Atherosclerosis

Atherosclerosis is the most common chronic disease of the arteries of the elastic (aorta, its branches) and the muscular-elastic (arteries of the heart, brain, etc.) type, with the formation of single and multiple foci of lipid, mainly cholesterol deposits - atheromatous plaques - in the inner shell of the arteries . Subsequent growth of the connective tissue (sclerosis) and calcification of the vessel wall leads to a slowly progressive deformation and narrowing of its lumen until the arteries completely empty out (obliteration) and thereby cause a chronic, slowly increasing insufficiency of the blood supply of the organ fed through the affected artery. In addition, acute occlusion of the lumen of the artery or a thrombus, or (much less often), the contents of the decomposed atheromatous plaque, or both simultaneously, which leads to the formation of foci of necrosis (infarction) or gangrene in the artery-fed organ (body part) . Atherosclerosis occurs with the greatest frequency in men aged 50-60 and in women over 60 years.

Pathogenesis is complex and not completely deciphered. Undoubtedly the importance of the so-called risk factors for the development of atherosclerosis. Some of them are unrecoverable: age, belonging to the male sex, weighed down by atherosclerosis, family heredity. Others are completely eliminable: hypertension, alimentary obesity, cigarette smoking. The third are partially (potentially) eliminated: different kinds of hyperlipidemia, diabetes mellitus, insufficient level of high-density lipoproteins. The risk factors include insufficient physical activity, excessive emotional overstrain and personal characteristics of a person. Counteraction to all of the above risk factors, or complete or partial elimination of removable factors form the basis for the prevention of atherosclerosis.

Symptoms, course. The clinical picture varies depending on the predominant localization and prevalence of the process, but always (with the exception of atherosclerosis of the aorta) is determined by the manifestations and consequences of tissue or organ ischemia, depending both on the degree of narrowing of the lumen of the main arteries, and on the development of collaterals. Diagnosis is justified by signs of lesions of individual vascular areas or arteries. Before all, and as a rule, it is harder to get affected by atherosclerosis of the aorta, especially the abdominal part of it. The most evident manifestation of atherosclerosis is transmural myocardial infarction. The diagnosis is also very likely when the combination of signs of stenosis of any major arteries and heart arteries; In persons of mature age who look much older than their years; In the case of hereditary atherosclerosis and hypertensive disease. The presence of risk factors should also be considered.

Treatment aims to prevent the progression of the process and stimulate the development of ways of roundabout blood flow. Basic principles of treatment:

1. Regular muscular activity (in any form), commensurate with the age and physical capabilities of the patient; Dosage of exercises, especially with the purposeful training of the most affected organ (arterial pool), the doctor recommends;

2. Rational nutrition with a predominant share of vegetable fats in the total fat content, enriched with vitamins and excluding weight gain;

3. With excessive body weight - insistently reducing it to the optimal level;

4. Control of stool regularity; Possible periodic methods of saline laxative (in part with the goal of evacuating cholesterol, excreted into the intestines with bile);

5. Systematic treatment of concomitant diseases, especially arterial hypertension, diabetes mellitus; But in the presence of a significant stenosis of the lumen of one or more major arteries, a sharp decrease in blood pressure (and also blood sugar level) should be avoided in view of the danger of falling blood (and glucose) in the stenosed arteries. Medical therapy of the actual atherosclerotic process plays a secondary role. The forecast is uncertain. The ability to work is determined by the functional safety of organs and systems, the main arteries of which are affected by atherosclerosis.

Atherosclerosis of the aorta. Its clinical manifestations are: gradually increasing, predominantly systolic, arterial hypertension, a short systolic (not rhomboid-shaped on the FCG) noise and a second tone accent at the fifth point and above the aorta; Over its bifurcation and iliac arteries; Signs of mild hypertrophy of the left ventricle of the heart on the ECG in the absence of diastolic hypertension in the anamnesis; An increase in the rate of propagation of the pulse wave on the tachooscillogram. Linear calcifications in the walls of the arch and abdominal aorta on radiographs (in the lateral projection) is the most demonstrable, albeit late diagnostic, feature.

