Atherosclerosis - Causes, symptoms and treatment. MF.

Atherosclerosis is a common progressive disease that affects large and medium arteries as a result of the accumulation of cholesterol in them, leading to a violation of blood circulation.
In economically developed countries, atherosclerosis is the most common cause of morbidity and overall mortality.

The causes of atherosclerosis

In the emergence and formation of atherosclerosis play a role:
- violations of lipid( fat) metabolism;
is a hereditary genetic factor;
- the state of the vascular wall.

Cholesterol refers to lipids( fats) and performs many important functions in the human body. It is a building material for the walls of cells of the body, it is part of hormones, vitamins, without which the normal existence of man is impossible. Up to 70% of cholesterol in the body is synthesized in the liver, the rest comes from food. In the body, cholesterol is not in a free state, but is a part of lipoproteins( complex compounds of protein and fats) that transfer it through the bloodstream from the liver to the tissues, and with excess cholesterol - from the tissues back to the liver where excess cholesterol is utilized. In case of violation of this process, atherosclerosis develops.

Accumulation of cholesterol

The main role in the development of atherosclerosis belongs to low density lipoproteins( LDL), which transport cholesterol from the liver to the cells, it must be strictly necessary quantity, at the excess of its level determine the risk of atherosclerosis.

Reverse transport of cholesterol from tissues to the liver provides high-density lipoproteins( HDL) - an anti-atherogenic class of lipoproteins. It clears the surface of cells from excess cholesterol. Increasing the level of LDL cholesterol and lowering the level of HDL cholesterol increases the risk of the onset and development of atherosclerosis.

Initial changes in the wall of arteries of large and medium caliber occur at a young age and evolve to fibroadenomatous plaques, which often develop after 40 years. Atherosclerotic vascular lesions occur in individuals under 20 years in 17% of cases, up to 39 in 60% of cases, and in 50 years and older in 85% of cases.

Cholesterol, fibrin and other substances penetrate into the middle of the arterial wall, which subsequently form an atherosclerotic plaque. Under the influence of excess cholesterol, the plaque increases, and there are obstacles to the normal flow of blood through the vessels at the site of constriction. Inflow of blood decreases, the inflammatory process develops, thrombi form and can come off, with the danger of clogging vital vessels, stopping blood delivery to organs.

The following factors play a role in the development and progression of atherosclerosis:
- modifiable( which can be eliminated or amended)
- not modifiable( they can not be changed).

To modifiable factors include:

1. Lifeform:
- hypodynamia,
- abuse of fatty cholesterol-rich food,
- personality and behavior characteristics - stress type of character,
- alcohol abuse,
- smoking.
2. Arterial hypertension, arterial pressure 140/90 mm Hg.and higher.
3. Diabetes mellitus, fasting blood glucose more than 6mM / L.
4. Hypercholesterolemia( increase in cholesterol in the blood).
5. Abdominal obesity( the waist in men is more than 102 cm and more than 88 cm in women).

To non-modifiable factors include:

1. Age: men over the age of 45 and women older than 55 years or with early menopause.
2. Male gender( men before women for 10 years fall ill with atherosclerosis).
3. Presence in a family history of cases of early atherosclerosis. Family hypercholesterolemia, which have a genetic basis. Myocardial infarction, stroke, sudden death in the immediate family at the age of 55 years of age men and 65 years of age.

Adverse effects of risk factors lead to disruption of the integrity of the endothelium( inner layer of blood vessels), which loses its barrier function, against the background of lipid metabolism disorders lead to the development of atherosclerosis.

Symptoms of atherosclerosis.

The deposition of cholesterol in the wall of the arteries is accompanied by compensatory swelling of the arteries, which means that for a long time there are no obvious symptoms of atherosclerosis. But over time, there is a transformation of atherosclerotic plaque from stable to unstable under the influence of systemic factors: physical stress, emotional stress, arterial hypertension, cardiac rhythm disturbance. They lead to the formation of cracks or rupture of the plaque. On the surface of an unstable atherosclerotic plaque, thrombi form - atherothrombosis forms, leading to a progressive narrowing of the vessels. There is a violation of blood circulation in the organs and tissues, there are clinical symptoms that are noticeable to the patient.

