Atherosclerosis

What is it?

Overview

What Is It?
Atherosclerosis occurs when your arteries narrow and become less flexible, which happens when plaque collects on the inner walls.

Diseases caused by atherosclerosis are the leading cause of illness and death for both men and women in the United States, according to the National Heart, Lung, and Blood Institute. Although breast cancer is often the illness most feared by women, the disease affects one out of eight women over the lifetime, compared to coronary heart disease, which is responsible for more than one in three female deaths in America. Atherosclerosis is often the first stage of coronary heart disease (CHD).

Often referred to as "hardening of the arteries," atherosclerosis occurs when your arteries narrow and become less flexible. This happens when cholesterol, fatty substances, cell waste products, calcium and fibrin—collectively called plaque—collect on the inner walls. The arteries respond to the buildup by becoming inflamed, which, in turn, results in the formation of scar tissue and the collection of other cells in the affected areas, further narrowing the artery.

Atherosclerosis can affect medium and large arteries anywhere in your body. If someone has atherosclerosis in one part of their body, they typically will have atherosclerosis in other parts of their bodies. Atherosclerosis restricts blood flow, thus limiting the amount of oxygen available to your organs. When blood flow to the heart is reduced, for instance, chest pain, or angina, may result. Similarly, when blood flow to the arteries in the legs is reduced, leg pain called claudication may result.

As the disease progresses, atherosclerosis can completely clog arteries, cutting off blood flow. This usually happens suddenly when a blood clot forms in the damaged arteries on top of the atherosclerosis. This is especially dangerous in arteries near the brain, heart or other vital organs. If blood flow to the heart is nearly or completely blocked, a heart attack results and muscle cells in the heart die. The result is permanent heart damage. Similarly, if blood flow is abruptly cut off to the brain, this can cause a stroke, which may also result in permanent brain damage. And if blood flow is abruptly cut off to the legs, the leg may have to be amputated. Thus atherosclerosis can lead to serious life-threatening complications if not addressed early through prevention and early treatment.

Atherosclerotic plaques have a cholesterol- or lipid-rich core covered by a fibrous cap. If this cap ruptures, it exposes this lipid-rich core to blood. The sticky core attracts platelets, forming a blood clot, called a thrombus, at the site. This clot can completely clog the artery and cut off blood flow.

More mature plaques (stable plaques) have a thick fibrous cap, which is less likely to rupture. Softer, fattier plaques (unstable plaques) have a weaker cap and are more likely to rupture.

Surprisingly, the majority of heart attacks occur in arteries that were less than 50 percent blocked before the attack. So the degree of blockage in a particular artery does not necessarily predict heart attack risk. However, the overall total burden of atherosclerosis throughout all the arteries does affect your risk of a heart attack.

We don't know what causes plaque to begin building up in arteries. Some experts think plaque begins to accumulate in places where the inner layer of an artery is damaged.

The specific arteries most at risk for atherosclerosis-induced blockage are those going to your brain (carotid), heart (coronary) and legs (femoral or iliac). Atherosclerosis in the legs is the most common form of peripheral arterial disease (PAD) and can lead to intermittent claudication—severe pain, aching or cramping when walking, numbness, reduced circulation, and if left untreated, gangrene (death of tissue).

While atherosclerosis typically progresses gradually—sometimes even starting in childhood—you are most at risk when arterial blockage builds up quickly, completely closing off an artery. This can happen if the plaque ruptures.

Risk Factors for Atherosclerosis

Over the last two decades, researchers have identified many risk factors for developing cardiovascular diseases. They include:

  • Elevated cholesterol levels (both total cholesterol and LDL ["bad"] cholesterol)
  • Elevated triglyceride levels
  • Low HDL cholesterol (the "good" cholesterol, which clears away artery-clogging LDL cholesterol—the "bad" cholesterol)
  • High blood pressure (hypertension)
  • Cigarette smoking
  • Diabetes (elevated blood sugar)
  • Advanced age

High cholesterol. More than half of women over age 55 need to lower their blood cholesterol, and a quarter of all American women have blood cholesterol levels high enough to pose a serious risk for coronary heart disease—a result of atherosclerosis.

Cholesterol begins collecting in the walls of the arteries at an early age. In fact, the earliest type of arterial lesion, the "fatty streak," is present even in young children.

According to the National Cholesterol Education Program (NCEP), elevated LDL cholesterol is a major cause of coronary heart disease. That's why the NCEP panel recommends aggressive treatment. Treatment may include lifestyle changes, such as exercising more and reducing the amount of saturated fat in your diet, and medication. A combination of approaches is typically recommended.

Other lipid abnormalities, such as elevated triglycerides or low HDL (the good cholesterol), are also associated with increased cardiovascular risk.

Cigarette smoking. Smoking accelerates the development of atherosclerosis, increases blood pressure and restricts the amount of oxygen the blood supplies to the body. Quitting smoking dramatically and immediately lowers the risk of a heart attack and reduces the risk of a second heart attack in people who have already had one.

Diabetes. Having diabetes poses as great a risk for having a heart attack in 10 years as heart disease itself, according to NHLBI. In fact, cardiovascular disease is the leading cause of diabetes-related deaths. People with diabetes who have not yet had a heart attack have the same risk of future heart attack as someone with known coronary heart disease. Because their risk of heart attack is so high, NHLBI recommends that people with diabetes be treated aggressively with LDL cholesterol–lowering medication and carefully manage their blood sugar to reduce their cardiovascular risk.

Age. Generally, women over age 55 and men over age 45 are at greatest risk for developing atherosclerosis. The risk of cardiovascular events increases with age.

Other risk factors for coronary heart disease include:

  • A family history of early heart disease (before the age of 60) in a member of your immediate family (parent, sibling, child)
  • Obesity
  • Metabolic syndrome
  • Physical inactivity and sedentary lifestyle
  • Postmenopausal status
  • Increased levels of high-sensitivity C-reactive protein (CRP), which is a marker of inflammation

Family History. Even though it is not included in the Framingham Risk Score, family history is one of the biggest risk factors overall for atherosclerosis. Your risk is greater if your father or brother was diagnosed before age 55, if your mother or sister was diagnosed before age 65 or if you have a sibling with early coronary disease.

Obesity. Overweight women are much more likely to develop heart-related problems, even if they have no other risk factors. Excess body weight in women is linked with coronary heart disease, stroke, congestive heart failure and death from heart-related causes.

