Coronary atherosclerosis and coronary heart disease

Atherosclerosis of the vessels that supply blood to the heart, i.e. Coronary atherosclerosis and coronary heart disease (CHD) are directly related to each other, since the reduction of blood supply to the heart muscle tissues (myocardium) in most cases occurs against the background of narrowing of the coronary (venous) arteries due to atherosclerotic lesions of their walls. This type of CHD is defined as atherosclerotic heart disease (ICD-10 code - I25.1). [1], [2]

Epidemiology

According to WHO's worldwide observational epidemiologic study The Global Burden of Disease, coronary heart disease affected more than 1.7% of the world's population (nearly 126 million people) in 2017.

In the United States, according to CDC statistics, more than 20 million adults aged 20+ have been diagnosed with IBS, and this represents 7.2% of the population.

In European countries, coronary heart disease accounts for up to 4 million deaths annually, and at least 60% of CHD cases are related to coronary atherosclerosis. [3]

Causes of the coronary atherosclerosis

The causes of atherosclerosis are considered to be disorders of lipid metabolism, which lead to dyslipoproteinemia (excess of atherogenic lipoproteins in the blood) and hypercholesterolemia - increased content of low-density lipoprotein cholesterol (LDL) in the blood plasma. low-density lipoprotein (LDL) cholesterol in plasma, in which cholesterol is deposited in vascular walls as localized accumulations called atheromatous or atherosclerotic plaques. [4]

A coronary heart disease is a consequence of impaired blood flow in the epicardial coronary arteries, whose lumen is reduced by the presence of these plaques in the vessel walls. Depending on the localization, this can cause insufficient blood supply to a certain area of the myocardium - ischemia (from Greek ischo - delaying and haima - blood). [5]

Read more in the publications:

• Atherosclerosis - Causes and risk factors
• Coronary heart disease: causes and risk factors

Risk factors

Cardiologists consider arterial hypertension (in combination with abnormally elevated LDL in the blood), obesity (especially with the typical abdominal distribution of adipose tissue in men) and genetic predisposition (presence of hypercholesterolemia and/or CHD in the family history) as the main risk factors for atherosclerotic heart disease.

There is an increased likelihood of coronary artery atherosclerosis and coronary heart disease in hypodynamia (lack of physical activity), diabetes mellitus, chronic renal failure or functional thyroid insufficiency, as well as in smokers and those who consume alcohol in large quantities.

By the way, increase the risk of atherosclerotic lesions of the heart vessels unhealthy diet, in particular, sugar and sweeteners, unbalanced amount of carbohydrates in the diet, high consumption of animal fats and proteins (especially red meat), saturated fats, trans fats, sodium.

Pathogenesis

The mechanism of atherosclerosis, which is implicated in coronary heart disease, stroke, and peripheral arterial disease, is due to the deposition of lipids in the form of esterified cholesterol in the endothelial and smooth muscle cells of the inner layer of the arterial wall (intima).

In some areas of the vascular wall more lipids are deposited, activation of T-lymphocytes of the inner envelope mononuclear macrophage system (cellular immunity) leads to their transformation into tissue macrophages, which - by absorbing oxidized LDL and producing proinflammatory cytokines - initiate the development of the inflammatory process (as a local protective response) and form nuclei of so-called foam cells and cellular detritus.

At the next stage of atherogenesis, the lipid core formed by the foam cells is covered by a layer of smooth muscle and fibrous tissue cells that migrate from the middle sheath of the arterial wall to the inner sheath and synthesize increased amounts of extracellular matrix.

And the pathogenesis of IBS lies in the fact that the formation in the form of atherosclerotic plaque protrudes into the lumen of the vessel and leads to asymmetric remodeling of the vascular wall, progressive narrowing of the coronary arteries and their thickening. [6]

Over time, atheromatous plaques undergo calcification and ulceration with the threat of destruction and the formation of blood clots, exacerbating coronary artery stenosis and ischemia. And the decrease in myocardial blood supply below a critical level leads to ischemic necrosis of the area of its tissues. [7]

Symptoms of the coronary atherosclerosis

Narrowing of the lumen of the coronary artery leads to ischemia of the muscular tissues of the heart, the first signs of which are manifested by angina pectoris or stable angina pectoris - with discomfort behind the sternum, pain in the heart area (giving and shoulder, neck and arm), weakness, cardiac arrhythmia, palpitations, increased blood pressure. [8]

There may also be unstable angina, in which patients complain of dizziness, shortness of breath, and chest pains. [9]

How myocardial ischemia manifests itself, in detail in the article - Coronary heart disease: symptoms

Note that there can also be asymptomatic, that is painless myocardial ischemia.

Complications and consequences

The dramatic decrease in blood flow to the myocardium in coronary atherosclerosis is fraught with consequences such as acute coronary syndrome.

Also a life-threatening complication of CHD is transmural myocardial infarction.

Diagnostics of the coronary atherosclerosis

To detect atherosclerotic heart disease, patient history is reviewed and a heart study is performed.

Instrumental diagnosis is described in detail in publications:

• Instrumental methods of cardiac examination
• Coronary heart disease: diagnosis

Required laboratory tests include blood tests for total cholesterol, LDL, HDL-C, LDL-C, HDL-C, triglycerides; for C-reactive protein, and others. [10]

Differential diagnosis

A differential diagnosis with systemic scleroderma or SLE-related coronary occlusion, coronary arteritis, and coronary artery vasospasm is required.

