Atherosclerosis (hardening of the arteries) is the most common form of arteriosclerosis, a class of diseases in which the walls of a person's arteries become thicker and less elastic. In atherosclerosis, fatty material (atheromas) accumulates under the inner lining of arterial walls. It can affect medium and large arteries in the brain, heart, kidneys, other vital organs, and arms and legs. When it develops in the carotid arteries, atherosclerosis can lead to stroke. In the coronary arteries, it can result in heart attack.

The disease develops slowly. It shows few symptoms until the arteries have narrowed severely or have actually become obstructed. Nevertheless, atherosclerosis is the leading cause of illness and death in the United States and most other Western countries. It causes about one million deaths per year in the United States alone, double the number of deaths from cancer.

Treatment should start before symptoms appear, with preventive measures. Recommended measures include lowering cholesterol and blood pressure, ceasing cigarette smoking, losing excess weight, and starting physical activity. When symptoms emerge, treatment focuses on the complications of atherosclerosis, such as angina pectoris, heart failure, kidney failure, stroke, and peripheral arterial occlusion.

Some degree of the condition is normal with aging. Researchers have advanced two main theories. The lipid hypothesis is that low-density lipoprotein (LDL) leaks into the arterial walls when its plasma level increases. As a result, LDL accumulates in smooth muscle cells and foam cells, and is oxidized in such a way that it becomes more reactive. This causes the appearance of streaks of fat-containing cells that, as they grow, invade the deeper levels of the arterial walls. These large accumulations, or plaques, cause the artery to narrow and harden.

The chronic endothelial injury hypothesis suggests that injury to the endothelium, the innermost layer of the arterial wall, starts the process. As the injury heals, the endothelium takes up more LDL, which builds up into plaque. Some researchers believe that both processes occur simultaneously. However the atherosclerotic plaque arises, it grows slowly over the years, gradually narrowing the artery, and making the patient vulnerable to thrombosis.

• Male gender
• Menopause in women
• Hypertension
• Elevated levels of low-density lipoprotein (LDL)
• Decreased levels of high-density lipoprotein (HDL)
• Cigarette smoking
• Diabetes
• Obesity
• Familial atherosclerosis
• Sedentary lifestyle
• Increasing age
• High sucrose intake
• Hyperhomocysteinemia
• Elevated fibrinogen levels
• Deficiency of coenzyme Q10, L-carnitine
• Air pollution
• Stress
• Sleep deficiency
• Social isolation
• High degrees of negative attitudes (such as hostility and cynical distrust)
• Excessive experience of negative emotions (such as depression, anger, and anxiety)
• High ratio of free radical markers to antioxidants

• Pain and cramps at the site of the narrowed artery, such as chest pain or leg cramps when walking
• Gradual or sudden increase in the extent of the above
• Hardened feel, like small, hard pipes, of arteries in forearms or carotid arteries in the neck
• Clinical signs and symptoms include aneurysm, thrombosis, embolus, and stenosis
• Lowered or absent pulses
• Circulation of a bruit over a narrowed vessel
• In more severe cases muscle atrophy, ulcer, or gangrene

• Hypothyroidism
• Poorly controlled diabetes
• Kidney failure
• Malnutrition

Listen for a bruit during your stethoscope examination of the patient's neck, abdomen, or groin area. The sound may indicate turbulence in the blood flow caused by a narrowing of the arteries. Check blood pressure. Estimate blood flow by feeling for pulsations in the wrists, legs, and feet; a decrease in pulsations may indicate partly obstructed blood flow. The ankle-arm index (systolic blood pressure at the ankle divided by the brachial systolic blood pressure in the arm) of less than .9 is a highly accurate quantitative indicator of significant atherosclerosis.

Check blood sugar level for diabetes. Take blood for fasting serum cholesterol, LDL, HDL, and triglycerides.

• Streaks of lipid in arteries
• Plaque with associated fibrosis and calcification
• Neovascularization
• Arterial obstruction

Conventional X rays of the chest and blood vessels provide limited diagnostic information. Ultrasound or computed tomography can help to locate the presence and measure the extent of decreased blood flow. Arteriography of the appropriate organ or limb can locate the site of damage more precisely.

• Family and personal history
• Blood pulsations check
• A stress test will indicate the state of the patient's heart, which may be affected by atherosclerosis.

Persuade patients that prevention is the best form of treatment. Eliminate controllable risk factors: high blood cholesterol, high blood pressure, obesity, lack of exercise, cigarette smoking.

Several prescription medications can reduce blood cholesterol and other fats.

• Cholestyramine and colestipol (12 to 32 g in two to four divided doses) bind bile acids in the intestinal tract, thereby causing the liver to increase its manufacture of bile acids and reduce production of cholesterol. May cause constipation and bloating.
• Nicotinic acid (2 to 6 g daily in divided doses), taken in large quantities, reduces triglycerides and LDL cholesterol, while increasing HDL cholesterol. Side effects may include flushing and changes in liver function.
• Gemfibrozil (600 mg bid) has effects similar to nicotinic acid and is more convenient to take. It may have adverse intestinal effects.
• Probucol (500 mg bid) lowers total cholesterol, but also reduces HDL.
• Statins, such as lovastatin (20 to 80 mg daily), pravastatin, simvastatin, and fluvastatin, interfere directly with the manufacture of cholesterol and may promote the resorption of cholesterol deposits.
• Aspirin lessens the likelihood that blood clots will form. Recommend 325 mg per day unless contraindicated for patients at risk of stroke or heart attack.
• Anticoagulants in crescendo and unstable angina are thought to forestall thrombotic events resulting from rupture of atherosclerotic plaques.