Inactivity. Not exercising contributes directly to heart-related problems and increases the likelihood that you'll develop other risk factors, such as high blood pressure and diabetes.

Metabolic Syndrome. This deadly cluster of risk factors includes five components: abdominal obesity (a large waistline); high blood pressure; glucose intolerance or high fasting blood sugar levels (diabetes or prediabetes); abnormal lipids such as a high triglyceride level; and low HDL (good) cholesterol. If you have three out of five of these risk factors, you are diagnosed with metabolic syndrome, which is associated with a markedly increased risk of cardiovascular disease.

Stress. Although stress has been implicated in the development of atherosclerosis, its exact relationship to heart disease has not been determined. Regular exercise can reduce stress and improve your mood.

Postmenopausal status. A woman's risk of developing atherosclerosis and heart disease increases once she reaches menopause. Prior to menopause, women are mainly protected from heart disease by estrogen, the reproductive hormone produced by the ovaries. This protection is why women tend to develop heart disease 10 years after men. However this 10-year protection is not seen in women who smoke or have diabetes.

Among its many roles, estrogen helps keep arteries free from plaque by improving the ratio of LDL (low-density lipoprotein) and HDL (high-density lipoprotein) cholesterol. It also increases the amount of HDL cholesterol, which helps clear arteries of LDL cholesterol—the kind that most contributes to plaque buildup.

Estrogen also helps keep the lining of your blood vessels strong and pliable, which helps reduce your risk of atherosclerosis. Despite the theoretical benefits of estrogen, replacing natural estrogen hormones with drugs after menopause is not an effective way to prevent heart disease and may even be harmful.

High-sensitivity C-reactive protein. Chronic inflammation has been shown to be a risk factor for cardiovascular disease. While the reasons are not fully known, inflamed atherosclerotic plaques may be more prone to rupture. C-reactive protein (CRP) is a marker of inflammation that can be measured in the blood and is strongly linked to obesity and sedentary lifestyles. However, CRP has been shown to predict cardiovascular risk even above traditional risk factor assessment. Weight loss and exercise can lower CRP levels. Statins, a common class of medications used to treat cholesterol, can also lower CRP. Sometimes doctors will order CRP testing to refine risk prediction among intermediate-risk individuals when the decision to treat with statin therapy is unclear. Older or elderly individuals who have normal or even low levels of cholesterol but who have high levels of CRP may also benefit from statin therapy.

Global Risk Factor Assessment. The Framingham Risk Score is a useful, office-based risk prediction model. It assigns a point score for each major risk factor (age, smoking, total cholesterol, HDL cholesterol, systolic blood pressure) to predict your 10-year risk of developing future CHD events. You can estimate your own 10-year risk at: http://hp2010.nhlbihin.net/atpiii/calculator.asp.

If you have more than a 20 percent risk of future cardiac events over the next 10 years, you should be treated very aggressively, the same as someone with known heart disease. Intermediate-risk individuals with scores between 10 percent and 20 percent should have further evaluation. Low-risk individuals with scores of less than 10 percent usually don't need drug therapy, but should make lifestyle changes such as diet and exercise, which are recommended for everyone.

Recently, several studies have suggested that the Framingham Risk Score may underestimate cardiovascular risk in a substantial number of individuals, particularly women and younger adults. The Adult-Treatment Panel (ATP) version of the Framingham Risk Score only predicts coronary heart disease events, but for women under the age of 75, strokes are more common than the CHD events predicted by the risk calculator. Certain individuals with low- or intermediate-risk Framingham Risk Scores may be candidates for other testing if they have other risk factors such as a strong family history that are not included in the Framingham Risk Score.

Women and young adults often have low Framingham Risk Scores for short-term risk over the next 10-years but have substantial lifetime risk. Even the presence of one major cardiovascular risk factor by the age of 50 is associated with increased lifetime risk of cardiovascular disease and shorter median survival compared to women with optimal risk factor status. Thus "low-risk" over the next 10 years is not the same as "no risk," and it is imperative that risk factors are screened for and treated appropriately. It is important to prevent risk factors from developing through a healthy lifestyle.

Recently, another global risk assessment tool called the Reynolds Risk Score was developed, which has been shown to have improved predictive ability for all cardiovascular events compared to the Framingham Risk Score. This tool incorporates many of the traditional risk factors used in the Framingham Risk Score, but adds two other important risk factors: family history of premature coronary artery disease and high-sensitivity C-reactive protein. You can estimate your 10-year risk at www.ReynoldsRiskScore.org.

Both risk assessment tools were developed among predominantly Caucasian populations and may not apply well to individuals from other races or ethnicities.

Symptoms of Atherosclerosis:

Often, you will experience no symptoms of atherosclerosis until the disease has progressed significantly. However, there are some conditions that may suggest atherosclerosis is present, although these conditions may happen for other reasons.

  • Angina. If clogged arteries prevent enough oxygen-carrying blood from reaching your heart, the heart may respond with pain called angina pectoris. Episodes of angina occur when the heart's need for oxygen increases beyond the oxygen available from the blood nourishing the heart. Silent angina occurs when the same inadequate blood supply causes no symptoms.

    Physical exertion is the most common trigger for angina. Other triggers can be emotional stress, extreme cold or heat, heavy meals, alcohol and cigarette smoking. The pain is a pressing or squeezing pain, usually felt in the chest or sometimes in the shoulders, arms, neck, jaws or back.

    Angina suggests that coronary heart disease exists. People with angina have an increased risk of heart attack compared with those who have no symptoms. When the pattern of angina changes—if episodes become more frequent, last longer or occur without exercise—your risk of heart attack in subsequent days or weeks is much higher and you should see your health care professional immediately.

    If you have angina, learn its pattern—what causes an angina attack, what it feels like, how long episodes usually last and whether medication relieves the attack. Angina is usually relieved in a few minutes by resting or taking prescribed angina medicine, such as nitroglycerin.

    Episodes of stable angina seldom cause permanent damage to heart muscle.

    Heart attack pain may be similar to angina, but the symptoms of angina quickly disappear with rest. Heart attack pain, however, usually persists despite resting or taking nitroglycerin and should be evaluated immediately. Like angina, heart attack pain can be a pressure or tightness in chest, arms, back or neck.

    Often symptoms include shortness of breath, sweating, nausea, vomiting, indigestion or dizziness.

    Women, especially those with diabetes, may not have the typical symptoms of chest pain like men, but have other symptoms such as shortness of breath or indigestion. A heart attack is an emergency. A delay in treatment could mean more of the heart muscle tissue is permanently damaged.

