Atherosclerosis is a condition where fatty deposits build up in the arteries, restricting blood flow. It can lead to cardiovascular diseases like heart attacks and strokes. Risk factors include high blood pressure, high cholesterol, smoking, and diabetes. Treatment focuses on lifestyle changes and medications to control cholesterol and blood pressure in order to slow the progression of the disease.

1. November, 2015
Cardiovascular disease

2. ATHEROSCLEROSIS
DEFINITION
Atherosclerosis is a condition in which patchy deposits of fatty material (atheroma’s
or atherosclerotic plaques) develop in the walls of medium-sized and large arteries,
leading to reduced or blocked blood flow. This progressive process silently and
slowly blocks arteries, putting blood flow at risk.

4. Causes
Atherosclerosis is a slow, progressive disease that may begin as early as childhood.
Although the exact cause is unknown, atherosclerosis may start with damage or
injury to the inner layer of an artery. The damage may be caused by:
 High blood pressure, Diabetes
 High cholesterol, often from getting too much cholesterol or saturated fats in your
diet
 High triglycerides, a type of fat (lipid) in your blood
 Smoking and other sources of tobacco
 Inflammation from diseases, such as arthritis, lupus or infections, or inflammation
of unknown cause

5. The plaques of atherosclerosis cause the three main kinds of cardiovascular:
 Coronary artery disease: Stable plaques in the heart's arteries cause angina (chest
pain on exertion). Sudden plaque rupture and clotting causes heart muscle to die. This is
a heart attack, or myocardial infarction.
 Cerebrovascular disease: Ruptured plaques in the brain’s arteries cause’s strokes with
the potential for permanent brain damage. Temporary blockages in an artery can also
cause transient ischemic attacks (TIAs), which are warning signs of stroke; however,
there is no brain injury.
 Peripheral artery disease: Narrowing in the arteries of the legs caused by plaque causes
poor circulation. This causes pain on walking and poor wound healing. Severe disease
may lead to amputations.

7. Atherosclerosis Treatment
Once a blockage has developed, it's generally there to stay. With medication and lifestyle
changes, though, plaques may slow or stop growing. They may even shrink slightly with
aggressive treatment.
 Lifestyle changes: Reducing the lifestyle risk factors that lead to atherosclerosis will slow
or stop the process. That means a healthy diet, exercise, and no smoking. These lifestyle
changes won't remove blockages, but they’re proven to lower the risk of heart attacks and
strokes.
 Medication: Taking drugs for high cholesterol and high blood pressure will slow and
perhaps even halt the progression of atherosclerosis, as well as lower your risk of heart
attacks and stroke.
 Angiography and stenting: Cardiac with angiography of the coronary arteries is the most
common angiography procedure performed. Angioplasty (catheters with balloon tips) and
stenting can often open up a blocked artery. Stenting helps to reduce symptoms, although it
does not prevent future heart attacks.
 Bypass surgery: Surgeons "harvest" a healthy blood vessel (often from the leg or chest).
They use the healthy vessel to bypass a segment blocked by atherosclerosis.

8. Treatment
 Cholesterol medications. Aggressively lowering your low-density lipoprotein (LDL) cholesterol, the
"bad" cholesterol, can slow, stop or even reverse the buildup of fatty deposits in your arteries. Boosting
your high-density lipoprotein (HDL) cholesterol, the "good" cholesterol, may help, too.
 Anti-platelet medications. Prescribe anti-platelet medications, such as aspirin, to reduce the likelihood
that platelets will clump in narrowed arteries, form a blood clot and cause further blockage.
 Cholesterol medications. Aggressively lowering your low-density lipoprotein (LDL) cholesterol, the
"bad" cholesterol, can slow, stop or even reverse the buildup of fatty deposits in your arteries. Boosting
your high-density lipoprotein (HDL) cholesterol, the "good" cholesterol, may help, too.
 Anti-platelet medications. Prescribe anti-platelet medications, such as aspirin, to reduce the likelihood
that platelets will clump in narrowed arteries, form a blood clot and cause further blockage.