Complications of atherosclerosis of the aorta that directly threatens the life of the patient include exfoliating aortic hematoma, which is manifested by a seizure of prolonged, painful pain in the cervicothoracic or abdominal cavity (usually from behind), a collapse is possible, symptoms of acute blood loss occur; Characteristic of the absence of ECG signs of myocardial infarction. Subintimal hematoma of the aortic wall often encircles the mouth of its branches, causing - depending on the localization of the intimal rupture - symptoms of either ischemic stroke, or asymmetry in the completeness of the pulse and blood pressure level on the hands, or severe arterial hypertension (nephrogenic) or occlusion of the iliac arteries. Another, more frequent complication of atherosclerosis is the aortic aneurysm, which, like its stratifying hematoma, is fraught with a sudden rupture with fatal bleeding, or into the thoracic (more often pleural) cavity, or into the retroperitoneal space (occasionally into the duodenum). Aneurysm of the thoracic aorta is often manifested by gross systolic murmur, dysphagia, hoarseness of the voice (compression of the recurrent nerve with the paresis of the voice fold of the larynx), palpation tangible and synchronous pulse by twitching the thyroid cartilages down; It is recognized in multi-axis radiography. An aneurysm of the abdominal aorta (more frequent localization) is recognized with deep palpation, sometimes radiologically; The current is often less than symptomatic (see also Aneurysm in the chapter "Surgical Diseases"). The stenosing atherosclerosis of the abdominal aorta, especially its terminal part, can be complicated by thrombosis of the bifurcation area with acute impairment of the blood supply of the lower extremities (Lerish syndrome): acute pain, violation of sensitivity and movement in both legs, pallor of the skin, gangrene may develop. Treatment is surgical, less effective and thrombolytic therapy is not always permissible. Atherosclerosis of the aorta is differentiated with nonspecific and specific (syphilitic, bacterial septic) aortitis. Patients with aneurysm of the aorta are referred to specialized institutions for examination and resolution of the possibility of reconstructive surgery.

Atherosclerosis of the branches of the aortic arch, symptoms of chronic (and with thrombotic occlusion - acute) insufficiency of blood supply to the brain or upper limbs are observed. A reconstructive surgical operation is possible.

Atherosclerosis of mesenteric arteries is manifested by two main syndromes: abdominal toad and thrombosis of arterial (often and venous) branches with infarction of the intestinal wall and mesentery. Abdominal toad - an attack of colicky abdominal pains - occurs shortly after eating, is often alleviated by nitroglycerin, vomiting and bloating are not uncommon; Fasting stops the attacks of the abdominal toad; Diagnosis is difficult (a rare syndrome, the absence of specific signs), highly relevant in connection with the danger of late detection of acute abdominal diseases.

Treatment - divided food intake, nitroglycerin, papaverine 0,04-0,06 g 3-4 times a day before meals, pancreatin (1-1,5 g) or panzinorm (1-2 tablets) after meals. About thrombosis of the mesenteric arteries, see Occlusion of the main arteries in the chapter "Surgical diseases".

Atherosclerosis of the renal arteries is manifested clinically by chronic kidney ischemia (often in the form of renovascular hypertension) with outcome in arteriosclerotic nephrosclerosis and chronic renal failure. The final diagnosis is established in specialized nephrologic or angiosurgical institutions; When surgical treatment is impossible, hypotensive therapy is performed (see Arterial hypertension). Thrombosis of the renal artery - acute syndrome with sudden pain, soreness with palpation and with concussion of the lumbar region on the side of thrombosis, acute renal failure (oligoanuria) and, as a rule, high arterial hypertension; Diagnostic examination and treatment is carried out in specialized institutions.

About arteriosclerosis of arteries of the lower extremities, see Occlusion of the main arteries in the chapter "Surgical diseases"; Arteries of the brain see Stroke in the chapter "Nervous Diseases"; About atherosclerosis of the coronary arteries of the heart, see Ischemic (coronary) heart disease.