Depending on the localization in the vascular system, atherosclerosis is the basis of such diseases:

1. Coronary heart disease( angina pectoris, myocardial infarction, sudden cardiac death, arrhythmias, heart failure).
2. Cerebrovascular diseases( transient ischemic attack, ischemic stroke).
3. Atherosclerosis of lower limb arteries( intermittent claudication, gangrene of the feet and shins).
4. Atherosclerosis of the aorta.
5. Atherosclerosis of the renal arteries.
6. Atherosclerosis of the mesenteric arteries( intestinal infarction).

Atherosclerosis lesion

The atherosclerotic process leads to the defeat of several vascular pools. In case of stroke, the probability of developing myocardial infarction in such patients is 3 times higher, and peripheral arteries damage increases the risk of myocardial infarction by 4 times, stroke - by 3 times.

Coronary artery atherosclerosis has many symptoms, depending on the severity of atherosclerosis, manifested by angina pectoris or acute coronary insufficiency, characterized by the development of myocardial infarction, heart failure. All forms of ischemic heart disease proceed against the background of atherosclerosis. On cardiac manifestations of atherosclerosis account for about half of all atherosclerotic lesions.

Aortic atherosclerosis often occurs after 60 years. When atherosclerosis of the thoracic aorta appears intense burning pain behind the sternum, giving to the neck, back, upper abdomen. With physical activity and against the background of stress, the pain intensifies. Unlike angina, pain continues for days, periodically increasing and weakening. Swallowing disorders, hoarseness of voice, dizziness, fainting may occur. Atherosclerosis of the abdominal aorta is characterized by abdominal pain, bloating, constipation. With atherosclerotic lesions of the aortic bifurcation( aortic separation on the branch), Lerish syndrome develops with such manifestations as intermittent claudication, coldness of the lower limbs, impotence, and finger ulcers of the feet. A terrible complication of atherosclerosis of the aorta is an aneurysm( separation) and aortic rupture.

Atherosclerosis of mesenteric vessels is manifested by sharp, burning, cutting pains in the abdomen during meals, lasting 2-3 hours, bloating, breaking stool.

For arteriosclerosis of the renal arteries is characterized by a persistent increase in blood pressure, changes in the analysis of urine.

Atherosclerosis of peripheral arteries is manifested by weakness and increased fatigue of the leg muscles, sensation of chilliness in the limbs, intermittent claudication( pain in the limbs appears during walking, forcing the patient to stop).

Examination of atherosclerosis.

The primary diagnostics of atherosclerosis is performed by the therapist, the family doctor during the annual dispensary examination. Measures blood pressure, determines the body mass index, identifies risk factors( hypertension, diabetes, obesity).

1. Determination of lipid levels, after 30 years:
- total cholesterol( norm less than 5.0 mmol / l);
- LDL cholesterol( norm below 3.0 mmol / l);
is the cholesterol of HDL cholesterol( norm above 1.0 mmol / L( in men) and above 1.2 mmol / l( in women),
- triglycerides of blood plasma( norm below 1.2 mmol / l)
-cholesterol / HDL cholesterol( atherogenicity index is a factor in the development of cardiovascular complications) Low risk from 2.0 to 2.9, average risk is from 3.0 to 4.9, high risk is more than 5.

2. Determination of the risk group in patients without clinical manifestations of atherosclerosis. To determine the individual degree of risk for patients, the SCORE( Systemic Coronary Risk Assessment) scale allows to estimate the probability of fatal cardiovascular events( myocardial infarction, stroke) for 10 years. Low risk is <4%, moderate risk is 4-5%, high risk is 5-8% and very high risk is> 8%.