    If you think you are having a heart attack, call 9-1-1. After you call 9-1-1, the operator may recommend that you chew one adult-strength (325 mg) aspirin after he or she makes sure you don't have an allergy to aspirin or a condition that may make taking it too risky. If the operator doesn't talk to you about chewing an aspirin, the emergency medical technicians or physicians at the hospital will give you one if it's right for you.
  • Cardiac arrhythmias. These occur when the heart momentarily beats too fast or beats irregularly. Chest pain, dizziness and shortness of breath are symptoms of cardiac arrhythmias. Atherosclerosis is one cause of rapid or irregular heartbeat; however, it can also be caused by angina, valvular heart disease, blood clots, thyroid abnormalities, electrolyte imbalance or previous heart damage. Arrhythmias may be frequent or infrequent.
  • Silent ischemia. Sometimes atherosclerosis causes no symptoms. Silent ischemia is a condition caused by atherosclerosis, but isn't associated with the chest pain or other symptoms common to other types of heart conditions. This condition occurs when arteries with atherosclerosis can't deliver enough blood to the heart. An electrocardiogram (EKG or ECG), a measurement of electrical impulses produced by the heart, may indicate silent ischemia. However, unless you know your risks for heart disease and decide, with the advice of your health care professional, that you need a heart checkup, you may never know you have ischemia. People with diabetes are especially at risk for this condition.
  • Intermittent claudication. This leg disorder predominantly affects elderly people. It causes severe pain, aching or cramping in the legs when you walk due to atherosclerosis in the major arteries that supply blood to the legs (femoral and iliac). Severe cases of peripheral arterial disease can lead to gangrene and amputation.
  • Transient ischemic attack (TIA) and strokes. If you experience a sudden onset of weakness or numbness on one side of your face, arm or leg, or an inability to talk or find words, or lose vision in one eye, you may be having a stroke or a TIA. Neurological symptoms that last less than 24 hours are called TIAs, whereas symptoms that persist for longer are classified as strokes.

    TIAs and strokes are often the result of atherosclerosis in the arteries that supply blood to the brain, such as the carotid arteries. This is very serious. If you think you are experiencing a stroke, you should call 9-1-1 to seek medical attention immediately. This is the brain's equivalent of a "heart attack," during which the brain is deprived of oxygen-carrying blood supply. Any delay in medical treatment may permanently damage your brain.

Diagnosis

Diagnosis

The earlier atherosclerosis is diagnosed the better. You'll want to take many of the following steps to determine if you're at risk for this condition. Discuss other steps listed below with your health care professional.

  1. Office-based Physical Exam. All women should undergo an annual exam to assess their risk factors for cardiovascular disease and for any symptoms of atherosclerosis. The physical exam should include measuring your blood pressure and height and weight to calculate a body mass index (BMI). A normal blood pressure is less than 120/80. If you have high blood pressure, you should see your health care professional more frequently to make sure your blood pressure is being adequately treated to the goal of less than 130/85. If you're overweight, you have a higher risk of diabetes and metabolic syndrome. Your doctor should encourage you to follow a healthy diet and to exercise regularly to reduce your risk.

    Often, atherosclerosis is not diagnosed until you have complications. However, before you experience complications, your health care professional may be able to hear a blowing sound called a bruit when holding a stethoscope over a damaged artery. Also, you may have a decreased pulse in the affected area. Sometimes, atherosclerosis causes the blood pressure in each of your arms to be significantly different, another symptom your health care professional can easily check. More commonly, there are no apparent signs on physical exam to suggest the presence of atherosclerosis, and thus individuals with risk factors may be referred for additional testing.

  2. Laboratory tests. Beginning at age 20, women should have their blood cholesterol measured. If it is normal, it can be rechecked every five years. However, if it is abnormal, it should be monitored more frequently, such as at least once a year. A complete lipoprotein level (a blood test that measures total cholesterol, LDL cholesterol, HDL cholesterol and triglyceride levels) is recommended by NHLBI as the initial test to determine if your cholesterol levels are within normal ranges. This type of test, called a fasting lipoprotein test, is taken when you haven't eaten for a prescribed amount of time—usually between nine and 12 hours. Blood-level cholesterol is measured in milligrams per deciliter (mg/dL; a deciliter is one-tenth of a liter).

    If you are at risk for high cholesterol or other conditions that contribute to the development of heart disease, your health care professional may recommend more frequent testing.

    Here are "at-a-glance" guidelines for your cholesterol levels. Be sure to ask your health care professional if your blood cholesterol goals should be different based on any individual heart disease risks you may have, such as diabetes and high blood pressure, or if you smoke:

    • Total cholesterol levels:
      Desirable: less than 200 mg/dL
      Borderline high-risk: 200 to 239 mg/dL
      High risk: 240 and above

    • HDL (high density lipoprotein) levels:
      Optimal: above 60 mg/dL. (considered protective against heart disease.)
      40 to 50 mg/dL: the high the level the less your risk for heart disease
      Less than 40 mg/dL: considered a major risk factor for heart disease

    • LDL (low-density lipoprotein) levels:
      Optional goal for high-risk patients: less than 70 mg/dL
      Optimal: less than 100 mg/dL
      Near optimal:100 to 129 mg/dL
      Borderline high: 130 to 159 mg/dL
      High: 160 to 189 mg/dL
      Very high: 190 mg/dL and above

    According to NHLBI's updated 2004 cholesterol guidelines:

    For individuals at very high risk for heart attack, such as those who have had a recent heart attack or unstable angina, the overall LDL cholesterol goals should be less than 70 mg/dL; drug therapy with statins is usually recommended to reach this goal.

    For patients at high risk for heart attack, LDL cholesterol goals should be less than 100 mg/dL with an optional goal of less than 70 mg/dL, and drug therapy is usually recommended to reach these goals. High-risk individuals include people with known atherosclerosis (such as those with a prior heart attack, stroke or peripheral arterial disease), people with diabetes or kidney disease or people with enough risk factors to give them a 10-year risk of a heart attack of more than 20 percent under the Framingham Risk Score. Studies suggest that high-risk and very high-risk patients may benefit from statin therapy even if their cholesterol levels are not elevated to prevent further events.

