Atherosclerosis: Treatment

Treatment of atherosclerosis involves active elimination of risk factors for preventing the formation of new plaques and reducing existing ones. Recent studies indicate that LDL should be <70 mg / dL for an existing disease or a high risk of cardiovascular disease. Changes in lifestyle include diet, cessation of smoking and regular physical activity. Often, drugs are needed to treat dyslipidemia, AH and diabetes mellitus. These lifestyle changes and medicines directly or indirectly improve endothelial function, reduce inflammation and improve the clinical outcome. Anti-platelet drugs are effective in all patients.

[1], [2], [3], [4]

Diet

It is recommended that the consumption of saturated fats and simple carbohydrates be reduced significantly, as the share of fruits, vegetables and vegetable fiber increases. Such changes in the diet contribute to the normalization of the amount of lipids and are essential for all patients. Caloric content of food should be limited to maintain normal body weight.

A slight decrease in the amount of fat in food probably does not slow down or stabilize the course of atherosclerosis. Effective changes suggest limiting the intake of fats to 20 g / day, including 6-10 g of polyunsaturated fats containing -6 (linoleic acid) and -3 (eicosapentaenoic acid, doxahexaenoic acid respectively) fatty acids in equal proportions, <2 g saturated fat, the rest - in the form of monounsaturated fats. Fatty acids, which are very atherogenic, must be avoided.

Increasing the amount of carbohydrates to compensate for the reduction of saturated fats in the diet increases the concentration of triglycerides and reduces HDL in the blood plasma. Thus, any deficiency of calories needs to be replenished with proteins and unsaturated fats, rather than carbohydrates. It is necessary to avoid excessive consumption of sugar, although it has no direct connection with the risk of cardiovascular pathology. Instead of sugar recommend complex carbohydrates (for example, vegetables, whole grains).

Fruits and vegetables probably reduce the risk of atherosclerosis of the coronary arteries, but this effect is the result of the intake of flavonoids or the reduction in the amount of saturated fat with an increase in the proportion of plant fiber, as well as vitamins, is unclear. Flavonoids (found in red and violet grades of grapes, red wine, black tea and dark beer) have a protective effect; their high concentrations in red wine can be an explanation for the relatively low incidence of arteriosclerosis at the French with the fact that they smoke more and consume more fat than Americans. However, no clinical studies indicate that eating food rich in flavonoids or using food additives instead of foods prevents atherosclerosis.

Increasing the proportion of plant fiber reduces the amount of total cholesterol and can have a beneficial effect on the concentration of insulin and glucose. Recommend daily intake of at least 5-10 g of digestible fibers (for example, oat bran, beans, soy products); this amount reduces the LDL content by about 5%. Non-digestible fibers (such as cellulose, lignin) probably do not affect the amount of cholesterol, but can bring additional health benefits (for example, reduce the risk of bowel cancer, perhaps by stimulating intestinal motility or decreasing contact time with food carcinogens). However, excessive fiber intake leads to a violation of absorption of certain minerals and vitamins. In general, foods rich in flavonoids and vitamins are also rich in fiber.

Alcohol increases the amount of HDL and has a weak antithrombotic, antioxidant and anti-inflammatory property. Apparently, these effects are the same for wine, beer and strong liquors, they arise at a moderate level of consumption: 1 ounce 5-6 times a week has a protective effect against atherosclerosis of the coronary arteries. However, in higher doses, alcohol can cause significant health problems. It is known that the graph of the relationship between alcohol use and total mortality is in the form of the letter J; mortality is lowest in men who consume <14 doses of alcohol per week, and women who consume <9 doses per week.

There is little evidence that the presence of vitamins, flavonoids and trace elements in food reduces the risk of atherosclerosis. The only exception is supplements containing fish oil.

