Understanding Arteriosclerosis: The Silent Killer Explained

Quick overview:

• Description: Vascular disease in which arteries harden and narrow; The most common form is atherosclerosis, in which plaques build up on the inner walls of blood vessels; Blood flow is disturbed and, in the worst case, interrupted (emergency!).
• Symptoms: No symptoms for a long time, often only noticeable due to secondary illnesses, such as pain and tightness in the chest in coronary heart disease or a heart attack, speech problems and paralysis in a stroke or painful, numb and pale legs in intermittent PAD.
• Causes and risk factors: Not yet fully understood, atherosclerosis involves a complex interaction of several factors that lead to plaque formation in the arteries. Risk factors include age, increased blood lipid levels, high blood pressure, diabetes mellitus and smoking.
• Treatment: lifestyle changes (healthy diet, exercise, quitting smoking, etc.), treatment of previous illnesses such as diabetes or high blood pressure, cardiovascular medications such as lipid-lowering drugs, surgery (catheter, stent, bypass).
• Course and prognosis: Regression possible in the early stages; to positively influence the course through the correct treatment and avoidance of risk factors; Secondary diseases are often linked to shortened life expectancy.
• Examinations and diagnosis: blood test, imaging procedures such as X-rays, ultrasound or MRI, (stress) ECG, cardiac catheter examination, if necessary, urine tests.
• Prevention: If possible, avoid risk factors and early treatment of underlying diseases that promote arteriosclerosis.

Description: What is arteriosclerosis?

By definition, arteriosclerosis means the hardening (sclerosis) of the arteries in the body. This disease is also known colloquially as hardening of the arteries. The walls of the arteries thicken, lose their elasticity over time and in many cases become increasingly narrow. These changes increasingly restrict blood flow.

In principle, arteriosclerosis can develop in all arteries of the body, such as the neck, brain, heart, kidneys, pelvis, legs or arms. Places where the blood flow encounters physical obstacles are particularly often affected – for example at vascular branches. The main artery (aorta) can also harden as arteriosclerosis progresses (atherosclerosis of the aorta).

Forms of arteriosclerosis

By far the most common form of arteriosclerosis is atherosclerosis. Blood lipids, protein components or connective tissue are deposited on the inner walls of the arterial vessels. Doctors refer to these deposits as plaques.

In everyday language, the terms hardening of the arteries, arteriosclerosis and atherosclerosis are often equated. In addition to atherosclerosis, there are other forms of arteriosclerosis:

Media sclerosis or Mönckeberg sclerosis refers to the hardening of the middle layer of the arterial vessel wall (media). It is the result of too much calcium in the blood and is associated with diseases such as chronic kidney failure or diabetes.

In arteriolosclerosis, the inner walls of small arteries (arterioles) in the body become calcified. People who already suffer from diabetes mellitus or high blood pressure often become ill.

Possible consequences of arteriosclerosis

The arteries transport blood rich in oxygen and nutrients from the heart to all organs, muscles, and tissues. If the blood vessels become increasingly inelastic and possibly narrower, the blood can no longer flow freely.

In the worst case, a clot of blood platelets (thrombus) forms. Such a thrombosis can block the artery and completely stop blood flow. The thrombus can also be carried along by the bloodstream and block the artery as an embolus somewhere else (embolism). A blocked artery puts you at risk for a heart attack, stroke, or acute vascular occlusion in the arms or legs (acute limb ischemia).

If the blood flow is interrupted – for example by a thrombosis or embolism – organs or limbs are no longer supplied with oxygen. An acute artery occlusion is always a medical emergency.

Atherosclerosis can also weaken the vessel wall to such an extent that the artery expands and an aneurysms form. If this tears, those affected can bleed to death internally.

The possible complications of arteriosclerosis – such as heart failure, heart attack or stroke – are among the most common causes of death worldwide.

Atherosclerosis: symptoms

Atherosclerosis develops slowly. It often remains undetected for years or decades until dangerous secondary diseases and their symptoms finally appear. Which symptoms then manifest themselves depends on which vessels in the body are affected.

Atherosclerosis can cause blockage of the arteries, which can lead to a heart attack, stroke, or acute vascular blockage in the arms or legs. This is an emergency that must be treated as quickly as possible.

If the coronary arteries are narrowed, you have coronary artery disease. Symptoms arise from reduced blood flow to the heart muscle. Patients experience chest tightness or left-sided chest pain (angina pectoris).