If a diagnosis of atherosclerotic changes is suspected, a specialist consultation is indicated:
- a cardiologist( for ischemic heart disease);
- oculist( atherosclerosis of the vessels of the fundus);
- neurologist( cerebral atherosclerosis);
- nephrologist( atherosclerosis of the renal arteries);
- a vascular surgeon( atherosclerosis of the vessels of the lower extremities, aorta).

To determine the degree of atherosclerotic lesion, additional instrumental methods of investigation may be prescribed:

1. Electrocardiography, with exercise tests, ultrasound examination of the heart, aorta.
2. Angiography, coronary angiography, intravascular ultrasound. These are invasive methods of investigation. Identify atherosclerotic plaques, allow to evaluate the total atherosclerotic lesion. Applied in patients with clinical manifestations of atherosclerosis( ischemic heart disease).
3. Duplex and triplex scanning. Investigation of blood flow with ultrasound visualization of vessels: carotid arteries, abdominal aorta and its branches, arteries of the lower and upper extremities. Identifies atherosclerotic plaques in the arteries, assesses the blood flow in the vessels.
4. Magnetic resonance imaging. Visualization of the wall of arteries and atherosclerotic plaques.

Treatment of atherosclerosis.

1. Without clinical manifestations of atherosclerosis, a modifiable lifestyle is recommended for a patient with moderate risk( up to 5% SCORE score) and total cholesterol level above 5 mmol / l. It includes: giving up smoking, drinking alcohol, anti-atherosclerotic diet, increasing physical activity. When the target cholesterol level is reached( total cholesterol to 5 mmol / l, LDL cholesterol below 3 mmol / l), a repeated examination should be carried out at least once every 5 years.

Initiation of treatment of a high-risk patient( above 5% SCORE) and total cholesterol levels above 5 mmol / L should also begin with recommendations for a 3-month lifestyle change and a re-examination at the end of this period. When the patient achieves the target levels of total cholesterol to 5 mmol / l and LDL cholesterol below 3 mmol / l, annual lipid levels are monitored. If the risk remains high( above 5% on the scale SCORE), prescribe drug therapy.

2. Patients with signs of atherosclerotic lesion of any localization are recommended a lifestyle modification and drug therapy.

Antiatherosclerotic Diet.

Recommendations for diet compliance are given to all patients, taking into account the level of cholesterol and other risk factors: obesity, hypertension, diabetes. The food ration should be varied, in accordance with the patient's cultural traditions. The caloric content of the daily ration should be sufficient to achieve and maintain a normal weight.

The consumption of total fat should not exceed 30% of the calorie content of the diet.
It is recommended to limit the intake of animal fats( butter, cream, meat, fat), replacing them with vegetable fats. Daily consumption of fresh vegetables and fruits should be at least 400 grams per day.

It is recommended to consume low-fat meat and poultry without skin, dairy products, low-fat cottage cheese, cereal bread, bran, products enriched with ω3-unsaturated fatty acids( marine and ocean fish - salmon, mackerel, tuna, etc.).Limitation of consumption of table salt to 6 grams per day, which corresponds to 1 teaspoon. Compliance with the diet can reduce cholesterol to 10%.

Normalization of body mass index.

Excess body weight and obesity, especially abdominal( the waist in men more than 102cm and more than 88cm in women), increase the risk of developing cardiovascular diseases. To reduce weight, an individual diet is selected with regard to age and concomitant diseases.

Physical activity in atherosclerosis.

Increased physical activity gives a positive effect for patients with atherosclerosis.
Patients without clinical manifestations of atherosclerosis are shown physical activity for 40 minutes, daily. The intensity of the load should be 60% of the maximum heart rate( calculated = 220 - age).

Patients with cardiovascular diseases need a constant regime of dynamic physical exertion, taking into account the results of stress tests. Useful walking, swimming, dancing - moderate intensity 60-90min a week. Isometric( force) loads are inadmissible.

It is recommended to use any opportunities for physical activity: walking, less often using a car.

Cessation of smoking.

