Arteriosclerosis

arteriosclerosis, also called hardening of the arteries, chronic disease characterized by abnormal thickening and hardening of the walls of arteries, with a resulting loss of elasticity. Arteries carry oxygenated blood full of nutrients from the heart to organs throughout the body. The arterial wall is made up of three distinct layers—an outer layer of tissue (adventitia), a muscular middle layer (media), and an inner layer of epithelial cells (intima); the latter is the one most commonly affected by arteriosclerosis. There are three recognized types of arteriosclerosis: atherosclerosis, arteriolosclerosis, and Monckeberg medial calcific sclerosis.

Atherosclerosis is the most common and most important pattern of arteriosclerosis because its end result can be a harmful clot in the blood that may cause a heart attack or stroke or disease of the peripheral blood vessels. How the entire process occurs is not entirely understood, but most scientists agree that it begins when the inner layer of a blood vessel (the endothelium of the intimal layer) becomes injured. Some factors that cause mechanical damage to the endothelium are high cholesterol and triglycerides (a type of lipid, or fat), high blood pressure, and tobacco smoke. People who have an abnormally large amount of cholesterol or other lipids in their blood are often treated with lipid-lowering medications to prevent or slow the process of atherosclerosis.

Once damage has occurred, platelets, cholesterol, other cells, and debris accumulate over time in the damaged endothelium. These cells release chemicals that attract still more cells to the site of the injured layer. Fat is deposited and builds up in and around these cells. The cells at the impaired area produce connective tissue that also deposits there. This conglomeration of cells, fat, debris, and connective tissue is called an atheroma, or fatty plaque. The bigger the plaque, the more it affects the size of the arterial lumen, the area through which the blood flows. If the wall of the vessel is overly thickened from a large atheroma or multiple atheromas, there will be decreased blood flow, which decreases oxygen supply to the body’s organs. If blood flow is cut off to the heart, this can cause a myocardial infarction (heart attack). If the blood supply to the brain is blocked, a stroke may result. Similarly, if the blood flow to the extremities is stopped, gangrene may occur. Often what blocks blood flow to these vital organs is a clot.

Atherosclerosis typically does not produce symptoms until the vessel’s luminal diameter has been decreased by 70 to 80 percent. Angina pectoris, or chest pain brought on by exertion, can be caused by this blockage of the lumen. In this situation, a person’s arteries may still have enough room for blood to travel when the person is at rest, but, when he or she works hard and the heart pumps more blood, the blocked arteries are unable to accommodate the extra blood, leading to poor oxygenation and chest pain.

Acute (sudden) events, such as a heart attack, stroke, or sudden death, often are caused by the rupture of plaques that decrease the lumen by only 50 percent. This happens because the plaque rupture releases several chemicals that aid in coagulation or are “proclotting.” The most important of these is tissue factor, which initiates the clotting pathway. This leads to the formation of a clot in situ, on top of the preexisting fatty plaque. As a result, the slow accumulating process of atherosclerosis, if severe, may cause symptoms such as angina pectoris, but the life-threatening events, such as heart attack or stroke, usually are associated with sudden plaque rupture on top of an already somewhat narrowed lumen.

Arteriolosclerosis affects small arteries and arterioles (very small arteries). It involves thickening of the vessel walls that narrows the lumen. Similar to atherosclerosis in the larger vessels, the process of arteriolosclerosis can lead to ischemia, or insufficient blood flow to organs supplied by the blocked vessels. Arteriolosclerosis is most often seen in people who have diabetes mellitus or high blood pressure, though it is also a normal part of aging.

Monckeberg medial calcific sclerosis is the third type of arteriosclerosis and is characterized by deposits of calcium in muscular arteries in people over age 50. While these calcifications may be seen with imaging technologies, such as X-ray, or may be palpable, they do not decrease the size of the arterial lumen. This is not considered a clinically significant disease and does not generally cause events such as heart attacks.