Atherosclerosis

What is atherosclerosis?

Atherosclerosis is the gradual buildup of plaque in the walls of your arteries. Arteries are blood vessels that carry oxygen-rich blood to organs and tissues throughout your body. Plaque (atheroma) is a sticky substance made of fat, cholesterol, calcium and other substances.

As plaque builds up, your artery wall grows thicker and harder. This “hardening of the arteries” is usually a silent process in the early stages. You may not notice symptoms for a long time. But eventually, as the plaque grows, the opening (lumen) of your artery narrows, leaving less room for blood to flow. This means less blood can reach your organs and tissues. Plus, the constant force of blood flow can lead to plaque erosion or rupture, causing a blood clot to form.

A narrowed artery is like a highway reduced to one lane. But a blood clot is like a barricade in the middle of the road. It blocks blood flow to certain organs or tissues the artery normally feeds. The effects on your body depend on where the blood clot forms. For example, blockages in a coronary artery deprive your heart of oxygen-rich blood, leading to a heart attack.

How common is atherosclerosis?

Atherosclerosis is very common. The complications of plaque buildup (including heart attacks and strokes) are the leading cause of death worldwide.

In America, about half of people age 45 to 84 have atherosclerosis but aren’t aware of it, according to the U.S. National Institutes of Health.

What are the symptoms?

Atherosclerosis symptoms often don’t start until an artery is very narrow or blocked. Many people don’t know they have plaque buildup until they have a medical emergency like a heart attack or stroke.

You may notice symptoms of atherosclerosis if your artery is more than 70% blocked. You can have symptoms in different parts of your body, depending on the location of the blockage. Affected locations may include:

Heart

Coronary artery disease (CAD, which can lead to a heart attack) happens in the arteries that supply blood to your heart.

You may experience:

• Shortness of breath (dyspnea) during light physical activity.
• Chest pain or discomfort (angina).
• Pain in your back, shoulders, neck, arms or belly.
• Feeling dizzy or lightheaded.
• Heart palpitations.
• Fatigue.
• Nausea or vomiting that may feel like indigestion.

Digestive system

Mesenteric ischemia happens when you don’t have enough blood flow in parts of your digestive system. You may experience:

• Pain or cramping in your belly (abdomen) after eating.
• Bloating, nausea and vomiting.
• Diarrhea.
• Unintentional weight loss due to “food fear” (fear of pain after eating).

Legs and feet

Peripheral artery disease (PAD) refers to poor blood flow in the arteries in your limbs.

You may experience:

• Muscle pain (intermittent claudication).
• Burning or aching pain in your feet and toes when you rest, especially when lying flat.
• Changes in skin color (like redness).
• Cool skin on your feet.
• Frequent skin and soft tissue infections, often in your legs or feet.
• Sores on your feet or toes that don’t heal.

Kidneys

With renal artery stenosis (narrowing of the arteries that take blood to your kidneys), you may experience:

• Markedly elevated blood pressure that doesn’t respond to multiple medications.
• Changes in how often you pee.
• Swelling (edema).
• Feeling drowsy or tired.
• Skin that feels dry, itchy or numb.
• Headaches.
• Unexplained weight loss.
• Nausea, vomiting or loss of appetite.

Brain

With carotid artery disease, the first symptoms are usually a transient ischemic attack (TIA) or stroke.

You may experience:

• Dizziness.
• Drooping on one side of your face.
• Loss of feeling, loss of muscle strength or weakness on one side of your body.
• Severe headache.
• Slurred speech or difficulty forming words.
• Vision loss in one eye. You may notice a dark shade coming down over your field of sight.

What causes atherosclerosis?

Researchers believe atherosclerosis causes may include:

• High LDL cholesterol and triglyceride levels.
• Tobacco products.
• High blood pressure.
• Diabetes.

These factors can damage your artery’s inner lining (endothelium). This causes atherosclerosis to begin. The damage usually occurs slowly and over time.