    For moderately high-risk patients: LDL cholesterol goals should be set for less than 130 mg/dL (or better yet, less than 100 mg/dL) and drug therapy should be used at LDL levels of 100 to 129 mg/dL to reach this goal. Moderately high-risk individuals include those whose 10-year risk of a heart attack is 10 percent to 20 percent, those with more than two risk factors for heart disease, those with a positive family history of premature coronary disease or those with the metabolic syndrome.

    For low-risk patients, LDL cholesterol goals should be less than 160 mg/dL. Low-risk individuals are those whose 10-year risk of heart disease is less than 10 percent, and who have less than two risk factors for heart disease. Usually, lifestyle changes such as diet and exercise are recommended first, but drug therapy can be added if these are not enough to meet their goal.

    Note that lifestyle changes such as diet and exercise are recommended for everyone—even those on drug therapy! When lifestyle changes alone are not adequate, the most common class of medications used to treat high cholesterol is called statins (examples include atorvastatin (Lipitor), simvastatin (Zocor), rosuvastatin (Crestor), pravastatin (Pravachol), lovastatin and fluvastatin). Statins are highly effective in reducing cholesterol levels and also reduce the risk of having a first or recurrent heart attack.

    In fact, while there are several types of cholesterol-lowering medications available, at this time the group of cholesterol medications called statins have been shown to be the most effective at reducing cardiovascular events. Thus, if cholesterol-lowering medications are indicated, statin therapy should be the first therapy used for preventing subsequent cardiovascular events in most individuals, especially in high-risk and very high-risk individuals. If an individual cannot tolerate one particular statin due to side effects, usually other types of statins at lower doses can be tried. Once an individual is maximized on the highest dose of statin tolerated, if their LDL cholesterol is still not at goal, another category of cholesterol medications can be added to their regimen.

    • Triglyceride (another type of lipid) levels:
      Ideal: Less than 100 mg/dL
      Normal: less than 150 mg/dL
      Borderline high: 150 to 199 mg/dL
      High: 200 to 499 mg/dL
      Very high: 500 mg/dL and higher


      Normal triglycerides are considered less than 150 mg/dL. If you're at moderate or high risk for heart disease and still have high triglycerides (despite reaching your cholesterol goal with a statin), you may require an additional medication. This includes a fibrate such as gemfibrozil (Lopid) or niacin. Fish oil and omega-3 fatty acids may also help reduce triglyceride levels.

      The main target of therapy is achieving your LDL goal. A secondary target is your non-HDL cholesterol. Non-HDL is your total cholesterol minus your HDL cholesterol. This number reflects some of the other atherogenic lipid problems, such as elevated triglycerides. The non-HDL goal is typically 30 points higher than your LDL goal. For example, if your LDL goal is less than 100 mg/dL, your non-HDL goal is less than 130 mg/dL). Specific treatment depends on your cholesterol level and other risk factors, but in general, the first stage of treatment is lifestyle changes, such as improvements in diet and exercise. If lifestyle changes don't work, statin drugs are usually tried first, and other medications may be added if necessary.

    • LDL particles. Cholesterol is carried into the vessel wall through particles called lipoproteins. Depending on its size, each particle carries different amounts of cholesterol within it. Many patients with diabetes or metabolic syndrome do not have elevated blood levels of total or LDL cholesterol, but they have elevated triglycerides and low levels of the good HDL cholesterol. This is associated with a pattern of small, dense LDL-particle size, which is linked to promoting atherosclerosis.

      A standard lipid blood test will give you the LDL level concentration but does not tell you about your total particle count. In certain cases when more information is needed to determine your risk, your doctor may order tests to measure your LDL particle size or your total LDL particle count. In a given lipid blood concentration, there will be more total particles if your particle size is small and fewer total particles if your particle size is large. There is also a test called apolipoprotein B (apoB), which is a good estimate of your total count of the bad atherogenic particles.

    Your doctor may order blood tests other than lipid levels, to determine your risk of heart disease. These include:

    • Fasting sugar (high levels may mean diabetes or prediabetes)
    • Insulin levels (high levels may mean diabetes or prediabetes)
    • Kidney function (abnormal kidney function is a risk factor for heart disease)
    • C-reactive protein (high levels of CRP suggest inflammation in the body and is a marker for increased risk of heart disease)
  3. Ankle brachial index. This simple test performed in a health care professional's office screens for peripheral arterial disease (PAD). The blood pressure reading measured in each leg is divided by the average blood pressure reading in both arms. Normally, the blood pressure in the legs is the same or higher than the blood pressure in the arms, so a value of 1 or higher is normal. An ABI of less than 0.90 suggests peripheral arterial disease. Even if you don't have any symptoms, but do have PAD, you should be treated aggressively with medical therapy because you have a higher risk for future cardiovascular events, including heart attacks and strokes.

    There are other tests that can help your health care professional determine if you have atherosclerosis. These are:

    • Coronary angiography (or arteriography). This test is used to explore the coronary arteries. A dye is injected into the artery of an arm or leg via a fine tube, or catheter that passes through the aorta into the arteries of your heart. Your heart and blood vessels are then filmed while your heart pumps. The picture that is seen, called an angiogram or arteriogram, shows any blockages caused by atherosclerosis, as well as other problems. This is an invasive test and is only used for high-risk individuals who are believed to have a good chance of having significant coronary heart disease.

      This is the most accurate way to assess the presence and severity of coronary disease. Sometimes this is done in combination with an ultrasound probe, which is passed through the catheter down into the coronary arteries. This procedure is called intravascular ultrasound or IVUS. IVUS allows for even better detail of the arterial wall to assess the severity of a lesion and the type of plaque buildup, such as "soft" plaques vs. "hard" plaques.

      You may also be injected with a fluid that blocks X-rays, called a "contrast medium" or "dye," which allows getter visibility of certain tissues. The injection may sting and leave a metallic taste in your mouth, a warm or cool sensation at the injection site and in some cases, hives. Many of these dyes are iodine-based, so you need to tell your health care professional if you are allergic to iodine.

      If your health care professional decides that you need to have an angiography, you may have to fast four to six hours before the test because of the sedative medications you receive during the test.

      If a significant blockage is found during the angiogram, the cardiologist may try to open up the blockage with a balloon with or without a stent—a process called angioplasty.
    • Imaging tests. To study your arteries to determine whether or not you have hardening or narrowing of large arteries or calcium deposits on artery walls or to determine other information about the structure or function of your heart, your doctor may use imaging techniques such as a computerized tomography (CT) scan or a magnetic resonance angiogram (MRA), a noninvasive test that gives similar information to a CT scan without using X-rays.

