronary stenting are the mainstays of PCI
o Other technologies include
devices that ablate plaque (atherectomy)
devices that remove clots from vessels (thrombectomy)
devices that capture and remove embolic debris (embolic protection).
o Guidelines for PCI
Class I indications
Patients with class II-IV angina or acute coronary syndrome with one or more
significant lesions in one or more coronary arteries suitable for PCI
Patients with acute ST-segment elevation myocardial infarction (STEMI) who can
undergo angioplasty of the infarct artery within 12 hours of symptom onset or
patients who have recurrent ischemia or infarction (rescue PCI)
Patients older than 75 years who develop cardiogenic shock within 36 hours of
an acute STEMI
Patients with early ischemia (usually within 30 days) after CABG
Class II indications
Patients with focal saphenous vein graft (SVG) lesions or multiple stenosis who
are poor candidates for reoperation
The presence of one or more lesions with reduced likelihood of success, or vessel
or vessels subtending a less-than-moderate area of viable myocardium
Patients with STEMI in whom thrombolytic therapy is contraindicated
Patients with STEMI who experience cardiogenic shock or hemodynamic
instability after thrombolysis
Patients with ischemia occurring 1-3 years postoperatively and preserved left
ventricular function with discrete lesions in graft conduits
Patients with disabling angina secondary to new disease in a native coronary
circulation
Class III indications
Patients with no evidence of myocardial injury or ischemia on objective testing
who have not undergone a trial of medical therapy, who have a small amount of
salvageable myocardium, or who are at high risk of procedural success or
morbidity or mortality
Patients with insignificant coronary stenosis
Patients with significant left main coronary artery disease (CAD) who are
candidates for coronary artery bypass grafting (CABG)
Patients who opt for elective PCI of a non–infarct-related artery at the time of
myocardial infarction (MI)
Patients with no evidence of myocardial ischemia after 12 hours of MI or routine
PCI of the infarct artery after thrombolytic therapy
Patients with total vein graft occlusions
Patient Education
The most effective and cost-efficient means of reducing the burden of disease secondary to atherosclerosis in
the general population is primary prevention.
The role of diet and exercise in the prevention of atherosclerotic cardiovascular disease has been well
established.
Education of the general population regarding healthy dietary habits and regular exercise will reduce the
prevalence of multiple coronary heart disease risk factors.
For patients with risk factors refractory to lifestyle interventions, education can enhance compliance with
prescribed therapy.