Stages of atherosclerosis

The stages of atherosclerosis happen over many years and include:

• Endothelial damage and immune response. Damage to your endothelium triggers chemical processes that cause white blood cells to travel to the injury site. These cells gather and lead to inflammation within your artery.
• Fatty streak formation. This is the first visible sign of atherosclerosis. It’s a yellow streak or patch of dead foam cells at the site of endothelial damage. In this case, foam cells are white blood cells that consume cholesterol to try to get rid of it. Continued foam cell activity causes further damage to your endothelium.
• Plaque growth. Dead foam cells and other debris keep building up, turning a fatty streak into a larger piece of plaque. A fibrous cap (made of smooth muscle cells) forms over the plaque. This cap prevents bits of plaque from breaking off into your bloodstream. As the plaque grows, it gradually narrows your artery’s opening (lumen), so there’s less room for blood to flow through.
• Plaque rupture or erosion. In this stage, a blood clot forms in your artery due to plaque rupture or plaque erosion. Plaque rupture happens when the fibrous cap that covers the plaque breaks open. With plaque erosion, the fibrous cap stays intact, but endothelial cells around the plaque get worn away. Both events lead to the formation of a blood clot. The clot blocks blood flow and can lead to a heart attack or stroke.

What are the risk factors for atherosclerosis?

There are many risk factors for atherosclerosis. You may be able to change some of these risk factors, but not others (like age).

Risk factors include:

• Being a male older than age 45.
• Being a female older than age 55.
• Having a biological family history of premature cardiovascular disease. This means a close male family member who received a cardiovascular disease diagnosis before age 45. Or a close female family member who was diagnosed before age 55.
• Diabetes.
• High blood pressure (hypertension).
• High cholesterol (hyperlipidemia), especially high LDL cholesterol or high levels of a specific lipoprotein called lipoprotein (a).
• Metabolic syndrome.
• Smoking or tobacco use.
• Lack of physical activity.
• Eating foods high in saturated fat, trans fat, sodium and sugar.

What are the complications of atherosclerosis?

Atherosclerosis interferes with the normal workings of your cardiovascular system. It can limit or block blood flow to various parts of your body, including your heart and brain. Possible complications of reduced blood flow include:

• Carotid artery disease.
• Coronary artery disease.
• Heart attack.
• Arrhythmia (abnormal heart rhythms).
• Heart failure.
• Mesenteric ischemia.
• Peripheral artery disease.
• Chronic kidney disease (CKD).
• Renal artery stenosis.
• Stroke.
• Transient ischemic attack (TIA).
• Aneurysms and rupture of blood vessels from weakened artery walls.

Early diagnosis and treatment of atherosclerosis can help you avoid or delay complications.

How is atherosclerosis diagnosed?

To diagnose atherosclerosis or calculate your risk for developing it, a healthcare provider will:

• Perform a thorough physical exam. This includes using a stethoscope to listen to your heart and blood flow through your arteries. For example, your provider will check your carotid arteries (in your neck) for a whooshing sound called a “bruit.” This sound may indicate the presence of plaque.
• Ask about your medical history and family history. These details can help show your risk for atherosclerosis and its complications.
• Ask about your lifestyle. Your provider may ask about habits like past or present use of tobacco products.
• Order blood tests. Cardiac blood tests show your cholesterol levels and many details about your heart function.

What tests will be done to diagnose atherosclerosis?

Your healthcare provider may order additional tests to diagnose atherosclerosis and plan treatment. These tests include:

• Angiography. This test uses special X-rays and a contrast dye to locate and measure blockages.
• Ankle-brachial index. This test compares the blood pressure in your ankle to the pressure in your arm to measure blood flow in your arms and legs.
• Chest X-ray. A chest X-ray takes pictures of the inside of your chest.
• CT scan (computed tomography scan). This scan takes pictures of the inside of your body and can show any hardening and narrowing of your large arteries.
• Heart MRI (magnetic resonance imaging). This test can show issues with blood flow in your arteries.
• Echocardiogram (echo). An echo takes pictures of your heart’s valves and chambers and measures how well your heart pumps.
• Electrocardiogram (EKG). An EKG measures your heart’s electrical activity, rate and rhythm.
• Exercise stress test. This test measures your heart function while you’re physically active.
• Carotid ultrasound. This test takes ultrasound pictures of the arteries in your neck (carotid arteries). It can detect hardening or narrowing of these arteries as blood flows to your brain.
• Abdominal ultrasound. This ultrasound takes pictures of your abdominal aorta. It checks for ballooning (abdominal aortic aneurysm) or plaque buildup in your aorta.