9. Alternative medicine
It's thought that some foods and herbal supplements can help reduce your high cholesterol level
and high blood pressure:
 Alpha-linolenic acid (ALA)
 Artichoke, Barley, Garlic, Oat bran (found in oatmeal and whole oats
 Beta-sitosterol (found in oral supplements and some margarines, such as Promise Activ)
 Blond psyllium (found in seed husk and products such as Metamucil)
 Calcium
 Cocoa, Cod liver oil, Omega-3 fatty acids
 Coenzyme Q10
 Sitostanol (found in oral supplements and some margarines, such as Benecol)

10. Atherosclerosis Prevention
Atherosclerosis is progressive, but it's also preventable. For example, nine risk
factors are to blame for upwards of 90% of all heart attacks:
 Smoking
 High cholesterol
 High blood pressure
 Diabetes
 Abdominal obesity ("spare tire")
 Stress
 Not eating fruits and vegetables
 Excess alcohol intake (more than one drink for women, one or two drinks for
men, per day)
 Not exercising regularly

11. Hyperlipidemia is a disorder of lipid metabolism, also called
hyperlipoproteinemia, that results in abnormally high levels of cholesterol,
triglycerides, and lipoproteins in the blood circulation.
Hyperlipidemia is a key contributor to atherosclerosis, coronary artery disease
(CAD), and peripheral vascular disease (PVD). Hyperlipidemia also can cause
health conditions such as pancreatitis.
11
Hyperlipidemia

12. Chest pain (angina) that feels like burning, pressure or tightness.
Pain elsewhere in the body, such as the left upper arm or jaw
(referred pain)
Nausea
Vomiting
Shortness of breath
Sudden, heavy sweating (diaphoresis)
Signs and Symptoms

13. Some forms of hyperlipidemia are familial or hereditary and may manifest regardless
of lifestyle. Medications can cause hyperlipidemia as well, notably oral contraceptives
(birth control pills), estrogen therapy, thiazide diuretics, and corticosteroids.
Hyperlipidemia may also be a sign of other health conditions such as Cushing’s
syndrome, Diabetes, Liver dysfunction, and Systemic Lupus Erythematosus (SLE). In
most people who have hyperlipidemia, however, it appears that lifestyle factors
interact with genetics..
13
Differential Diagnostic

14. Measuring lipid levels in the blood and considering them individually as well as in
correlation to each other can be determined the extent of cardiovascular that risk
they pose.
There are five types, or classifications, of hyperlipidemia that have unique
presentations, genetic factors, and characteristic progressions. The five types of
hyperlipidemia are:
14
Classification

15. Type I
A rare inherited lipid disorder sometimes called apolipoprotein C-II deficiency, in
which very low density lipoprotein (VLDL) triglycerides and lipids called
chylomicrons accumulate in the bloodstream.
15 Classification(cont.)

16. Type II
A common group of familial or acquired lipid disorders, sometimes called
hypercholesterolemia, in which low-density lipoprotein (LDL) cholesterol levels in
the blood are elevated, and there may be apolipoprotein B deficiency
16
Classification(cont.)

17. Type III
An uncommon familial lipid disorder in which VLDL and total cholesterol are
elevated, usually resulting from apolipoprotein E deficiency
Type IV
A common familial or acquired lipid disorder in which blood lipid elevations are
associated with OBESITY and decline with weight loss
17
Classification(cont.)

18. Type V
An uncommon lipid disorder in which triglycerides are extremely elevated, though
other blood lipid levels are fairly normal, and that frequently causes pancreatitis
Most forms of hyperlipidemia can occur without evidence of familial or hereditary
connections.
18 Classification(cont.)