      A non-contrast cardiac CT can detect calcium buildup in the arteries, which is a marker of atherosclerotic plaque (calcium shows up on the CT as bright white, similar to bone, and can be seen without contrast). This is called a coronary artery calcium (CAC) score and is sometimes ordered in intermediate-risk individuals for screening when further assessment of CHD risk is needed. People with high levels of CAC have a lot of plaque in their arteries, which is associated with increased risk of cardiovascular events. If you have high CAC scores, more intensified treatment such as statins may be recommended, in addition to lifestyle changes.

      A cardiac CT with dye contrast (called a CT angiogram or CTA) can further show whether there is any narrowing or stenosis of the coronary arteries. Because CTAs have the increased risk of dye and increased radiation compared to non-contrast CTs, they are not recommended for routine screening where no symptoms are present but may be used for evaluation if you have chest pain or angina.
    • Doppler ultrasound. Your doctor may use an ultrasound tool called a Doppler ultrasound to take your blood pressure at different points on your arm or leg. By measuring these pressures, your doctor can gauge the blood flow through your arteries as well as the degree of any blockages.

    • Resting EKG. An electrocardiogram may show signs of prior heart damage such as an enlarged heart or areas of prior heart attack. For many women with angina, the EKG at rest is normal. This is not surprising because symptoms of angina occur during stress. Therefore, your heart's functioning may be tested under stress, typically exercise.

    • Exercise stress test. This test shows how well the heart functions with increased physical activity. An EKG and blood pressure are taken before, during and after the workout. Other stress tests in addition to the EKG use radionucleotide markers such as thallium, or ultrasound (echocardiography), to take pictures of the heart before and after the stress to look for changes in the heart that might suggest blockages. Usually the stress test involves running on a treadmill, but if you can't use the treadmill, the heart can be stressed using medications such as dobutamine or adenosine or some newer stress agents similar to adenosine.

    Although the CT scan, EKG and nuclear or echo stress tests may suggest blockages, the blockages can only be confirmed with a contrast coronary angiography.

Treatment

Treatment

Lifestyle changes (Diet, exercise, weight loss):

  1. Diet. Changing your dietary habits remains the single most effective way to stop atherosclerosis from progressing. Eating a diet low in saturated fat and cholesterol reduces blood cholesterol, a primary cause of atherosclerosis. Although saturated fat and trans fats are definitely bad for you, other types of fat, such as polyunsaturated fats found in fish (omega-3), nuts and flaxseed, or monounsaturated fats found in olive oil, may be good for you. Eating less saturated fat and reducing calories in general should also help you lose weight.

    In addition to watching saturated and trans fats, it is also important to watch excess sugar intake, such as sugar, honey and high fructose corn syrup, which are frequently found in sweetened beverages and desserts and also hidden in many processed foods. The body will convert excess calories such as from sugars into triglycerides as a way of storing energy. So lowering your sugar intake will also lower your triglyceride levels, in addition to your blood glucose levels.

    Reducing sodium intake is important for both the prevention and treatment of high blood pressure. The DASH (Dietary Approaches to Stop Hypertension) diet, endorsed by the major heart organizations, is one strategy for lowering high blood pressure. It is rich in lower-calorie foods such as fruits and vegetables and whole grains and low in sodium.

    The Therapeutic Lifestyle Changes (TLC) Diet plan, developed by the NHLBI calls for less than 7 percent of your calories to come from saturated fat and for less than 200 mg of dietary cholesterol. Twenty-five percent to 35 percent or fewer of total daily calories can come from fat, provided most of these calories are from unsaturated fat, which doesn't raise cholesterol. Sodium intake should be limited to no more than 2,400 mg per day. In addition, the guidelines encourage the use of certain foods rich in soluble fiber to boost the diet's LDL-lowering power.

  2. Exercise. You also can benefit from exercise. Recent research finds that even moderate amounts of physical activity are associated with lower death rates from coronary heart disease. As little as 30 minutes of moderate activity on most, and preferably all, days of the week helps protect the heart and is recommended by the American Heart Association. However, the recommendations rise to 60 to 90 minutes of moderate activity most, and preferably all, days of the week in women who need to lose or maintain weight. Examples of moderate activity are brisk walking, bicycling, raking leaves and gardening. Vigorous exercise includes running, jogging, swimming laps and cross-country skiing. Being physically fit and active provides cardiovascular benefits independent of weight loss.

    Wearing a pedometer may help you keep track of your physical activity. The American Heart Association recommends aiming for 10,000 steps a day, which is five miles (2,000 steps per mile), but all steps count. Aim to get more steps in your day by taking stairs instead of elevators, parking farther away and other small changes.

  3. Weight loss. If you are overweight, losing weight can help lower blood cholesterol levels. It is also the most effective lifestyle change to reduce high blood pressure, another risk factor for atherosclerosis and heart disease. The best way to lose weight is through a combination of diet and exercise.

Pharmacologic (drug) therapies:

  1. Anti-platelet (or blood-thinning) medications. Your doctor may prescribe an anti-platelet medication, such as aspirin or clopidogrel (Plavix) to reduce your chances of a blood clot if you have atherosclerosis or are at high risk for it.

  2. Anticoagulants. Anticoagulants, such as heparin or warfarin (Coumadin), can also help prevent clots from forming. Warfarin may be prescribed if you have heart arrhythmias called atrial fibrillation or flutter or if you have had certain types of strokes. Newer anticoagulants, such as dabigatran, rivaroxaban and apixaban, can be used in place of warfarin for certain indications like atrial fibrillation.

  3. Cholesterol-lowering therapies. Cholesterol- and triglyceride-lowering medications that may be recommended include:

    • Statins. Six statin drugs are available in the United States: atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor, Altoprev), pravastatin (Pravachol), simvastatin (Zocor) and rosuvastatin (Crestor). In addition, statins are found in the combination medications lovastatin and niacin (Advicor), atorvastatin and amlodipine (Caduet), and simvastatin and ezetimibe (Vytorin). Statins are most effective at lowering the LDL cholesterol, but they may also have modest effects on raising HDL cholesterol and lowering triglycerides. They are generally the first-line medications used.

      Make sure you talk to your health care professional to see if you are a candidate for statin therapy. If you experience any side effects such as muscle aches or dark urine, stop taking the drug immediately and call your health care professional.

