Have A Heart

Have A Heart!

Dr. S.M.Sadikot.
Hon. Endocrinologist,
Jaslok Hospital and Research Centre,
Mumbai 400026

Macrovascular disease, or atherosclerosis as it is widely called, is a progressive disease of the large and medium sized arteries. The name is derived from the Greek "athero" meaning gruel or paste and "sclerosis" meaning hardening.

Atherosclerosis is often referred to as "hardening of the arteries."

  • It is a build up of cholesterol and other fat substances within the walls of the arteries.
  • It is a progressive disease and can develop in any artery in the body.
  • A gradual build up of fatty deposits (cholesterol and fat), called plaque, that occurs on the inside of the lining of the artery wall causing the opening to narrow. These deposits usually develop over many years.
  • Narrowing of the arteries by 70% or more decreases the blood flow through the artery and may prevent body tissues and organs from receiving an adequate blood supply. This lack of blood flow decreases the amount of oxygen being delivered to the tissues and organs resulting in symptoms such as aching or pain in the chest (angina) or cramping in the legs.

Permanent damage to body tissues and organs can occur if the blood and oxygen supply disruption is prolonged or very severe. Permanent damage results in the death of that area being supplied and is referred to as an infarction.

The inner lining of the normal artery is smooth and free of blockages or obstructions. Scientists think the disease starts when the very inner lining of the artery (the intima) is damaged. In the early stages of the disease, lipid is deposited in the intima, the so called "fatty streaks". These streaks are flat or slightly elevated pale yellow areas, of variable size and shape. This progresses to the stage of a fibrous plaque.

Fibrous plaques are raised firm pale areas in the intima of arteries which on cross section reveal central lipid rich debris with surrounding fibrous tissue. The streaks are only minimally raised and thus do not produce any obstructions or symptoms.

Unless corrective measures are taken at this stage, the disease stage increases in severity. The increasing size of the plaque as well as some of the complications which can occur in a smaller plaque results in further narrowing of the artery and a reduction of blood flow. Eventually it might result in the complete blockage, leading to the death of the cells or part of an organ supplied by that artery.

Fibrous Plaque

Some of these more severe stages are shown below, finally resulting in a complete block.

Calcification
Calcification

The process by which organic tissue becomes hardened by a deposit of calcium salts within its substance.

Haemorrhage
Haemorrhage

The escape of blood from the vessels.

Ulceration
Ulceration

A local defect or excavation, of the surface of an organ or tissue, which is produced by the sloughing of inflammatory necrotic tissue.

Thrombosis
Thrombosis

The formation, development or presence of a thrombus.

If you have diabetes, you have a major risk factor for getting atherosclerosis. Not only do the arteries get affected earlier, but the rate at which the disease progresses is much faster in people who have diabetes.

Coronary and cerebral artery disease is 2-4 times as common in a person with diabetes and whilst vascular blocks in the legs (peripheral vascular disease) is 4-6 times more common.

The prevalence of atherosclerosis is increased manifold in people with diabetes, occurs earlier in life, progresses faster to the more sever forms and is associated with an increased chance of death from these complications.

Not only is diabetes itself a major factor in causing damage to the endothelium, people with diabetes have other risk factors which themselves can damage the inner linings of the arteries. In the presence of high blood glucose levels, the potential of these other risk factors to cause atherosclerosis is increased manifold.

Modifiable major risk factors

  • a) Uncontrolled and high blood glucose levels
  • b) High blood pressure
  • c) High cholesterol levels, especially the "bad" LDL-cholesterol levels which are above 100mg%
  • d) Low levels of the "good" HDL-cholesterol (below 45mg%)
  • e) High levels of triglycerides in the blood (more than 150mg%)
  • f) Obesity, especially "central"obesity with a high waist-hip ratio
  • g) Sedentary lifestyle with little or no exercise
  • h) Presence of kidney disease as judged by albumin in the urine;
  • i) Raised levels of insulin in the blood
  • j) Smoking, or the use of tobacco in any form

Predisposing risk factors

  • a) Genetic factors (family history)
  • b) Age of the patient
  • c) Duration of diabetes

Everyone gets atherosclerosis. It is said that if we all lived to be 100 years old, we would eventually die of atherosclerosis. So one cannot prevent atherosclerosis. But what one can do is to see that the additional burden placed by the presence of diabetes is decreased significantly.

As we have seen above, a person with diabetes is definitely more prone to atherosclerosis. Not only that, but the damage to the arteries occurs earlier, progresses faster and is seen in a much more severe form.

It is in this area that one can, and must, do all that is possible.

If you see the risk factors for people with diabetes to get macrovascular disease, it is obvious that there are some risk factors over which we have no control. It is still not possible to change your genes and neither is it possible to stop the passage of time. One gets older everyday!

But modifying many of the other risk factors is in your hands!

It is obvious that a good control of the blood glucose level, normalizing the blood pressure and the levels of "fats" found in the blood can go a long way to decrease the severity of atherosclerosis. Your doctor can keep telling you to exercise and lose weight especially if you have a large waist line, but your doctor cannot "exercise" for you!

Many of these aspects are covered in more detail in other sections of the booklet. But there is one area which is of utmost importance. Smoking and tobacco in any form MUST be avoided.

You can see for yourself why tobacco is so harmful to your arteries. Compared to a non smoker, many changes take place in the blood of the smoker which are not only injurious to the intima ( where atherosclerosis starts) but increases the rate at which the damage proceeds.

Moroever, you can see clearly that a smoker has arteries which are narrowed. This not only increases the blood pressure, but also compromises the blood flow in the artery which in any case may be decreased due to atheromatous plaques!

Smoker, Nonsmoker

As a joke goes," Smokeā€¦.make a Cardiologist happy!"

So there are many ways by which you can prevent the damage caused by diabetes to your arteries.

Your doctor will advise you about all this, but finally, it is up to you!

Inspite of the tremendous strides have taken place in treating atherosclerosis, especially in the surgical procedures such as angioplasty and bypass surgeries, and the routine use of aspirin as a blood thinner, diet and lifestyle modification still remain the mainstay of treatment.

But then it is the very same diet and lifestyle modification which may have prevented the problem in the very first place! Whilst, these are still important, one cannot help feeling that carrying out these changes in one's diet and lifestyle, after one's arteries have been seriously damaged, is like going out to buy the most expensive lock after everything in one's house has been stolen!