1. Professor of cardiology and internal medicine
Atherosclerosis
Saadeldeen majeed
Professor of cardiology and internal medicine

2. Pathogenesis of Atherosclerosis
According to injury hypothesis considers atherosclerosis to be a diffuse, slowly progressing, chronic inflammatory response of the arterial wall initiated by injury:

3. Pathogenesis of Atherosclerosis
1. Chronic endothelial injury.
2 .Insudation of lipoproteins [LDL].
3. Modification of lipoproteins by oxidation.
4. Adhesion of blood monocytes.
5. Adhesion of platelets.

4. Pathogenesis of Atherosclerosis
6. migration of smooth muscle cells
from the media into the intima.
7. proliferation of smooth muscle cells
in the intima.
8. enhanced accumulation of intra and
extra cellular lipids.

5. ATHEROSCLEROTIC PLAQUE
The change of the large arterial intima is called atherosclerotic plaque or atheroma
atherosclerotic plaque is the intimal thickening with lipid accumulation
It consists of fibrous cap, necrotic core and fibrous basis.

6. Atherosclerotic plaque
It has three principle components:
1- cells –smooth muscle cells, macrophages,
other leukocytes.
2 - Extra cellular matrix- collagen, elastic fibers,
and proteoglycans.
3 - Intra cellular and extra cellular lipids.

13. Normal coronary artery
Lumen has been distended at a pressure of 100mmHg with 10% formal saline
used with permission from
M.J. Davies
Atlas of Coronary Artery Disease 1998
Lippincott-Raven Publishers

15. Eccentric plaque with a central zone containing yellow lipid
Early coronary atherosclerosis
Eccentric plaque with a central zone containing yellow lipid
used with permission from
M.J. Davies
Atlas of Coronary Artery Disease 1998
Lippincott-Raven Publishers

17. Stable angina. Eccentric coronary stenosis
used with permission from
M.J. Davies
Atlas of Coronary Artery Disease 1998
Lippincott-Raven Publishers

20. Stable angina. Eccentric coronary stenosis
thick cap
used with permission from M.J. Davies
Atlas of Coronary Artery Disease 1998
Lippincott-Raven Publishers

22. Unstable angina with plaque disruption
used with permission from M.J. Davies
Atlas of Coronary Artery Disease 1998
Lippincott-Raven Publishers

24. Unstable angina with plaque disruption
The plaque cap is torn,
projects into the lumen, exposing a mass of thrombus filling the lipid core
used with permission from
M.J. Davies
Atlas of Coronary Artery Disease 1998
Lippincott-Raven Publishers

25. Development of Atherosclerotic Plaques
2.03
Fatty streak
Normal
Lipid-rich plaque
Foam cells
Fibrous cap
Lipid core
Thrombus
Ross R. Nature. 1993;362:

26. Vulnerable Versus Stable Atherosclerotic Plaques
2.05
Vulnerable Plaque
Lumen
Thin fibrous cap
Inflammatory cell infiltrates:
proteolytic activity
Lipid-rich plaque
Lipid
Core
Fibrous Cap
Stable Plaque
Thick fibrous cap
Smooth muscle cells: more extracellular matrix
Lipid-poor plaque
Lumen
Lipid
Core
Fibrous Cap
Libby P. Circulation. 1995;91:

27. Major modifiable Risk Factors
Cigarette smoking (passive smoking?)
Elevated total or LDL-cholesterol
Hypertension (BP 140/90 mmHg or on antihypertensive medication)
.. Low HDL cholesterol (<40 mg/dL)†
Obesity: Body Mass Index (BMI)
Weight (kg)/height (m2)
Weight (lb)/height (in2) x 703
Obesity BMI >30 kg/m2 with overweight defined as 25-<30 kg/m 2
Abdominal obesity involves waist circumference >40 in. in men, >35 in. in women
Physical inactivity: most experts recommend at least 30 minutes moderate activity at least 4-5 days/week
† HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.

28. Nonmodifiable Risk Factors
Age- Age (men 45 years; women 55 years)
the older you get, the greater the chance.
Sex- males have a greater rate even after women pass menopause.
Race- minorities have a greater chance.
Family history- if family members have had CHD, there is a greater chance. Family history of premature CHD
CHD in male first degree relative <55 years
CHD in female first degree relative <65 years
Unchangeable Risk Factors: Age, the older you get the greater the chance of heart disease. Four out of five people who die of congestive heart disease are 65 years of age or older. Sex, males have a greater rate of congestive heart disease. Race, minorities have a greater chance of heart disease. African Americans have a greater chance of high blood pressure. The risk is also higher in Mexican Americans, America Indians, native Hawaiians and Asian Americans. Also included as unchangeable risk factors is your family history and your own personal medical history.