How is atherosclerosis treated?

Atherosclerosis treatment includes lifestyle changes, medications, procedures or surgeries. Depending on the location of your atherosclerosis, you may see a cardiologist (heart), nephrologist (kidneys), neurologist (brain and spine) or vascular surgeon (blood vessels).

Your healthcare providers will develop a plan based on your needs. Common treatment goals include:

• Lowering your risk of blood clots.
• Preventing complications like a heart attack or stroke.
• Easing symptoms.
• Helping you develop patterns of eating that support your heart and blood vessels.
• Slowing or stopping plaque buildup in your arteries.
• Improving blood flow by widening your arteries or bypassing (avoiding) blockages.

Lifestyle changes

Lifestyle changes may lower your risk of complications. Your provider will create a plan specific to your needs. General tips include:

• Avoid all tobacco products (including smoking and vaping).
• Follow a heart-healthy eating plan like the Mediterranean diet.
• Build physical activity into your daily routine.

Medications

Medications target risk factors for plaque buildup and may help slow the progression of atherosclerosis. Your provider may prescribe medications that lower your blood pressure or cholesterol, manage your blood sugar levels and prevent blood clots.

Procedures or surgeries

Various minimally invasive procedures and complex surgeries can help people with severe blockages or a high risk of complications. Common treatment options include:

• Angioplasty.
• Atherectomy.
• Carotid endarterectomy.
• Coronary artery bypass grafting (CABG).
• Peripheral artery bypass.
• Stent placement.
• Vascular disease bypass.

Can atherosclerosis be prevented?

You may not be able to prevent atherosclerosis. But you can reduce your risk and lessen the effects of the disease. Here are some steps you can take:

• Eat foods low in saturated fat, trans fat, cholesterol, sodium (salt) and sugar.
• Get regular physical activity. Start with short walks and build up to 30 minutes a day most days of the week.
• Keep a weight that’s healthy for you. Ask your provider what that should be.
• Manage any health conditions, especially diabetes, high blood pressure and high cholesterol.
• Don’t use tobacco products.
• Have a yearly checkup with a healthcare provider.

What can I expect if I have atherosclerosis?

Early diagnosis and treatment can help people with atherosclerosis keep doing the activities they like to do. But the disease can cause medical emergencies and even be fatal. That’s why knowing your risks and working with your healthcare provider to lower them is important.

How do I take care of myself?

It’s essential to work closely with your healthcare provider. They’ll keep a close eye on your condition and tell you how often you should come in for appointments. Go to all of your appointments and be an active partner in your care. Tell your provider right away about any new or changing symptoms. Early treatment can lower your risk of life-threatening complications.

Also, take care of your mental health. It’s normal to feel anxious about what the future could bring. You may also feel overwhelmed by the need to make lifestyle changes. But those feelings shouldn’t prevent you from enjoying life. Some tips for managing your thoughts and worries include:

• Share your feelings with a counselor or support group.
• Connect with others who have cardiovascular disease. You can share your experiences and learn from each other.
• Talk to your family and friends about the lifestyle changes you’re making. Explain why these changes are important to you and ask them to help you stay on track.

When should I go to the ER?

Call 911 or your local emergency number right away if you or someone near you has symptoms of a heart attack, stroke or TIA. These are medical emergencies that require immediate care.

What questions should I ask my doctor?

Questions to ask your healthcare provider may include:

• Which treatment is best for me?
• What numbers should my blood pressure and cholesterol be?
• When should my kids start getting their cholesterol checked?
• Can you recommend a program to help me stop smoking?