    • Niacin. Niacin is a water-soluble B vitamin. Unfortunately, you can't lower your cholesterol by taking a vitamin supplement; to have such an effect, it must be taken in doses well above the daily vitamin requirement. Although nicotinic acid is inexpensive and available over the counter, never take it to lower your cholesterol without guidance from a health care professional because of potential side effects. The extended release form is available by prescription as Niaspan. It decreases triglycerides, raises HDL-cholesterol and modestly lowers LDL-cholesterol. Unfortunately, this medication causes some people to itch and flush (turn red).

    • Bile acid sequestrants. The three main bile acid sequestrants currently prescribed in the United States are cholestyramine resin (Questran), colestipol (Colestid) and colesevalam (WelChol). Available as powders, tablets or granules, these drugs work by binding with bile acids that contain cholesterol in the intestines. They can be prescribed alone or in combination with another drug.

    • Fibrates. These drugs reduce triglycerides by reducing the liver's production of LDL cholesterol and assisting in the removal of triglycerides from the blood. The most widely used fibrates in the United States are gemfibrozil (Lopid) and fenofibrate (Tricor). Fibrates are not recommended as the sole drug therapy for women with heart disease for whom LDL cholesterol reduction is the main goal.

    • Cholesterol absorption inhibitors. This class of drugs lowers cholesterol by preventing it from being absorbed in the intestine. The first approved drug in this class is ezetimibe (Zetia). It may be used alone or together with a statin.

    • Omega-3 fatty acids. Omega-3 fatty acids such as fish oil may be help raise HDL cholesterol and lower elevated triglycerides. It can be given in a prescription form or over the counter.

Drugs for peripheral arterial disease

If you have severe pain or cramping in your legs when you walk, your health care professional may recommend clopidogrel (Plavix), cilostazol (Pletal) or pentoxifylline (Trental). Cilostazol is generally avoided in individuals with congestive heart failure.

If you take medication to improve your cholesterol, lower blood pressure or treat other heart disease symptoms, be sure to ask about potential side effects; interactions with other medications, food or beverages; and when and how you should take the prescribed medications.

Revascularization procedures for atherosclerosis

In the past, opening arteries damaged by atherosclerosis around the heart meant performing bypass surgery (open heart surgery), requiring that the chest be opened surgically and blood flow redirected around the damaged artery. Now, alternatives to open heart surgery, such as balloon angioplasty, allow for a quicker, less painful recovery. However, not everyone is a candidate for balloon angioplasty and some people still require surgery. Also, not everyone with atherosclerosis requires opening the arteries with angioplasty. Some individuals with stable coronary artery disease and stable angina may be candidates for treatment with aggressive medical therapy alone. These decisions depend on the individual, the types of blockages, the results of stress testing, the severity of symptoms and other factors.

  • Coronary angioplasty or balloon angioplasty. Your health care professional will first perform a coronary angiogram to see which arteries are blocked. Through a catheter (or tube) in your leg (femoral) or arm (brachial) artery, a catheter will be advanced to the heart and dye will be injected into the coronary arteries. If angioplasty is indicated, the cardiologist will position a catheter with a tiny balloon on its tip in the narrowed coronary. The balloon is inflated and deflated to stretch or break open the narrowing and improve the passage for blood flow. Typically, your doctor will insert a stent, a small scaffolding designed to prop the artery open. As the balloon inflates, it expands the stent. Angioplasty is not surgery, and it is performed while you are awake. It typically takes about one or two hours. But there is recovery time which generally involves laying flat for three to six hours after the procedure to allow the leg (or arm) artery to heal to prevent bleeding.

    If angioplasty doesn't widen the artery or if complications occur, bypass surgery may be needed. Patients with certain types of blockages may not be candidates for angioplasty and may be referred for bypass surgery.

    One continuing challenge cardiologists face in treating atherosclerosis is that plaque deposits may return (a condition referred to as restenosis). Even patients who've had angioplasties sometime require future treatments to widen arteries clogged with new blockage. Today, new drug-coated stents markedly decrease the rates of restenosis compared to the older generation of stents. Additionally, new drugs and new types of stents are in development, and the future is promising for advancements in this area.

  • Atherectomy. Coronary atherectomy is a procedure that removes plaque from the arteries that supply the heart muscle using a rotating shaver or laser catheter. Atherectomy may be followed with stenting or balloon angioplasty.

  • Endarterectomy. This surgical procedure, performed under general anesthesia, removes plaque from your arteries. For your carotid arteries, the surgeon makes a cut in your neck, opens the artery there, and removes plaque until the inside of the artery is clean and smooth.

  • Thrombolytic therapy. If a blood clot is blocking an artery, your doctor may insert a drug directly into that artery at the point of blockage to break up the clot at the time of angiography. During an acute heart attack, if angioplasty is not immediately available at your hospital, doctors may give thrombolytic therapy vein to break up clots in your body. There are some risks to thrombolytic therapy including bleeding in the brain. Thus if angioplasty is available, this is generally preferred to systemic thrombolytic therapy for heart attacks.

  • Coronary artery bypass. In this surgery, a blood vessel (usually taken from the leg, arm or chest) is sewn onto the blocked artery so blood can bypass the blocked area. Several bypasses can be performed if several arteries are blocked. Bypass surgery relieves symptoms of heart disease but does not cure it. You will still need to make lifestyle changes like those described earlier and take medications.

Prevention

Prevention

Try to follow these tips to prevent atherosclerosis:

  • Quit smoking. Smoking accelerates the development of atherosclerosis, which often leads to coronary heart disease. Women who smoke are two to six times as likely to suffer a heart attack as nonsmoking women, and the risk increases with the number of cigarettes smoked per day. The good news is that quitting dramatically cuts your risk, even during the first year, no matter what your age.

  • Lower your blood pressure. Even slightly high blood pressure levels can double your risk for heart disease. Normal blood pressure is less than 120/80 mm Hg. High blood pressure, or hypertension, is a blood pressure reading of 140/90 mm Hg or higher. Between 120/80 mm/Hg and 139/89 mmHg is considered prehypertension.

    High blood pressure also increases your chance of stroke, congestive heart failure and kidney disease. High blood pressure can be treated successfully with medication. Commonly prescribed drugs include diuretics, angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers, beta blockers and calcium channel blockers (CCBs).

    If your blood pressure is not too high, you may be able to control it entirely through weight loss (if you are overweight), regular physical activity and cutting down on alcohol, as well as salt and sodium. Sodium is an ingredient in salt that is found in many packaged foods, carbonated beverages, baking soda and some antacids.