19. Hyperlipidemia itself does not cause symptoms. Doctors detect hyperlipidemia
through blood tests, conducted after an 8- to 12-hour fast, that measure blood
lipid levels. The pretest fast is important to remove any dietary influences.
Elevated blood lipid levels are diagnostic. When blood lipid levels are
extremely high and other risks for cardiovascular disease(CVD) exist, the
doctor may recommend further evaluation to look for CAD, PVD, and other
atherosclerotic conditions.
19
Symptoms of Hyperlipidemia and Diagnostic Path

20. Regardless of the cause of elevated blood lipids, the important therapeutic
goal is to reduce them. For people who have mild to moderate elevations and
no other cardiovascular disease risk factors (including family history of
hyperlipidemia), lifestyle changes alone may be enough to bring lipid levels
down to acceptable ranges.
20
Hyperlipidemia Treatment Options

21. Health care providers are generally willing to give this approach about two
months to lower blood lipid levels. When lipid levels remain elevated despite
lifestyle changes, or the person cannot make adequate lifestyle changes, health
experts recommend lipid-lowering medications. Lowering blood lipids results in a
significant decrease in cardiovascular risk, especially for early CAD and Heart
Attack.
21 Hyperlipidemia Treatment Options

22. MEDICATIONS TO TREAT HYPERLIPIDEMIA
(LIPID-LOWERING MEDICATIONS)
Statins
atorvastatin fluvastatin lovastatin
(Lipitor) (Lescol) (Mevacor)
pravastatin simvastatin
(Pravachol) (Zocor)
Fibrates
clofibrate fenofibrate gemfibrozil
(Atromid-S) (Tricor) (Lopid)
Bile acid sequestrants
cholestyramine colesevelam colestipol
(Questran, Prevalite) (WelChol) (Colestid)
Selective cholesterol absorption inhibitors
ezetimibe (Zetia)
22
Hyperlipidemia Treatment Options

23. Many health care providers recommend niacin, either alone or in combination
with lipid-lowering medications, to help lower blood lipid levels. Niacin decreases
the liver’s production of VLDL and low density lipoprotein (LDL), which curtails
triglyceride production. Niacin can cause unpleasant facial flushing and tingling
sensations in the fingers and toes, however, even at low doses.
23
Niacina

24. The key risk factors for hyperlipidemia are family history and lifestyle
habits. Most people can lower their risk for hyperlipidemia through
eating habits and exercise. Even in combination with medication,
lifestyle factors are important for maintaining healthy lipid metabolism.
24
Risk Factors

25. Acute coronary syndrome (ACS) is a term used for any condition brought on by
sudden, reduced blood flow to the heart. It is a very seriously as this is a life-
threatening condition. ACS symptoms are the same as those of a heart attack. And if
ACS isn't treated quickly, a heart attack will occur. Unstable angina is an example of
ACS; on the other hand the first sign of acute coronary syndrome can be the sudden
stopping of the heart (cardiac arrest). ACS is treatable if diagnosed quickly, the
treatments vary, depending on the signs, symptoms and overall health condition.
Acute Coronary Syndrome

26. Chest pain (angina) that feels like burning, pressure or tightness.
Pain elsewhere in the body, such as the left upper arm or jaw (referred
pain)
Nausea
Vomiting
Shortness of breath
Sudden, heavy sweating (diaphoresis)
Signs and Symptoms

27. Some additional heart attack symptoms include:
Abdominal pain
Pain similar to heartburn
Clammy skin
Lightheadedness, dizziness or fainting
Unusual or unexplained fatigue
Feeling restless or apprehensive
Signs and Symptoms

28. Coronary atherosclerosis
The plaques, made up of fatty deposits, as a result the arteries become
narrow and make it more difficult for blood to flow through them.
Most cases of ACS occur when the surface of the plaque ruptures and
causes a blood clot to form
The combination of the plaque buildup and the blood clot dramatically
limits the amount of blood flowing to your heart muscle. If the blood flow is
severely limited, a heart attack will occur.
Causes

29. The risk factors are similar to those for other types of heart disease.
 Older age (older than 45 for men and older than 55 for women)
 High blood pressure
 High blood cholesterol
 Cigarette smoking
 Lack of physical activity
 Type 2 diabetes
 Family history of chest pain, heart disease or stroke. For women, a history of
high blood pressure, preeclampsia or diabetes during pregnancy
Risk factors