Endarterectomy removes the plaque from inside of the arteries. It is used particularly for the carotid artery, at the point where it divides into internal and external branches; plaque at that junction commonly causes transient ischemic attacks or ischemic stroke. After removing the plaque, the surgeon closes the junction, a procedure that may require a patch of synthetic material. Surgeons must restore blood flow carefully to prevent clots. Reblockage is uncommon. In fact, the surgery has a high success rate, although it carries some risks.

Lifestyle changes, diet, and exercise should be an integral part of any treatment plan. Nutritional supplements can be very effective. Hawthorn has an important role in both treating and preventing atherosclerosis. Mind-body techniques, such as yoga, meditation, relaxation, and biofeedback show promise in increasing cardiovascular health. Counseling strategies and behavioral techniques help patients to manage stress, move toward more positive attitudes, and establish broader, supportive social relationships. There is increasing evidence that elevated levels of homocysteine may be important in the genesis of atherosclerosis and cardiovascular disease, and that nutrition can be helpful at modifying those levels.

• Vegetarian diet promotes stabilization or possible reversal of the atherogenic process.
• Antioxidants: vitamin C (1,000 mg tid), vitamin E (400 IU/day), coenzyme Q10 (30 to 50 mg tid), selenium (200 mcg/day), lipoic acid (recycles vitamins E and C when they've been used, 50 mg bid)
• Essential fatty acids high in omega-3 fatty acids (1,500 mg bid): While there has been much emphasis on low-fat diets, there are some intriguing studies that show that a low-fat diet may actually increase LDLs and that it may be more important to alter the fats in the diet, decreasing saturated fats and trans fatty acids, and replacing them with poly- and monounsaturated fats. Hydrogenated oils are at least, if not more, as atherogenic as saturated fats.
• Diet: Garlic, ginger, and onions all have a beneficial effect on platelet aggregation. Increase fiber (especially water-soluble), fruits, vegetables, and vegetarian sources of protein.
• Homocysteine metabolism: Folic acid (800 mcg/day), B6 (50 mg/day), B12 (400 mg/day), betaine (200 to 1,000 mg/day)
• Chromium (200 mcg/day): deficient in AS, supplementation may result in plaque regression
• Magnesium (500 mg): decreases arrhythmias, angina, and death rates following infarction, especially when given with potassium
• Bromelian (150 to 250 mg qid away from meals): inhibits platelet aggregation and breaks down plaque
• Carnitine (750 to 1,500 mg bid): important in fatty acid metabolism, depleted in cardiac muscle during acute infarctions

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Hawthorn (Crataegus monogyna): Proanthocyanadins stabilize collagen to prevent cholesterol deposits on arterial walls, prevents free radical damage, reduces peripheral vascular resistance, angina, cholesterol, and increases coronary and myocardial perfusion; historic use in congestive heart failure; dose is 3 to 5 g as either dried herb, solid extract, or liquid extract.
• Ginkgo (Ginkgo biloba): peripheral arterial occlusion, intermittent claudication, platelet aggregation, watch with thrombolytic therapy (250 mg tid)
• Mistletoe (Viscum album): atherosclerosis, possible antihypertensive, historically for exhaustion and nervousness, yet a strong potential for toxicity
• Linden (Tilia cordata): atherosclerosis, historic use as a hypotensive, especially with digestive problems and nervousness
• Rosemary (Rosmarinus officinalis): increases coronary artery blood flow, historically used to stimulate digestion and relieve nervous tension
• Gentian (Gentiana lutea): bitter, digestive tonic, historic use to aid in smoking cessation, avoid with ulcers

Hawthorn and/or ginkgo are recommended. Concentrated extracts may be required to achieve the recommended doses. In addition, a tincture (30 to 60 drops tid) or tea (1 cup tid) of one to four of the above herbs, taken before meals, may be helpful.

Constitutional treatment may be helpful in stimulating overall vitality and should be prescribed by an experienced practitioner.

May be helpful in decreasing tension, stimulating proper digestion and elimination, and increasing a sense of well-being.

May be helpful at relieving tension and increasing overall sense of well-being.

Emphasize preventive measures.

Careful lifestyle choices represent the first line of attack on incipient atherosclerosis. Approaches include:

• Achieving and maintaining normal weight
• Controlling high blood pressure, diabetes, and other disorders that may contribute to the buildup of plaque in arteries
• Eating a diet low in saturated and hydrogenated fats and cholesterol, and high in starches, fiber, fruits, and vegetables
• Exercising for 15 minutes or more three to four times per week
• Avoiding cigarette smoking and second-hand smoke

• Coronary artery disease
• Congestive heart failure
• Cardiac arrhythmias
• Stroke
• Myocardial infarction
• Ischemia and pre-gangrene of the lower limgs
• Premature renal failure

Focus on prevention—it is the best treatment with the best results. Treat complications if they emerge.

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