If a blood clot blocks an already narrowed coronary artery, a heart attack occurs. This often manifests itself as severe pain in the chest, which can radiate to the arms. Pain in the upper abdomen or back, tightness, shortness of breath, nausea and vomiting are also warning signs.

If the blood flow is disturbed due to a narrowing of the carotid artery (carotid stenosis), the brain is no longer optimally supplied with oxygen- and nutrient-rich blood. In the worst-case scenario, there is a risk of a stroke. Functional disorders of the nervous system such as paralysis or speech disorders occur.

Atherosclerosis can also occur in the pelvis and legs, as well as in the shoulders and arms. Media sclerosis or atherosclerosis of the extremity arteries manifests itself, for example, as peripheral arterial disease (PAD), also known as smoker’s leg. It occurs due to circulatory problems in the thighs and calves. Leg pain occurs after even short walking distances (intermittent claudication). Because those affected have to take breaks from walking again and again, it is also referred to as “intermittent claudication”. Narrowing of arteries in the pelvis also leads to impotence in many men.

If blood flow is interrupted due to vascular occlusion in the arms or legs, acute limb ischemia occurs. The extremity hurts, becomes pale and can no longer be moved properly. Such ischemia is a vascular surgical emergency and the most common cause of amputation.

Arteriosclerosis in the renal vessels (such as atherosclerosis of the renal artery) leads to symptoms of impaired kidney function and high blood pressure. In the worst case, kidney failure occurs, in which some of those affected hardly excrete urine, but often do not experience any symptoms.

Development of arteriosclerosis: causes and risk factors

The development of arteriosclerosis is very complex and has not yet been fully understood. Researchers assume that arteriosclerosis begins with damage to the inner layer (in atherosclerosis) or the middle layer (in media sclerosis) of the arterial vessel walls.

However, exactly how this arterial damage (lesions) occurs is not exactly known. However, certain risk factors such as high blood pressure, smoking and elevated blood lipids appear to contribute. A connection with infections or chronic inflammatory diseases such as rheumatism is also discussed.

The common explanatory model for the pathogenesis of atherosclerosis is called the “response-to-injury” theory. According to this, the injury to the inner layer of the blood vessels (intima) promotes the storage of cholesterol (especially LDL cholesterol “low density lipoprotein”, also called LDL) and cell components. LDL cholesterol oxidizes, triggering an inflammatory response.

Monocytes, which are white blood cells, are called into action. They transform into phagocytes (macrophages) that migrate into the vessel wall and absorb as much LDL as possible.

The immune cells swell into fat-rich foam cells, which are deposited as growing “fatty streaks” in the artery wall. These fatty streaks can develop into atherosclerotic plaques. The artery wall becomes thicker and harder, and the diameter of the blood vessel (lumen) becomes smaller.

At the same time, the macrophages release growth factors that stimulate smooth muscle cells within the vessel wall to multiply. The muscle cells then migrate to the plaques and cover them with a solid layer, making the blood vessels even narrower.

Atherosclerosis risk factors

There are certain physical conditions and lifestyle habits that increase the risk of atherosclerosis.

Older people are more likely to suffer from hardening of the arteries. It also affects more men than women. Experts believe the reason is female hormones, primarily estrogen, which is said to have a protective influence. Men also develop arteriosclerosis earlier.

Heredity also plays a role (genetic predisposition). If close relatives (men under 55, women under 65) suffer from cardiovascular disease due to arteriosclerosis, the risk for the person concerned is also increased. Hereditary lipid metabolism disorders as well as geographical origin also influence the risk of arteriosclerosis.

Age, gender and genetic makeup cannot be changed. But lifestyle also has an influence on the risk of arteriosclerosis. Diet, lack of exercise, smoking or metabolic diseases such as diabetes promote the development of the disease in all age groups:

• High LDL cholesterol levels promote plaque formation.
• High blood pressure directly damages the inner walls of blood vessels.
• A diet rich in saturated fatty acids, such as those found in animal foods, promotes high LDL cholesterol levels and obesity – both factors increase the risk of arteriosclerosis.
• Smoking causes circulatory problems, can damage blood vessels and increase blood pressure and cholesterol levels. In addition, substances from tobacco smoke contribute to the formation of so-called unstable plaques. These are deposits in the arteries that can break open.
• Elevated blood sugar levels caused by diabetes mellitus (diabetes) damage the blood vessels (angiopathy).
• Overweight and obesity (obesity) are also associated with a higher risk of atherosclerosis.
• Lack of exercise can increase blood pressure, worsen cholesterol metabolism and promote obesity and diabetes.
• High levels of triglycerides (neutral fats) in the blood can increase the risk of atherosclerosis.
• Chronic stress can stimulate inflammatory processes in the body and constrict blood vessels.
• Rheumatoid arthritis (“joint rheumatism”) and other chronic inflammatory or autoimmune diseases can stimulate plaque formation.
• If left untreated, sleep apnea (obstructive sleep apnea syndrome) promotes other risk factors such as high blood pressure or diabetes and is linked to stroke and heart attack.
• Estrogen has a protective influence on the vascular walls. Estrogen deficiency after menopause (time of last menstrual period during menopause) increases women’s cardiovascular risk.
• Alcohol can damage the heart muscle and promote other atherosclerosis risk factors.

