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Atherosclerosis

Brief Overview: According to UpToDate, “This is a condition in which fatty deposits called "plaques" build up inside the arteries in the body. Arteries are the blood vessels that carry blood away from the heart out to the body. Atherosclerosis is the reason most people have a heart attack or a stroke.

Atherosclerosis can affect arteries all over the body. There are different names for it depending on which arteries it affects:

  • Carotid artery disease– This affects the carotid arteries, which bring blood to the brain. It can lead to stroke.
  • Coronary artery disease, also called coronary heart disease – This affects the coronary arteries, which bring blood to the heart muscle. It can cause chest pain and lead to heart attack.
  • Renal artery stenosis– This affects the renal arteries, which bring blood to the kidneys. It can cause high blood pressure or lead to kidney disease.
  • Peripheral artery disease– This affects the arteries that bring blood to the arms and legs. People sometimes have pain, tingling, or numbness in their legs when they walk.”

Prevalence:

  • Atherosclerosis is the underlying cause of most cardiovascular disease, the leading cause of death worldwide.
  • Prevalence increases with age, though early plaque formation can begin in adolescence.
  • Highly prevalent among individuals with hypertension, diabetes, hyperlipidemia, and smoking history.

Etiology:

  • Endothelial injury from chronic inflammation and oxidative stress.
  • Accumulation of LDL cholesterol in arterial walls leading to plaque formation.
  • Smooth muscle proliferation and fibrous cap formation.
  • Plaque rupture can result in acute thrombosis and ischemic events.

Risk Factors:

  • Dyslipidemia
  • HTN
  • Smoking
  • Diabetes
  • Overweight/obesity, sedentary lifestyle
  • Genetic predisposition

Commonly Associated Conditions:

  • Coronary artery disease (CAD)
  • Myocardial infarction (heart attack)
  • Ischemic stroke or transient ischemic attack (TIA)
  • Peripheral artery disease (PAD)
  • Carotid artery stenosis
  • Chronic kidney disease
  • Erectile dysfunction (vascular)

Common Medications:

Medications aim to reduce cardiovascular risk, slow plaque progression, and prevent clot formation.

  • Statins (first-line therapy):
    • Atorvastatin, rosuvastatin, simvastatin
    • Lower LDL cholesterol and stabilize plaques
  • Antiplatelet agents:
    • Aspirin (low-dose)
    • Clopidogrel (in select patients)
    • Reduce risk of thrombotic events
  • Antihypertensive medications:
    • ACE inhibitors (lisinopril), ARBs (losartan)
    • Beta-blockers (metoprolol)
    • Calcium channel blockers (amlodipine)
    • Thiazide diuretics
    • Control blood pressure and reduce vascular strain
  • Glucose-lowering agents (for diabetes):
    • Metformin
    • SGLT2 inhibitors or GLP-1 receptor agonists (cardiovascular benefit in select patients)
  • Additional lipid-lowering therapies (if needed):
    • Ezetimibe
    • PCSK9 inhibitors (specialist-directed)

Common Labs, Imaging, and Tests:

  • Lipid panel: total cholesterol, LDL, HDL, triglycerides
  • HgbA1c and/or fasting glucose
  • Blood pressure monitoring
  • High-sensitivity C-reactive protein (hs-CRP) (risk stratification in select patients)
  • Electrocardiogram (ECG)
  • Stress testing (exercise or pharmacologic)
  • Coronary artery calcium (CAC) score (risk assessment)
  • Carotid ultrasound
  • Ankle-brachial index (ABI) for PAD
  • CT angiography or cardiac catheterization (advanced evaluation)

Common Symptoms:

Often asymptomatic until advanced disease develops. Symptoms depend on affected vascular territory:

  • Chest pain or pressure (angina)
  • Shortness of breath
  • Leg pain with walking (claudication)
  • Fatigue or reduced exercise tolerance
  • Dizziness or transient neurologic symptoms
  • Erectile dysfunction

Common Treatments:

  • Aggressive risk factor modification (lipids, BP, glucose).
  • Long-term medication adherence (statins, antiplatelets, antihypertensives).
  • Lifestyle changes (diet, exercise, smoking cessation).
  • Revascularization procedures when indicated:
    • Percutaneous coronary intervention (PCI/stents)
    • Coronary artery bypass grafting (CABG)
    • Peripheral or carotid interventions

Physical Findings:

  • Hypertension
  • Abnormal heart sounds or bruits (carotid, femoral)
  • Diminished peripheral pulses
  • Cool extremities or delayed capillary refill
  • Signs of chronic ischemia (skin changes, ulcers in PAD)

Potential Complications and Contraindications:

  • Potential complications:
    • Myocardial infarction
    • Stroke or TIA
    • Heart failure
    • Peripheral limb ischemia or amputation
    • Sudden cardiac death
  • Contraindications / cautions:
    • Statin intolerance or myopathy (monitor liver enzymes and symptoms)
    • Bleeding risk with antiplatelet therapy
    • Hypotension with aggressive BP lowering in frail patients

General Health and Lifestyle Guidance:

  • Heart-healthy diet: Mediterranean or DASH-style eating pattern, as recommended by healthcare provider/dietician.
  • Regular physical activity: at least 150 minutes/week of moderate exercise if approved by healthcare provider
  • Smoking cessation – most impactful modifiable intervention.
  • Weight management and waist circumference reduction.
  • Stress management and adequate sleep.
  • Encourage regular follow-up and lab monitoring, as directed by healthcare provider.
  • Reinforce that atherosclerosis is chronic but can be managed.

Suggested Questions to Ask Patients:

  • Do you have a history of heart disease, stroke, or circulation problems?
  • Are you taking cholesterol or blood pressure medications consistently?
  • Have you experienced chest pain, leg pain with walking, or shortness of breath?
  • Do you monitor your blood pressure or blood sugar at home?
  • Do you smoke or have you smoked in the past?
  • What does a typical day of eating and activity look like for you?
  • Have you had any medication side effects or adherence challenges?

Suggested Talking Points:

  • Atherosclerosis develops slowly, often without symptoms, but it can be managed effectively.
  • Medications like statins don’t just lower cholesterol—they stabilize plaques and reduce heart attack risk.
  • Lifestyle changes work together with medications to protect your heart and blood vessels.
  • Consistent medication use is key—even when you’re feeling well.
  • Managing blood pressure, cholesterol, and blood sugar together lowers your risk of serious events.

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