30. By mean of physical examination the caregiver can:
Rule out other causes of the patient's symptoms
 Evaluate the patient for complications related to ACS.
The presence of clinical signs and symptoms may increase suspicion of ACS,
When the patient presents with symptoms and signs of potential ACS it is very
important obtain a 12 leads ECG as soon as possible
Pre-hospital ECG is important to know if the patient has ST elevation myocardial
infarction (STEMI ) or non ST elevation myocardial infarction NSTEMI.
Diagnosis

31. Serial cardiac biomarkers. Cardiac troponins is the preferred biomarker and is more
sensitive than creatine kinase isoenzyme (CK-MB). Cardiac troponins are useful in
diagnosis, risk stratification, and determination of prognosis. An elevated level of
troponins correlates with an increased risk of death, and greater elevations predict
greater risk of adverse outcome.
 limitations to these tests exist because they are insensitive during the first 4 to 6
hours of presentation unless continuous persistent pain has been present for 6 to 8
hours. For this reason cardiac biomarkers are not useful in the prehospital setting.
Diagnosis

32. it is recommended that biomarkers should be remeasured between 6 to 12
hours after symptom onset
Echocardiogram.
Stress test.
Nuclear scan, some time as part of stress test.
Computarized Tomography (CT) angiogram.
Coronary angiogram ( Cardiac Catheterization).
Other routine e.g. CBC with differential, CMP, lipid profile, renal function
profile, Urinalysis, etc.
Diagnosis cont-

33. The primary goals of therapy for patients with ACS are to:
Reduce the amount of myocardial necrosis that occurs in patients with acute
myocardial infarction (AMI), thus preserving left ventricular (LV) function,
preventing heart failure, and limiting other cardiovascular complications
Treatment for acute coronary syndrome varies, depending on your
symptoms and how blocked your arteries are.
Treatment

34. Aspirin. It is one of the first things you may be given in the emergency
room for suspected acute coronary syndrome. Aspirin decreases blood
clotting, helping to keep blood flowing through narrowed heart arteries.
Thrombolytics. These drugs, also called clotbusters, help dissolve a
blood clot that's blocking blood flow to your heart.
Treatment and drugs

35. Nitroglycerin. This medication for treating chest pain and angina temporarily
widens narrowed blood vessels, improving blood flow to and from your heart.
Beta blockers. These drugs help relax your heart muscle, slow your heart rate
and decrease your blood pressure, which decreases the demand on your heart.
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin
receptor blockers (ARBs). These drugs allow blood to flow from your heart
more easily.
Treatment and drugs

36. Calcium channel blockers. These medications relax the heart and allow
more blood to flow to and from the heart. Calcium channel blockers are
generally given if symptoms persist after you've taken nitroglycerin and beta
blockers
Clot-preventing drugs. Medications such as clopidogrel (Plavix) and
prasugrel (Effient) can help prevent blood clots from forming by making your
blood platelets less likely to stick together.
Treatment and drugs

37. Angioplasty and stenting. In this procedure, your doctor inserts a long, thin
tube (catheter) into the blocked or narrowed part of your artery. A wire with a
deflated balloon is passed through the catheter to the narrowed area. The
balloon is then inflated, compressing the deposits against your artery walls. A
mesh tube (stent) is usually left in the artery to help keep the artery open.
Coronary bypass surgery. This procedure creates an alternative route for
blood to go around a blocked coronary artery.
Treatment, Invasive procedures

38.  Don't smoke.
 Eat a heart-healthy diet.
 Physical activity and regular exercise
 Check your cholesterol
 Control your blood pressure
 Maintain a healthy weight
 Manage stress.
 Drink alcohol in moderation
Lifestyle

39. Arterial hypertension
Definition
It is defined as a systolic blood pressure (SBP) of 140 mm Hg or more, or a
diastolic blood pressure (DBP) of 90 mm Hg or more. The blood pressure is
compound of:
Peripheral vascular resistance
Heart rate
Stroke volume.