30. Clinical Manifestations of Atherosclerosis
2.09
Coronary heart disease
Stable angina, acute myocardial infarction, sudden death, unstable angina
Cerebrovascular disease
Stroke, TIAs
Peripheral arterial disease
Intermittent claudication, increased risk of death from heart attack and stroke
American Heart Association, 2000.

31. FORMS OF ATHEROSCLEROSIS
CEREBRAL ARTERIES INJURY
CARDIAC ARTERIES INJURY
RENAL ARTERIES INJURY
AORTA INJURY
INTESTINAL ARTERIES INJURY
EXTREMITY ARTERIES INJURY

33. What Does It Look Like?
The coronary artery is narrowed reducing the flow of oxygen to the heart.
It is easier for plaque to get inside a narrower artery.

34. CEREBRAL FORM OF ATHEROSCLEROSIS
Acute form may be as Hemorrhage within
The brain due to rupture
Of atherosclerotic aneurism

35. CEREBRAL FORM OF ATHEROSCLEROSIS
Chronic form may be as encephalopathy
With cerebral atrophy (decreasing memory)

36. Extremity form of atherosclerosis
Acute form may be as gangrenous necrosis.

38. Aortic form of atherosclerosis
Various forms of aorta lesion

39. RENAL FORM OF ATHEROSCLEROSIS
Acute form may be as infarction
Chronic form is called
Atherosclerotic
Nephrosclerosis or
Primary contracted
kidney

40. Intestinal form of atherosclerosis
Acute form may be as gangrenous necrosis of the intestine
Chronic form may be as ischemic enterocolitis

43. The Skinny on Fat
Saturated fats- basically means the fat is saturated with hydrogen, they are solid at room temperature. Examples are lard and butter.
Why are they bad for you? They increase levels of LDL , decrease HDL and increase total cholesterol.
Saturated fats can cause an increase in cholesterol. What is saturated fat? It is fat that is saturated with hydrogen and is a solid at room temperature. Examples are lard and butter. Saturated fats increase levels of LDL, decrease levels of HDL and increases total cholesterol. The American Heart Association recommends you limit saturated fat intake to 7-10% of your total calories.

44. The Skinny on Fat What are monounsaturated fats?
They are liquid at room temperature but start to solidify in the refrigerator.
Decrease total cholesterol and lower LDL levels.
Monounsaturated fat includes canola, olive and peanut oils and avocados.

45. The Skinny on Fat
What are trans fatty acids? They are unsaturated fats but they tend to raise total and bad cholesterol.
Where do you find them?
In fast-food restaurants
Commercial baked goods. Examples: doughnuts, potato chips, cupcakes.
Trans fatty acids have hydrogen added to them to give them a longer shelf life and they also tend to lower HDL levels.

46. What about Omega 3? Type of polyunsaturated fat.
Consistently lowers serum triglycerides and may also have an effect on lowering blood pressure.
Found in oily fish such as salmon, tuna, and herring.
Is available as a supplement.
The American Heart Association recommends eating fish two times per week. Mention other fish that contain Omega 3 fatting acids. Omega 3 fatty acids are available as a supplement but research is till being done to determine the supplements’ effectiveness.

48. Physical Inactivity
Increasing physical activity has been shown to decrease blood pressure.
Moderate to intense physical activity for minutes on most days of the week is recommended.
Exercise can help control blood cholesterol, diabetes and obesity, as well as help lower blood pressure.

50. Cigarette Smoking Causes an increase in blood pressure
Usually have lower levels of HDL
Within 1 year of quitting, CHD risk decreases, within 2 years it reaches the level of a nonsmoker.

52. Diabetes Mellitus
At any given cholesterol level, diabetic persons have a 2 or 3 x higher risk of atherosclerosis!
Insulin is required to maintain adequate levels of lipoprotein lipase, an enzyme needed to break down bad cholesterols.
About 2/3 of the people with diabetes die of some type of heart or blood vessel disease.

55. Obesity
People who are obese have 2 to 6 times the risk of developing hypertension.
Location of the body fat is significant.
Pears of apples?
People who are obese have 2 to 6 times the risk of developing hypertension even if they have no other risk factors.

57. Approaches to Primary and Secondary Prevention
Primary prevention involves prevention of onset of disease in persons without symptoms.
Primordial prevention involves the prevention of risk factors causative o the disease, thereby reducing the likelihood of development of the disease.
Secondary prevention refers to the prevention of death or recurrence of disease in those who are already symptomatic

58. Prevention Get regular medical checkups. Control your blood pressure.
Check your cholesterol.
Don’t smoke.
Exercise regularly.
Maintain a healthy weight.
Eat a heart-healthy diet.
Manage stress.
Prevention