In contrast to atherosclerosis, lifestyle plays a smaller role in the development of media sclerosis. The main risk factors include older age, diabetes mellitus and chronic kidney failure.

Atherosclerosis: treatment

There is no insider tip against arteriosclerosis. It is essential, if possible, to eliminate the risk factors. This can be achieved, for example, through lifestyle changes.

Medicines or operations can also be considered to prevent complications or to treat secondary diseases of arteriosclerosis. Which therapy is used in each individual case depends, among other things, on the extent of the vascular narrowing.

Lifestyle changes

Make sure you eat a healthy diet and get enough exercise. Patients with leg pain, such as PAD, also benefit from walking training.

For some patients, a cholesterol-lowering diet may be useful. Try to reduce excess weight. Avoid smoking and avoid chronic stress.

Diseases that increase the risk of arteriosclerosis must be treated. These include, for example, diabetes mellitus or high blood pressure.

Medication

First, antihypertensive drugs (ACE inhibitors and beta-blockers) can reduce the risk of complications from arteriosclerosis.

Lipid-lowering drugs reduce unfavourable blood lipid levels. Statins are the drugs of choice. Substances that inhibit cholesterol absorption in the intestine (cholesterol absorption inhibitors) and anion exchangers are also available. Monoclonal antibodies that reduce a specific enzyme (PCSK9 inhibitors) can also lower LDL cholesterol. Physicians rarely use fibrates anymore because there is still no evidence of a significant life-prolonging effect.

The same medications are often used for the drug therapy of advanced arteriosclerosis as for the treatment of some cardiovascular diseases. These contain active ingredients that inhibit blood clotting and can thus prevent the formation of a blood clot (thrombus). Examples are acetylsalicylic acid or clopidogrel.

Surgical treatment

Doctors usually must treat life-threatening effects of arteriosclerosis, such as advanced disease of the coronary arteries (coronary heart disease) or an impending blockage of the leg arteries, surgically. The choice of therapeutic method depends on the type and extent of the calcification.

• Balloon expansion with vascular support: A small balloon catheter is advanced through the bloodstream to the narrowed area and inflated. This causes the vessel to expand, and blood can flow freely again. If there is a risk of renewed vascular occlusion or if the arteriosclerosis is very severe, a small wire mesh (stent) is inserted into the vessel to keep it open.
• Bypass: The surgeon creates a “diversion” that directs blood past the narrowed area. To do this, he uses either the body’s own vessel (usually a piece of vein from the lower leg or a thoracic artery) or a plastic vascular prosthesis.
• Surgery for a narrowed carotid artery: Carotid stenosis usually involves surgery. The narrowing is often scraped out of the artery. To do this, the doctor makes an incision in the affected area, exposes the artery, and removes the arteriosclerotic deposits.
• Amputation: An acute vascular occlusion in the arm or leg or non-healing wounds on the foot, such as those that can arise in the context of PAD (especially in connection with diabetes through the development of diabetic foot syndrome), lead to amputation in extreme cases. Those affected learn to deal with the loss of the limb in outpatient or inpatient rehabilitation.

Atherosclerosis: disease progression and prognosis

There is currently no cure for arteriosclerosis. Anyone who already suffers from atherosclerosis or is at increased risk can slow down the development or progression of the disease by making lifestyle changes. In the early stages, the plaques in the vessels can even partially disappear.

As atherosclerosis progresses, it can lead to serious complications – such as coronary heart disease, heart failure, heart attack and stroke. Hardening of the arteries in the legs often develops into dangerous leg ischemia. Such complications often have a negative impact on the life expectancy of those affected.

The course and prognosis of arteriosclerosis depend on various factors:

• Location of critical plaques and vascular changes.
• The extent of the narrowing of the blood vessels (stenoses) and the length over which they hinder blood flow.
• Patient’s health: People who have ever had a heart attack or stroke are at greater risk.
• Elimination of risk factors (lifestyle changes, treatment of triggering metabolic diseases).

