Beruflich Dokumente
Kultur Dokumente
Angina
Atherosclerosis
Atherosclerosis is characterized by intimal lesions
called atheromas, or atheromatous or fribrofatty
plaques, which protrude into and obstruct vascular
lumens and weaken the underlying media.
They may lead to serious complications.
Atherosclerotic lesions are classified into six
types : isolated foam cells(fatty dots), fatty
streaks,
intermediate
lesions,
atheromas,
fibroatheromas and complicated lesions
fibers
and
Age : Age is a dominant influence. Death rates from IHD rise with each
decade into advanced age. Atherosclerosis is not clinically evident until
middle age or later, when the arterial lesions precipitate organ injury.
Between ages 40 and 60 the incidence of myocardial infarction increases
five-fold.
Sex : Males are much more prone to atherosclerosis and its consequences
that are females. In postmenopausal women, the incidence of
atherosclerosis-related diseases increases, probably owing to a decrease
in natural estrogen levels. The frequency of myocardial infarction
equalizes that of males by the seventh to eighth decade of life.
Hyperlipidemia
Hyperlipidemia or hypercholesterolemia is a major risk factor for
atherosclerosis. Elevated levels of serum cholesterol are sufficient to
stimulate lesion development, even if other risk factors are absent.
Low-density lipoprotein (LDL) cholesterol presents an increased risk,
and has a physiologic role as a vehicle for the delivery of cholesterol to
peripheral tissue.
High-density cholesterol (HDL) mobilizes cholesterol from developing
and existing atheromas and transport it to the liver for excretion in the
bile. The higher the level of HDL, the lower is the risk. Exercise and
moderate consumption of ethanol both raise the HDL level, whereas
obesity and smoking lower it.
Statins lower circulating cholesterol indirectly by inhibiting HMG CoA
reductase, a key enzyme required for cholesterol biosynthesis in the
liver.
Hypertension
Hypertension is a major risk factor for
atherosclerosis at all ages. Men between ages 45
and 62 whose blood pressure exceeds 169/95 mm
Hg have a more than fivefold greater risk of IHD
than those with BP of 140/90mm Hg or lower.
Antihypertensive therapy reduces the incidence of
atherosclerosis-related
diseases
particularly
strokes and IHD.
Cigarette Smoking
Cigarette smoking is a well-established risk factor in men.
In women it is thought to account for the relatively recent
increase in the incidence and severity of atherosclerosis in
women.
Smoking one or more packs of cigarettes per day for
several years increases the death rate from IHD by upto
200%.
Cessation of
substantially.
smoking
reduces
the
increased
risk
Diabetes Mellitus
Diabetes mellitus induces hypercholesterolemia
and
an
increased
predisposition
to
atherosclerosis.
The incidence of myocardial infarction is twice as
high in diabetics as in nondiabetics.
There is also an increased risk of strokes and
perhaps
a
100-fold
increased
risk
of
atherosclerosis-induced gangrene of the lower
extremities.
Other factors
Persons with homocystinuria (inborn error of metabolism) resulting in
high levels of circulating homocysteine (>100 mol/L) and urinary
homocysteine, have premature vascular disease (peripheral) or
coronary artery disease, stroke or venous thrombosis.
Hyperhomocystinemia can be caused by low folate and vitamin B
intake, hence folate and vitamin B6 ingestion may reduce the incidence
of cardiovascular disease.
Several markers of hemostatic and thrombotic function and
inflammation are potent predictors of risk for major atherosclerotic
events, including myocardial infarction and stroke. Such markers
include those related to fibrinolysis (e.g., elevated plasminogen
activator inhibitor-1) and inflammation (e.g., C-reactive protein)
Coronary and cerebrovascular disease have a corelation with
increased blood levels of Lp(a) lipoprotein (an altered form of LDL that
contains the apolipoprotein B-100 portion of the LDL linked to
apolipoprotein A.
(e.g.,
rate
hyperlipidemia,
of myocardial
Pathogenesis
Areas of disturbed, turbulent flow and low shear stress such as ostia of
the vessels arising from the aorta, branch points and along the posterior
wall of the abdominal aorta, are prone to atherosclerosis.
Steady laminar flow protects against atherosclerosis and induction of socalled atheroprotective genes in areas of laminar flow could explain the
nonrandom localization of early atherosclerotic lesions.
diets
develop
The risk factors for atherosclerosis are diagrammed here in relation to the
mechanisms that favor development of arterial atheroma formation.
Clinicopathologic Effects of
Atherosclerotic CAD
The complications of atherosclerotic CAD occur through
impaired coronary perfusion relative to myocardial demand
(myocardial ischemia).
The vascular changes that may cause ischemia in the
heart and other organs involve a complex dynamic
interaction among fixed atherosclerotic narrowing of the
epicardial coronaty arteries, intraluminal thrombosis
overlying a disrupted atherosclerotic plaque, platelet
aggregation and vasospasm.
Prevention
The impact of atherosclerosis and the consequences can
be reduced by :
Primary prevention programs, aimed at either delaying
atheroma formation or causing regression of established
lesions in persons who have never suffered a serious
complication of atherosclerotic CAD.
Secondary prevention programs intended to prevent
recurrence of events such as myocardial infarction in
patients with symptomatic disease.
Risk-factor modification: abstention from of cessation of
cigarette smoking, control of hypertension, weight
reduction and increased exercise, modification of alcohol
consumption and lowering total and LDL cholesterol levels
while increasing HDL.