Smoking( active and passive), as a result of a sharp decrease in HDL( anti-atherogenic class of lipoproteins), pathological effects on the vascular system, rheology of the blood, increases the risk of morbidity and mortality from cardiovascular complications by 20%.Smokers have a 2-fold higher risk of developing ischemic stroke than non-smokers.

Drinking alcohol.

Safe for health consumption of alcohol - no more than 20-30 ml of pure ethanol per day for men and not more than 20 ml per day - for women, only for practically healthy individuals, reduces the death rate from cardiovascular complications. Drinking alcohol( 12-24 g per day of pure ethanol) reduces the risk of cardiovascular complications( heart attack and stroke) by 20%, and the use of 5 portions of alcohol( 60 grams per day) increases the risk of cardiovascular complications by 65%.

Drugs.

Drug use, such as cocaine, amphetamine, heroin, causes abrupt changes in blood pressure, inflammatory changes in the vascular system, lead to a violation of the rheological properties of the blood. Increase the risk of stroke in 6.5 times in individuals under 35, and over 35 years - in 11.2 times.

Medical treatment of atherosclerosis.

Medical therapy for atherosclerosis involves the use of 4 groups of lipid-lowering drugs( lipid-lowering drugs): bile acid sequestrants, nicotinic acid, fibrates, statins. These drugs have a stabilizing effect on the atherosclerotic plaque, improve the function of the endothelium( the inner shell of the vessels), inhibit the development of atherosclerosis, differing in this case by the severity of the effect on various parameters of lipid metabolism.

Only the attending physician will recommend the necessary preparation and its dosage. The most commonly used statins. Treatment with statins contributes to a significant reduction in mortality and prevents cardiovascular complications. The necessary dose of statins is selected individually for each patient. The drug is taken once a day - in the evening before bedtime.

Auxiliary value is based on fish oil preparations, essential phospholipids. They are used only in combination with statins.

Surgical treatment of atherosclerosis.

At a threat of development of complications of atherosclerosis surgical treatment is shown, which restores the patency of the arteries( revascularization).In coronary heart disease, stenting or bypassing the coronary arteries is used to prevent the development of a heart attack. In cerebral atherosclerosis, stenting of the carotid arteries is used to prevent the development of a stroke. To prevent the development of gangrene of the lower extremities, prosthetics of the main arteries are performed. The surgeon( cardiac surgeon, vascular surgeon) determines the necessity and scope of surgical intervention.

Surgical treatment of atherosclerosis

Surgical treatment of atherosclerosis does not give a complete cure. The complication is eliminated, and not the cause that caused it( atherosclerosis).Therefore, after surgery, lifestyle changes, nutrition and conservative treatment are mandatory.

Prevention of atherosclerosis.

Primary prevention of atherosclerosis involves:

1. Control and achieve the target cholesterol level( total cholesterol to 5 mmol / L, LDL cholesterol below 3 mmol / l).
2. Refusal from smoking, drinking alcohol, taking drugs.
3. Adequate level of physical activity.
4. Normalization of body weight.
5. Limitation of emotional overload.
6. Normal blood glucose.
7. Blood pressure below 140/90 mm Hg.
8. Compliance with the principles of anti-atherosclerotic diet.

The measures of secondary prevention aimed at preventing complications of an already developed disease, in addition to measures of primary prevention, also include the administration of hypocholesterolemic drugs( statins), antiplatelet agents( acetylsalicylic acid).

Consultation of a doctor on the topic of atherosclerosis:

Question: Is it advisable to take statins for people of elderly and senile age( 70-80 years)?
Answer: The therapy of atherosclerosis with statins in the elderly not only reduces the risk of stroke and heart attack, but also reduces overall mortality.

Question: How long should I take statins?
Answer: To significantly improve the prognosis of life and reduce the risk of cardiovascular complications, statins should be used daily for at least 3-5 years without undue reduction of dose and unauthorized premature termination of treatment.

Physician therapist Vostrykova I.N.