The sooner you eliminate risk factors, the better your prospects are.

Arteriosclerosis stages

As arteriosclerosis progresses, circulatory disorders occur, which doctors divide into the following stages depending on the severity:

• Stage I: The vessels are already slightly narrowed, but those affected do not yet feel any symptoms.
• Stage II: The constrictions in the vessels lead to discomfort when exerted (in PAD this is the case, for example, when walking).
• Stage III: The constrictions cause discomfort even when resting.

• Stage IV: The constrictions have damaged tissue and cells have died due to the lack of acid and nutrients.

Atherosclerosis: examinations and diagnosis

During a medical examination, the doctor will ask you about your lifestyle habits. This allows him to create an individual risk profile. For example, he is interested in whether you smoke, exercise regularly and sufficiently, what you eat or whether you have previous illnesses that promote arteriosclerosis. He also asks about cardiovascular diseases in family members (family history).

Through a blood test, the doctor can use the blood values ​​to determine whether there are elevated blood fats (cholesterol, triglycerides) and blood sugar levels. If you suspect arteriosclerosis, the doctor will also determine your blood pressure, weight and possibly your abdominal circumference. He feels your pulse, which is weakened if there are relevant constrictions. When diagnosing arteriosclerosis, the doctor also looks for signs of typical secondary diseases and carries out appropriate tests. These are for example:

• Through so-called auscultation, i.e. listening with a stethoscope , abnormal flow noises can sometimes be heard over the heart, the main artery (aorta) or the arteries in the neck.
• Vascular narrowing or dilations of arteries can be detected from the outside using a special ultrasound examination (Doppler sonography). The result for carotid arteries can also be used to estimate the risk of a stroke.
• If coronary heart disease (CHD) is present, the doctor will not only carry out a normal ECG, but also a stress ECG. The doctor can detect deposits in the inner walls of the coronary arteries during a cardiac catheter examination. Sometimes he also inserts a small ultrasound probe directly into the coronary artery to be examined.
• If the doctor suspects peripheral arterial disease (PAD), he measures the distance the patient can walk without taking a break.
• If arteriosclerosis of the renal vessels is suspected, the examiner checks kidney function with blood and urine tests.
• Atherosclerosis is also the most common cause of impotence. Appropriate information from the patient and an ultrasound examination can provide information as to whether there is a narrowing of the blood vessels in the penis (or in the pelvis).

The extent of the narrowing of the blood vessels can be revealed using further imaging procedures. The blood vessels can be imaged using X-ray examinations, computer tomography or magnetic resonance imaging (MRI) with contrast medium.

Prevent Arteriosclerosis!

Atherosclerosis is a chronic disease that progressively damages the inner walls of the arteries and can – often only after decades – trigger a variety of serious secondary diseases such as coronary heart disease or PAD.

If you want to prevent arteriosclerosis, it is best to reduce the risk factors. Illnesses that promote arteriosclerosis – such as high blood pressure, sleep apnea, chronic inflammatory diseases, diabetes mellitus and renal insufficiency in the case of media sclerosis – should be treated.

To reduce the risk of atherosclerosis, reduce elevated blood lipid levels (cholesterol and triglycerides) and lose excess weight. A balanced, predominantly plant-based diet, rich in fibre and low in saturated fats as well as regular exercise help. The WHO recommends at least 150 to 300 minutes of moderate endurance training (a quick walk is enough) per week!

Since smoking has a negative effect on the blood vessels in several ways, stopping smoking is an important preventative measure for arteriosclerosis. Also avoid passive smoking.

Consume alcohol in moderate amounts at most. One standard glass of alcohol (e.g. a small beer or 0.1 litre of wine) for women or two standard glasses for men per day is considered low-risk consumption. You should avoid alcohol on at least two days a week.

Reduce chronic stress. Relaxation methods such as progressive muscle relaxation, meditation or autogenic training can support this.

Arteriosclerosis in the UAE

With an aging population, socialising over shisha pipes, an abundance of unhealthy fast foods and many living a sedentary lifestyle that revolves around driving everywhere the number of people diagnosed with arteriosclerosis in the UAE is on the rise. With the condition being mostly irreversible it is therefore essential that awareness is raised, and residence of the UAE are encouraged to live healthier lives. With an abundance of activities available and some of the best stocked supermarkets and fresh food markets in the world it is easier to make impactful improvements than most people think.