Atherosclerosis
Jason Ryan, MD, MPH
Vocabulary
• Arteriosclerosis
• Hardening of arteries
• Hyaline
• Hyperplastic
• Atherosclerosis
• Form of arteriosclerosis
• Most common type
Atherosclerosis
• Plaque accumulation in arterial walls
• Chronic inflammatory process
• Involves macrophages, T-cells
• Accumulation of lipoproteins especially LDL
• Underlying cause of many diseases
• Myocardial infarction
• Stroke
• Peripheral vascular disease
A. Rad et al./Wikipedia
Nephron/Wikipedia
OpenStax College/Wikipedia
Arterial Structure
• Intima
• Single layer of endothelial cells
• Basement membrane
• Media
• Smooth muscle cells
• Elastin
• Adventicia Bruce Blaus/Wikipedia
• Connective tissue
• Vasa vasorum (blood supply to artery wall)
• Nerve fibers
Type of Arteries
• Elastic
• Large amounts of elastin in media layer
• Expansion in systole, contraction in diastole
• Aorta, carotid arteries, iliac arteries
• Muscular
• Layers of smooth muscle cells
• Vasoconstriction/vasodilation to modify blood flow
• Arterioles: smallest muscular vessels (most flow resistance)
Atherosclerosis
• Large elastic arteries
• Aorta, carotid arteries, iliac arteries
• Medium-sized muscular arteries
• Coronary, popliteal
Luke Guthman/Wikipedia
Atherosclerosis
Pathogenesis
• Endothelial injury or dysfunction
• Details incompletely understood
• Believed to be related to risk factors
• Cigarette smoke
• High blood pressure
• High cholesterol
Atherosclerosis
Pathogenesis
• Branch points and vessel origins (ostia)
• Common sites of plaque
• Turbulent flow → endothelial stress
Atherosclerosis
Pathogenesis
• Lipids
• LDL accumulation in intima
• Oxidized by free radicals
• Oxidized LDL scavenged by macrophages
• Cannot be degraded
• Macrophages become foam cells
Public Domain
Atherosclerosis
Pathogenesis
• Chronic inflammation
• LDL oxidized from free radicals
• Damages endothelium, smooth muscle
• Macrophages release cytokines
Atherosclerosis
Pathogenesis
• Smooth muscle cells proliferate in intima
• Lay down extracellular matrix
• Key growth factor: PDGF
• Platelet-derived growth factor
OpenStax College/Wikipedia
Atheroma Growth
• Fatty streaks
• Macrophages filled with lipids
• Form line (streak) along vessel lumen
• Do not impair blood flow
• Can be seen in children, adolescents
• Not all progress
Npatchett/Wikipedia
Atheroma Growth
• Atherosclerotic plaques
• Intima thickens
• Lipids accumulate
• Usually patchy along vessel wall
• Rarely involve entire vessel wall
• Usually eccentric
Npatchett/Wikipedia
Npatchett/Wikipedia
Locations
• Abdominal aorta (large vessel)
• Coronary arteries
• Popliteal arteries
• Internal carotid
• Circle of Willis
Public Domain
Atherosclerosis Complications
• Ischemia
• Plaque rupture
• Exposes thrombogenic substances
• Clot formation
• May cause acute vessel closure (STEMI)
• Thrombus may embolize (stroke from carotid plaque)
Atherosclerosis Complications
• Hemorrhage into plaque
• Lesions: proliferating small vessels (“neovascularization”)
• Contained rupture may suddenly expand lesion
• Aneurysm
• Lesions may damage underlying media
• Plaque associated with abdominal aortic aneurysms
Public Domain
Dystrophic Calcification
• Commonly seen in atheroma
• Result of chronic inflammation
• Basis for “coronary CT scans”
Infarction
• Area of ischemic necrosis
• Two types: white and red
• White infarcts
• Occlusion of arterial supply to a solid organ
• Common in heart, kidneys, spleen
• Limited blood seepage from healthy tissue
• Tissue becomes pale (white)
White Infarct
Renal Infarction
Ryan Johnson/Flikr
Red Infarcts
Hemorrhagic Infarct
• Blood enters ischemic tissue
• Blockage of venous drainage
• Testicular torsion
• Tissues with dual circulation
• Blood flow from 2nd supply floods ischemic area
• Classic location: Lung (diffuse blood supply)
• Small intestine
• Flow re-established to necrotic area
• Angioplasty restores flow in coronary artery
Red Infarct
Lung Infarction
Yale Rosen/Wikipedia