Treatment of the coronary atherosclerosis

Atherosclerosis is treated by following diet for high cholesterol, and by using hypolipidemic agents (to lower cholesterol) such as Simvastatin (Simvatin, Vabadine, etc.). Trade names), Atorvastatin (Atorvasterol, Amlostat, Vasoclin, Livostop), Ezithimibe (Libopone), Clofibrate (Fibramide, Miscleron, Atemarol) or Cetamiphene; lipotropic drugs (Lipamide, lipoic acid, etc.). Read more in the materials:

• Atherosclerosis - Treatment
• Treatment of high cholesterol
• Pills for high cholesterol

For symptomatic atherosclerotic heart disease with ischemia, these medications may be prescribed:

• anti-ischemic (antianginal) drugs Advocard, Ranoladin (Ranexa), Cardimax, Trimetazidine and others;
• antiarrhythmic drugs with antianginal action Amiodarone (Amiocordin);
• agents in the beta-adrenoblocker group, including Atenolol, Metoprolol (Vasocardin, Corvitol, Betalok), Bisoprolol (Bisoprol);
• Isosorbide mononitrate vasodilators (Pentacard, Mononitroside, Mononitroside, Monosan, Olicard), Dilasidom;
• Calcium channel blockers: Verapamil, Amlodipine, Diltiazem (Diacordine, Diltazem, Cardil).

Also read:

• Coronary heart disease: treatment
• Effective pills to relieve heart pain

Physiotherapeutic treatment is performed, which is described in detail in the article - Physiotherapy for coronary heart disease

In addition, in atherosclerosis auxiliary treatment with herbs - to reduce the level of lipids in the blood serum - can be carried out with the use of extracts of dried roots of false ginseng (Panax notoginseng), red-root sage (Salvia miltiorrhiza), common shandra (Marrubium vulgare), Astragalus membranaceus; herb of sticky bark (Tribulus terrestris), seed oil of nigella (Nigella sativa). Flaxseed and garlic also reduce LDL cholesterol.

In life-threatening narrowing of the arterial lumen, surgical treatment is performed: coronary angioplasty by coronary artery stenting, as well as transluminal balloon angioplasty. [11]

Prevention

The reduction of CHD risk is proportional to the degree and duration of the achieved reduction in serum cholesterol levels. Assessment of the risk of cardiac atherosclerosis and myocardial ischemia by AHA (American Heart Association) specialists is considered the basis of primary prevention. Even under the age of 40, it is advisable to monitor the level of low-density lipoprotein cholesterol (LDL) in the blood, especially in the presence of traditional risk factors for coronary atherosclerosis (including arterial hypertension and diabetes mellitus). Cardiologists recommend avoiding unhealthy habits, following a healthy plant-based or Mediterranean diet, and moving more. [12]

Forecast

Since coronary atherosclerosis is the main cause of inadequate blood supply to the myocardium, the prognosis of coronary heart disease depends on the degree of vascular stenosis and the effectiveness of treatment. Severe or recurrent myocardial ischemia is dangerous with life-threatening heart rhythm disturbances, which can lead to sudden cardiac death.

List of authoritative books and studies related to the study of coronary atherosclerosis and coronary heart disease

1. "Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine" - by Douglas P. Zipes, Peter Libby, Robert O. Bonow (Year: 2021)
2. "Hurst's The Heart" - by Valentin Fuster, Richard A. Walsh, Robert A. Harrington (Year: 2021)
3. "Biomarkers in Cardiovascular Disease: Molecular Signaling and Novel Therapeutic Targets" - by Vinood B. Patel (Year: 2016)
4. "Ischemic Heart Disease: Treatments That Work" - by Keith McGregor (Year: 2018)
5. "Ischemic Heart Disease: A Rational Basis for Clinical Practice and Clinical Research" - by Mikhail R. Khaitovich (Year: 2011)
6. "Coronary Artery Disease: New Insights and Novel Approaches" - by Wilbert S. Aronow, Jerome L. Fleg (Year: 2020)
7. "Atherosclerosis and Coronary Artery Disease" - by John A. Elefteriades (Year: 2020)
8. "Coronary Artery Disease: Essentials of Prevention and Rehabilitation Programs" - by Glenn N. Levine, Peter H. Stone (Year: 2012)
9. "Atherosclerosis: Risks, Mechanisms, and Therapies" - by Keaney John F. Jr. (Year: 2015)
10. "Coronary Artery Disease: Diagnosis and Management" - by Zhuo Li (Year: 2020)

Literature

1. Shlyakhto, E. V. Cardiology: national guide / ed. By E. V. Shlyakhto. - 2nd ed., revision and addendum - Moscow: GEOTAR-Media, 2021
2. Cardiology according to Hurst. Volumes 1, 2, 3. GEOTAR-Media, 2023.
3. Chronic ischemic heart disease, Journal of Cardiology Vesnik #3, Volume X, 2015.
4. И. V. Sergienko, A. A. Ansheles, V. V. Kukharchuk, Dyslipidemias, atherosclerosis and coronary heart disease: genetics, pathogenesis, phenotypes, diagnosis, therapy, comorbidity, 2020.