  • Get regular exercise and lose weight. Fortunately, it doesn't take a lot of time or effort to become physically active. As little as 30 minutes of moderate activity on most, and preferably all, days of the week helps protect the heart and is recommended by the American Heart Association. The recommendations rise to 60 to 90 minutes of moderate activity most, and preferably all, days of the week in women who need to lose or maintain weight. Examples of moderate activity are brisk walking, bicycling, raking leaves and gardening. Vigorous exercise includes running, jogging, swimming laps and cross-country skiing.

    You can divide the 30 to 90 minutes of moderate activity into shorter periods of at least 10 minutes each. If you already engage in this level of activity, you can get added benefits by doing more.

  • Control your blood sugar if you have diabetes. Diabetes is typically diagnosed by a fasting glucose (sugar) over 125 mg/dL. Patients with diabetes should be treated to prevent complications from cardiovascular disease; treatment typically consists of a combination of lifestyle changes and medications. Your goal hemoglobin A1C with treatment should be less than 7 percent. Those with diabetes who also have good sugar control are much less likely to develop cardiovascular complications than those with poor sugar control.

    Those individuals with a fasting glucose (sugar) of 100 to 125 mg/dL may be considered prediabetes or glucose intolerant. This is often associated with metabolic syndrome, and individuals with glucose intolerance are at high risk for developing true diabetes within the next 10 years. Weight loss, healthy diet and exercise are important to improve blood sugar levels and prevent the onset of diabetes.

  • Lower your LDL-cholesterol level. According to the Centers for Disease Control and Prevention, about one in every six adults—or 16.3 percent of the United States adult population—has high total cholesterol. More women have high cholesterol than men.

  • Keep triglycerides in check. The lipoprotein profile that determines your cholesterol levels also measures another fatty substance called triglyceride. Produced in the liver, triglycerides are made up of saturated, polyunsaturated and monounsaturated fats. The optimal target triglyceride level for individuals without heart disease or heart disease-related risk factors is less than 100 mg/dL.

    For most people, cutting back on foods high in saturated fat and cholesterol and eating more fiber will lower both total and LDL cholesterol. Regular physical activity and weight loss if you're overweight also reduces blood cholesterol levels. Losing extra weight, quitting smoking and becoming more physically active may also help boost HDL cholesterol levels. Losing weight, exercising and cutting back on sugar intake can help lower triglycerides.

Facts to Know

Facts to Know

  1. Atherosclerosis is often the first stage of coronary heart disease.

  2. Diseases caused by atherosclerosis are the leading cause of illness and death in the United States.

  3. Atherosclerosis occurs when your arteries narrow and become less flexible because cholesterol, fatty substances, cell waste products, calcium and fibrin—collectively called plaque—collect on their inner walls. The arteries respond to the buildup by becoming inflamed, causing scar tissue and other cells to form in the affected areas, further narrowing the artery.

  4. What causes plaque to begin building up isn't known. Some experts think plaque begins to accumulate in places where the inner layer of an artery becomes damaged, possibly by elevated cholesterol levels, elevated triglyceride levels, high blood pressure or cigarette smoke.

  5. A woman's risk of developing atherosclerosis and heart disease increases as she ages. Prior to menopause, estrogen produced in the ovaries provides some protection from heart disease. However, hormone replacement in women after menopause does not reduce the risk of cardiovascular disease. And remember that women with diabetes or those who smoke are at risk for heart disease throughout their lives.

  6. Atherosclerosis can affect medium and large arteries anywhere in your body, restricting blood flow and limiting the amount of oxygen available to organs.

  7. Smoking accelerates the development of atherosclerosis, increases blood pressure and restricts the amount of oxygen the blood supplies to the body.

  8. Changing lifestyle habits remains the single most effective way to stop the atherosclerosis from progressing. Changing your diet to one low in fat, especially saturated fat, and cholesterol helps reduce high blood cholesterol, a primary cause of atherosclerosis.

  9. If you're overweight, losing weight can help lower blood cholesterol. It is the most effective lifestyle change for reducing high blood pressure, another risk factor for atherosclerosis and heart disease.

  10. High blood pressure, smoking, high cholesterol, elevated triglycerides, obesity, diabetes and lack of exercise jeopardize the function of the major heart arteries and are particularly threatening to women's health.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about atherosclerosis so you're prepared to discuss this important health issue with your health care professional.

  1. Do I have atherosclerosis (hardening of the arteries)? What tests can you order to find out?

  2. How does high cholesterol put me at risk for atherosclerosis? Is my blood cholesterol level too high?

  3. What can I do besides taking medication to improve my health and lower my risk for atherosclerosis?

  4. What medications can help lower my risk for atherosclerosis? What are they called and what do these medications do?

  5. What are the side effects of the medications you're recommending? Will they interact with any other medications that I am taking?

  6. What are the warning signs of a heart attack? What should I do if I think I'm having a heart attack?

  7. How does atherosclerosis affect my risk for a heart attack, angina or other heart problems? How often should I have my arteries, cholesterol level, blood pressure and heart checked?

  8. Can I still exercise? Will it do any harm to my arteries or my heart? What kind is best for me and how often should I exercise?

  9. What are angioplasty, atherectomy and endarterectomy? Are these appropriate options for me?

  10. What is bypass surgery? Can it help me?

Key Q&A

Key Q&A

  1. What is atherosclerosis?

    Often referred to as "hardening of the arteries," atherosclerosis occurs when your arteries narrow and become less flexible because cholesterol, fatty substances, cell waste products, calcium and fibrin—collectively called plaque—collect on their inner walls. The arteries respond to the buildup by becoming inflamed. This causes scar tissue to form and other cells to collect in the affected areas, further narrowing the artery. Atherosclerosis is a form of arteriosclerosis, which is a general term for the natural hardening of your arteries that happens with age.

  2. What causes plaque to build up?

    We don't know. Some experts think plaque accumulates in places where the inner layer of an artery is damaged, possibly by elevated cholesterol levels, elevated triglyceride levels, elevated blood glucose, high blood pressure and cigarette smoke. Smoking especially accelerates the development of atherosclerosis as well as increasing blood pressure and restricting the amount of oxygen the blood supplies to the body. Diabetes is also a major risk factor, and stress has also been implicated, although its exact association with heart disease has not been determined. There are also genetic factors that predispose individuals to early atherosclerosis.