[5], [6], [7], [8], [9], [10], [11], [12]

Physical activity

With regular physical activity (for example, 30-45 minutes walking, running, swimming or cycling 3-5 times a week), people are less likely to identify risk factors (AH, dyslipidemia, diabetes), diagnose the pathology of the coronary arteries (including MI) and record death from atherosclerosis (with and without previous ischemia). There is a clear causal relationship between physical activity and atherosclerosis, or just more healthy people are more likely to engage in regular training, is unclear. Optimal intensity, duration, frequency, and type of stress have not been established, but most studies prove the inverse linear relationship between physical exertion in fresh air and risk. Regular walking allows you to increase the distance that patients with peripheral arterial lesions can go through without pain.

A physical exercise program that includes physical exercise in the fresh air has a proven value in preventing atherosclerosis and reducing body weight. Before starting a new exercise program, the elderly and patients who have risk factors or who have recently undergone ischemia should undergo a medical examination anamnesis, physical examination and assessment of control of risk factors).

Antiplatelet drugs

Taking antiplatelet drugs inside is important, since most complications occur due to a disruption of the integrity of the plaque or its rupture with platelet activation and thrombosis.

Acetylsalicylic acid is used most widely. It is prescribed for secondary prevention and recommended for primary prevention of coronary artery atherosclerosis in high-risk patients (for example, patients with or without diabetes with atherosclerosis, patients with a risk of heart disease in the next 10 years, exceeding 20%). The optimal dose and duration are unknown, but usually prescribed 70-160 mg once a day for primary prevention, since this dose is effective, and the risk of bleeding is minimal. For secondary prevention and for patients with poorly eliminated risk factors, the effective dose is 325 mg. Approximately 10-20% of patients taking acetylsalicylic acid for secondary prevention, ischemic attacks are repeated. The cause may be resistance to acetylsalicylic acid; the detection of the effectiveness of suppression of thromboxane (determined by the level in the urine of 11-dihydrothromboxane B2) is being studied for the possibility of wide practical use. Some studies suggest that ibuprofen can withstand the antithrombotic effect of acetylsalicylic acid, so patients taking acetylsalicylic acid for prophylactic purposes are recommended by other NSAIDs.

Clopidogrel (usually 75 mg / day) replaces acetylsalicylic acid when ischemic attacks are repeated in patients taking it. Clopidogrel is used with acetylsalicylic acid for the treatment of acute MI without ST segment elevation; this combination is also prescribed for 9-12 months after NDA in order to reduce the risk of ischemia.

Ticlopidine is no longer widely used because it causes severe neutropenia in 1% of those taking the drug and has an adverse effect on the gastrointestinal tract.

[13], [14], [15], [16]

Other drugs

ACE inhibitors, angiotensin II receptor blockers, statins and thiazolidinediones (such as rosiglitazone, pioglitazone) have anti-inflammatory properties that reduce the risk of atherosclerosis regardless of their effects on blood pressure, lipid and glucose content. ACE inhibitors prevent the effects of angiotensin, leading to endothelial dysfunction and inflammation. Statins increase the release of nitric oxide in the endothelium, stabilize atherosclerotic plaques, reduce the accumulation of lipids in the arterial wall and cause a decrease in plaques. Thiazolidinediones can control the expression of proinflammatory genes. The routine use of statins for primary prevention of ischemia is controversial. However, several controlled studies support their use in high-risk patients (eg, those with diabetes mellitus with normal blood pressure and lipid content, as well as patients with multiple risk factors, including hyperlipidemia and / or AH). Statins are sometimes recommended for patients with normal LDL and high CRP; At present, there have been few studies in support of this practice, and the study continues.

For the treatment and prevention of hyperhomocysteinemia, folic acid is prescribed at a dose of 0.8 mg twice a day, but whether this reduces the risk of atherosclerosis of the coronary arteries is not established. Pyridoxine and cyanocobalamin also lower the content of homocysteine, but so far there is little evidence to support their use; research continues. The use of calcium preparations at a dose of 500 mg 2 times a day can help normalize blood pressure in certain people. They also study the use of macrolides and other antibiotics to find out if the cure for chronic carrier of S. Pneumoniae can help to suppress inflammation and inhibit the development and manifestations of atherosclerosis.