40. Arterial hypertension
The classification of blood pressure for 18 years or older
Normal: SBP <120 mmHg, DBP <80 mm Hg
Pre-HT: SBP 120-139 mmHg, DBP 80-89 mmHg
Stage 1: SBP 140-159 mmHg, DBP 90-99 mmHg
Stage 2: SBP 160 mmHg or greater, DBP 100 mmHg or greater

41. Arterial hypertension
Diagnosis
To establish the diagnose of hypertension is necessary to do an accurate evaluation
of blood pressure, perform a focused medical history, physical examination and
obtaining results of routine laboratory studies. A 12-lead electrocardiogram should
be obtained. These steps can help detect the following: Presence of end-organ
disease, possible causes of hypertension or cardiovascular risk factors.

42. Antihypertension Drugs
1. Diuretics
a. Thiazides: Hydrochlothiazide, chlortalidone
b. Loop: Bumetadine, furosemide
c. Potassium sparing: Amloride, Triamterene
d. Aldosterone antagonist: Espirolactone
2. Beta blocker
a. Non cardioselective: Propanolol, timolol
b. Cardioselective: Metoprolol, atenolol
3. Angiotensive converted enzyme (ACEi)
Captopril, lisinopril, enalapril.

43. Antihypertensive Drugs
4. Angiotensive receptor blocker (ARB)
losartan, valsartan
5. Calcium channel blocker (CCB)
a. Non dihydropyridine: Verapamil, diltiazem
b. Dihydropyridine: Nifedipine, amlodipine
6. Alpha blocker: Terazosyn, prazosyn
7. Central acting agent: Clonidine, methyldopa
8. Alpha-beta adrenergic antagonist: Carvedilol, labetalol

44. Management
Weight loss (5-20 mm Hg per 10 kg)
Limit alcohol <1 oz. of ethanol per day (SBP reduction, 2-4 mm Hg)
Reduce Na intake <2.4 g sodium (SBP reduction, 2-8 mm Hg)
Adequate intake of dietary K, Ca. and Mag.
Stop smoking and reduce saturated fat and cholesterol
Exercise at least 30 minutes daily for most days (SBP reduction, 4-9 mm Hg)

45. Management
Recommendations:
BP: Recommended goal of 139/89 mm Hg or less
Stage 1 hypertension: lifestyle changes and if needed a thiazide diuretic
Stage 2 hypertension: combination of a thiazide and an ACEi, or ARB
or a calcium channel blocker
For BP resistance: Medication doses can be increased and/or a drug
from a different class can be added to treatment.

46. Management
Another considerations in:
Heart failure: Diuretic, BB, ACE inh., ARB, aldosterone antagonist
Post-myocardial infarction: BB, ACE inh. , aldosterone antagonist
CAD risk: Diuretic, BB, ACE inh. , CCB
Diabetes: Diuretic, ACE inhibitor, ARB, CCB
CKD: ACE inhibitor, ARB
Recurrent stroke prevention: Diuretic, ACE inhibitor

47. Atherosclerosis. American Heart Association.
http://www.heart.org/HEARTORG/Conditions/Cholesterol/WhyCholesterolMatters/Atherosclerosis_UCM_3055
64_Article.jsp. Accessed Oct. 2, 2013.
Kalanuria AA, et al. The prevention and regression of atherosclerosis plaques: Emerging treatments. Vascular
Health and Risk Management. 2012;8:549.
Natural product effectiveness checker: High cholesterol. Natural Medicines Comprehensive Database.
http://www.naturaldatabase.com. Accessed Oct. 3, 2013.
What is atherosclerosis? National Heart, Lung, and Blood Institute.
http://www.nhlbi.nih.gov/health/dci/Diseases/Atherosclerosis/Atherosclerosis_All.html. Accessed Oct. 2, 2013.
References