  3. Will I know I have atherosclerosis by recognizing the symptoms?

    Not necessarily. Often the disease progresses for a long while before complications or symptoms arise. However, there are some conditions that may hint at an atherosclerosis diagnosis, including chest pain, or angina. However, it is estimated that two-thirds of women who die suddenly from coronary heart disease had no prior symptoms. Therefore it is important that you get screened for cardiovascular disease risk factors and treated as appropriate because waiting for symptoms to develop may be too late.

  4. What can I do to prevent atherosclerosis?

    Changing your habits remains the single most effective way to stop the disease from progressing. Changing your diet to one low in saturated fat and cholesterol helps reduce high blood cholesterol, a primary cause of atherosclerosis. A moderate amount of the healthier polyunsaturated and monounsaturated fats such as in fish, nuts and olive oil may be helpful but be aware of total calories consumed per day. Eating less sugar and eating a diet enriched in fruits, vegetables and fiber should also help you lose weight. If you are overweight, losing weight can help lower blood cholesterol and is the most effective lifestyle way to reduce high blood pressure, another risk factor for atherosclerosis and heart disease. You also can benefit from exercise.

  5. Is atherosclerosis dangerous?

    Yes! As the disease progresses, it can completely clog arteries, cutting off blood flow. This is especially dangerous in arteries near the brain, the heart or other vital organs. Completely or nearly blocked blood flow to the heart can lead to a heart attack and kill muscle cells in the heart. The result is permanent heart damage. Plaque may also break loose suddenly and travel through the bloodstream to your brain or heart, causing a stroke or a heart attack.

  6. Which arteries are most at risk for atherosclerosis?

    Although atherosclerosis can affect medium and large arteries anywhere in your body, those going to your brain (carotid), heart (coronary) and legs (femoral or iliac) are most at risk.

  7. How quickly does atherosclerosis occur?

    While atherosclerosis typically progresses gradually—sometimes even starting in childhood—you are most at risk when arterial blockage builds up quickly, completely closing off an artery. This can happen if plaque ruptures and a clot forms.

  8. Does my risk increase as I age?

    Yes! Prior to menopause, women are somewhat protected from heart disease, in part, by estrogen produced by the ovaries. The body's own natural estrogen helps keep your arteries free from plaque by improving the ratio of LDL (low-density lipoprotein) and HDL (high-density lipoprotein) cholesterol. It also increases the amount of HDL cholesterol, which helps clear LDL cholesterol—the kind that most contributes to plaque buildup—from the bloodstream. However, supplemental estrogen or estrogen therapy is not recommended after menopause to prevent against atherosclerosis and heart disease. Also, if you have a family history of early heart disease or if you have diabetes or smoke, you are at risk for heart disease even before menopause.

    Although risk increases with age, atherosclerosis is a process that develops over years, so don't put off making lifestyle changes until you are older because it may be too late. It is important to start with heart-healthy habits in youth and middle age to prevent complications later in life. Adults with even one major risk factor for heart disease by the age of 50 have an increased lifetime risk of cardiovascular disease and shorter median survival compared to adults with no risk factors.

Organizations and Support

Organizations and Support

For information and support on coping with Atherosclerosis, please see the recommended organizations and Spanish-language resources listed below.

American College of Cardiology (ACC)
Web Site: http://www.acc.org
Address: Heart House
2400 N Street, NW
Washington, DC 20037
Hotline: 1-800-253-4636
Phone: 202-375-6000
Email: resource@acc.org

American Heart Association (AHA)
Web Site: http://www.americanheart.org
Address: 7272 Greenville Avenue
Dallas, TX 75231
Hotline: 1-800-AHA-USA-1 (1-800-242-8721)
Email: Review.personal.info@heart.org

National Heart, Lung, and Blood Institute (NHLBI) - NHLBI Health Information Center
Web Site: http://www.nhlbi.nih.gov
Address: Attention: Web Site
P.O. Box 30105
Bethesda, MD 20824-0105
Phone: 301-592-8573
Email: nhlbiinfo@nhlbi.nih.gov

Pulmonary Hypertension Association
Web Site: http://www.phassociation.org
Address: 801 Roeder Road, Suite 400
Silver Spring, MD 20910
Hotline: 1-800-748-7274
Phone: 301-565-3004
Email: adrienne@phassociation.org

Sister to Sister: The Women's Heart Health Foundation
Web Site: http://www.sistertosister.org
Address: 4701 Willard Avenue, Suite 223
Chevy Chase, MD 20815
Hotline: 1-888-718-8033
Phone: 301-718-8033
Email: webmaster@sistertosister.org

Society of Interventional Radiology
Web Site: http://www.sirweb.org
Address: 3975 Fair Ridge Drive, Suite 400 North
Fairfax, VA 22033
Hotline: 1-800-488-7284
Phone: 703-691-1805
Email: info@sirweb.org

Vascular Disease Foundation
Web Site: http://www.vdf.org
Address: 1075 S. Yukon, Suite 320
Lakewood, CO 80226
Hotline: 888.VDF.4INFO (888.833.4463)
Phone: 303-989-0500
Email: info@vdf.org

WomenHeart: National Coalition for Women with Heart Disease
Web Site: http://www.womenheart.org
Address: 818 18th Street, NW, Suite 930
Washington, DC 20006
Hotline: 877-771-0030
Phone: 202-728-7199
Email: mail@womenheart.org

Women's Health Initiative (WHI)
Web Site: http://www.nhlbi.nih.gov/whi
Address: 2 Rockledge Centre
Suite 10018, MS 7936 6701 Rockledge Drive
Bethesda, MD 20892
Phone: 301-402-2900
Email: nihinfo@od31tm1.od.nih.gov

Women's Heart Foundation
Web Site: http://www.womensheart.org
Address: P.O. Box 7827
West Trenton, NJ 08628
Phone: 609-771-9600

Rural Nurse Organization Digital Library, Part of the UA CCHS Health Sciences Library Digital Libraries Program
Website: http://www.nlm.nih.gov/medlineplus/spanish/ency/article/000171.htm
Email: custserv@nlm.nih.gov

American Heart Association
Website: http://esamericanheart.convertlanguage.com/presenter.jhtml?identifier=3053186
Address: National Center Mailing Addresses
American Heart Association National Center
7272 Greenville Avenue
Dallas, TX 75231
Phone: 1-800-242-8721
Email: Review.personal.info@heart.org

Last date updated: 
Thu, 2012-05-10

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Last date updated: 2012-05-10