Arteriosclerotic Heart Disease

By Cardiologist on November 7th, 2011

Description of Medical Condition

Arteriosclerosis is a group of diseases characterized by thickening and loss ot elasticity of the arterial walls which progressively blocks the coronary arteries and their branches. Arteriosclerosis is the most common form of coronary arteriosclerosis. The process is chronic, occurring over many years, and is the most common cause of cardiovascular disability and death. Other forms of arteriosclerosis include arteriolosclerosis and medial calcific stenosis, both of which are uncommon in the coronary vasculature.

System(s) affected: Cardiovascular

Genetics: Tendency is inheritable

Incidence/Prevalence in USA: Common. Causes 35% of deaths in men age 35-50. Death rate age 55-64-1:100.

Predominant age: Men 50-60, women 60-70, for peak clinical manifestations

Predominant sex: Male > Female

Medical Symptoms and Signs of Disease

• Variable. May remain clinically asymptomatic even in advanced disease states, eg, silent ischemia.

• Clinical manifestations

– Substernal chest pain

– Exertional dyspnea

– Orthopnea

– Paroxysmal nocturnal dyspnea

– Cardiac arrhythmias

– Systolic murmur

– Cardiomegaly

– Pedal edema

What Causes Disease?

• Atherosclerosis

• Narrowing of coronary arteries

• Embolism compromising coronary arteries at orifices

• Subintimal atheromas in large and medium vessels

Risk Factors

• Elevated low density lipoprotein (LDL)

• Decreased high density lipoprotein (HDL)

• Elevated triglycerides

• Smoking

• Family history of premature arteriosclerosis

• Obesity

• Hypertension

• Stress

• Sedentary life style

• Increasing age

• Male sex

• Diabetes mellitus

Diagnosis of Disease

Differential Diagnosis

N/A

Laboratory

• Elevated triglycerides

• Elevated total cholesterol

• Elevated low density lipoproteins

• Decreased high density lipoproteins

• Elevated cholesterol/HDL ratio

Drugs that may alter lab results: N/A

Disorders that may alter lab results: N/A

Pathological Findings

• Gross — narrowed coronary arteries

• Micro — cholesterol plaques on intima of coronary vessels

• Fibrotic subendothelial connective tissue of intima with plaque

Special Tests

• ECG — variable. May be normal or may see ST segment elevation/depression and/or T wave inversion.

• Exercise stress test — positive

Imaging

• Angiography — narrowed coronary arteries

• Echocardiography — wall motion abnormalities

• Pharmacologic stress tests (dobutamine, dipyridamole. adenosine) — positive

• Stress thallium test — positive

Diagnostic Procedures

N/A

Treatment (Medical Therapy)

Appropriate Health Care

• Outpatient for management of risk factors

• Inpatient for acute ischemic syndromes

General Measures

• Prevention of further progression of the disease

– Smoking cessation

– Treatment of hypercholesterolemia (diet, drugs)

– Increase high density lipoprotein (diet, exercise)

– Control of blood pressure

– Diabetes mellitus treated early and adequately

– Exercise

– Prophylactic aspirin

– Stress reduction

– Diet changes

– Weight loss

• Treatment of complications

– Covered elsewhere under the individual topics (e.g. angina pectoris, myocardial infarction, heart failure, stroke, peripheral arterial occlusion, etc.)

Activity

Exercise may be helpful in preventing clinical coronary disease and useful for therapeutic measures

Diet

• Low-fat (20-30 grams of fat/day total intake)

• Weight-loss diet, if obesity a problem

• Increase soluble fiber

Patient Education

For patient education materials favorably reviewed on this topic, contact: American Heart Association, 7320 Greenville Avenue. Dallas, TX 75231,(214)373-6300

Medications (Drugs, Medicines)

Drug(s) of Choice

• Aspirin, 160-325 mg/day, unless contraindicated

• Cholesterol-lowering agents

– HMG-CoA reductase inhibitors (dose varies with product): atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor), rosuvastatin (Crestor)

– Cholestyramine or colestipol, (bile acid sequestrants)

12-32 gm orally BID-QID

– Omega-3 acid ethyl esters (Omacor)

– Niacin 2-6 gm daily in divided doses (highly efficacious, but side effects restrict use)

– Gemfibrozil 600 mg bid

– Fenofibrate 67-200 mg/day

– Probucol 500 mg bid

– Colesevelam 3.75-4.375 g/day OEzetimibe 10 mg/day

Contraindications: Refer to manufacturer’s literature

Precautions: SR form of niacin may be linked to hepatotoxicity. Refer to manufacturer’s literature.

Significant possible interactions: Refer to manufacturer’s literature

Patient Monitoring

Monitor cholesterol, triglyceride levels, other preventive programs (weight loss, smoking cessation)

Prevention / Avoidance

See General measures

Possible Complications

• Myocardial infarction

• Ventricular fibrillation

• Congestive heart failure

• Angina pectoris

• Sudden cardiac death

Expected Course / Prognosis

Guardedly favorable. Many risk factors can be modified.

Alternative Drugs

• Ticlopidine, Dipyridamole, Clopidogrel

• activity antiplatelet

Miscellaneous

Associated Conditions

• Obesity

• Hypertension

• Diabetes

• Hypercholesterolemia

Age-Related Factors

Pediatric: Preventive measures can begin early (proper nutrition, exercise, weight control, smoking deterrent programs, etc.)

Geriatric: Greatest incidence in this age group

Pregnancy

Rare in pregnant women

Synonyms

• Coronary artery disease (CAD)

• Coronary heart disease

• Coronary arteriosclerosis

International Classification of Diseases

414.00 Coronary atherosclerosis of unspecified type of vessel, native or graft

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