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Manifestations of atherosclerosis.
Atherosclerosis can manifest as coronary artery disease, peripheral artery disease or cerebrovascular disease
The formation of plaques occurs over several decades, starting as thickening of the inner surface layer of an artery exposed to the blood (the intima) and progressing to an advanced lesion called a fibroatheroma.3,4
Plaques may lead to acute events by narrowing the arteries and the formation of blood clots.5
For more detailed information on the progression of atherosclerosis, please see the Understanding arterial thrombosis section.
Plaque formation in atherosclerosis.
Formation of arterial plaques
Events such as heart attacks and stroke are caused by a sudden restriction in arterial blood flow to the heart or brain, respectively.2
The majority of these acute ischaemic events occur when, due to rupture or erosion, an atherosclerotic plaque releases material that promotes blood clotting.1,2 This leads to the formation of a large blood clot known as a thrombus.1
As well as causing heart attacks and strokes, atherosclerosis can also occur in the lower limbs, where it is known as peripheral artery disease and can lead to acute limb ischaemia, a condition characterized by a sudden decrease in limb perfusion; this can lead to pain and, in some cases, amputation.8,9 For more detailed information on the progression of atherosclerosis, please see the Understanding arterial thrombosis section.
Peripherial Artery Disease: causes and consequences
An overview of atherosclerosis, its causes and treatment options.
The basics of atherosclerosis
More recently, however, new risk factors have been identified, including:9
Risk factors for atherosclerosis.
Non-modifiable and modifiable risk factors for atherosclerosis
There are several factors that can increase the risk of serious acute events in patients with atherosclerotic disease. The most significant risk factor is polyvascular disease, where atherosclerotic plaques develop in multiple arterial beds at the same time (e.g. in both the coronary arteries and the arteries of the lower limb).10 Notably, 24.7% of patients with coronary artery disease and 61.5% with peripheral artery disease have concomitant disease in another arterial bed.11
Polyvascular disease occurs frequently in patients with atherosclerosis.
Data showing the occurrence of concomitant atherosclerosis
Certain co-morbidities can also increase the risk of acute events in patients with atherosclerosis and, in many cases, these overlap with the risk factors that increase the risk of developing atherosclerosis.8,10 Previous ischaemic events, diabetes and heart failure have all been shown to increase the risk of events, and patients with any of these conditions may require careful management.10
The symptoms associated with atherosclerosis depend on the arteries affected.
Coronary artery disease (CAD) most commonly manifests as discomfort or pain in the chest or shortness of breath. In patients with suspected CAD, the European Society of Cardiology (ESC) guidelines recommend that the first stage of diagnosis is to establish the probability of CAD based on clinical history, basic testing and assessment of left ventricular function. Once a diagnosis has been confirmed, an appropriate therapy will be determined based on the progression stage of the cardiovascular disease.14
Peripheral artery disease (PAD) is suspected in patients with pain in the lower legs, non-healing of wounds or an absent or abnormal pulse in the lower extremities. In these patients, ankle–brachial index (the ratio of blood pressure in a leg to that in the arm) is recommended to objectively confirm PAD. Suspicion of PAD may also arise from clinical history alone.15
Treatment of atherosclerosis focuses on providing symptomatic relief and reducing the risk of acute events. Where necessary, most patients will be encouraged to adopt certain lifestyle modifications including smoking cessation, adoption of a healthy diet and increased exercise.14,16
By making these lifestyle changes, patients can address several risk factors associated with increased risk of acute events; however, drug therapy may also be required. For example, patients with atherosclerosis may receive an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker to reduce blood pressure, a statin to address lipid levels and antithrombotic therapy to reduce the risk of clots. In some patients with atherosclerosis, surgical interventions may be required.14,16
For more detailed information on specific treatment approaches for coronary artery disease and peripheral artery disease, please see the Managing atherosclerosis section.
Effective vascular protection can limit the risks associated with atherosclerosis.
Overview of management of atherosclerosis