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Atherosclerosis
8 Atherosclerosis: The acute, chronic, recovery and prevention stages Chapter Objectives 1. Introduce atherosclerosis as a disease seen in integrative cardiovascular Chinese medicine. 2. Understand the history and physical examination procedures for monitoring atherosclerosis. 3. Introduce the methods of differential diagnoses. 4. Introduce treatment approaches according to Western medicine. 5. Introduce traditional Chinese medicine formulas for atherosclerosis. 6. Introduce nutritional supplements for atherosclerosis. 7. Introduce pharmaceutical drugs for atherosclerosis. 8. Discuss a perspective for treating patients with traditional Chinese herbal medicine, nutritional supplements, and/or pharmaceutical drugs in the acute and chronic stages. 9. Discuss a perspective for treating patients with traditional Chinese herbal medicine, nutritional supplements, and/or pharmaceutical drugs in the recovery and prevention stages.
Background Atherosclerosis is the diseased condition of the arteries around the heart and in the peripheral body. Atheroma is a soft substance made up of cholesterol and other substances found in the blood. It builds on the artery walls over decades, eventually reducing or blocking the flow of oxygenated blood. Hardened atheromas are often called plaque. Due to blood flow turbulence and other factors, the plaque can break. Breakage of the plaque can spill the soft sticky center content into the artery, causing cell fragments and platelets to stick to the content and form clots. Rapid buildup blocks blood flow, causing occlusion of the artery. Herbal, Bio-nutrient and Drug Titration According to Disease Stages in Integrative Cardiovascular Chinese Medicine. https://doi.org/10.1016/B978-0-12-817580-4.00008-1 Copyright © 2020 Elsevier Inc. All rights reserved.
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Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
• • • • • • •
•
• •
Composition of plaque: Cholesterol Atheromas Triglycerides Calcium Elastin White blood cells Main areas of blockage within the body: Coronary arteries: • Supply blood to the heart • Complete blockage causes myocardial infarction/heart attack • Aorta • Left coronary artery - Left descending artery - Circumflex artery • Right coronary artery - Right posterior descending artery - Descending artery - Acute marginal artery Carotid artery: • Supply blood to the head • Complete blockage causes ischemic or hemorrhagic stroke • Internal carotid artery - Scalp - Face - Neck • External carotid artery - Brain Renal artery: • Hypertension, increased urine protein, decreased kidney function, and foot and ankle edema Peripheral arteries: • Blockage causes numbness and pain • Arms - Brachial artery - Radial artery - Ulnar artery - Palmar arch • Legs - Iliac arteries - Femoral arteries - Popliteal arteries - Tibial arteries - Dorsalis pedis arteries
Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Patients who are not recommended or are not indicated for statin drugs will visit the traditional Chinese medicine (TCM) physician for cholesterol-lowering remedies. Obvious treatment principles are to balance yin and yang, clear heat, transform turbidity, expel toxins, dispel phlegm, and invigorate blood.
History and physical examination Patients will most likely have a history of:
Lipid levels • High LDL cholesterol and low HDL cholesterol • High triglycerides • Bacteroides: Gram-negative rod bacteria found in the gastrointestinal biome, soil, and seawater
Blood pressure • Sustained 140/90 mmHg and climbing higher • 130/80 mmHg or higher with diabetes
Inflammation • • • •
High C-reactive protein result Injury to arteries walls High blood sugar levels: diabetes and insulin resistance Insulin resistance
Genetics • Familial hypercholesterolemia types I, II, III, and IV History of stroke or myocardial infarction or presymptoms warning of future event: • Tight chest, neck, jaw, left arm, or shoulder blade area of the back • Severe fatigue • Severe headache • Clammy skin or cold sweat • Nausea or vomiting • Inability to breathe • Numbness or inability to move the face, arm, or leg on one side of the body • Trouble speaking • Trouble seeing • Dizziness and loss of balance leading to falling • Loss of consciousness
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Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Physical examination with confirming evidence: • Patient reports brain fog and forgetfulness when answering questions • Potential for hyperthyroid on palpation • Possible xanthomas around the eyes • Rapid weight gain and palpation of fatty areas around the waist and hips • Numbness and tingling of the arms, hands, legs, and feet • Blood pressure sustaining at 140/90 or above consistently over several office visits • Positive stress test and nuclear stress test results
Differential diagnosis Lab test
Detection
C-reactive protein Triglycerides Cardiac stress testing
Detects inflammation, a strong predictor of cardiovascular disease High levels suggest probability of atheromas forming in the arteries Performing exercise while connected to EKG to detect QRSPR changes that indicate reduction in oxygenation to the heart Sending a tube catheter through the femoral artery or radial artery to the main arteries of the heart to help detect blockages on X-ray
Angiogram/percutaneous intervention
Treatment approaches In both TCM and western medicine, the treatment goals for atherosclerosis include: • Relieving symptoms associated with clogged arteries • Assisting patients with lifestyle changes to reduce or eliminate risk factors and improve life quality • Reducing the risk and creation of atheromas, blood clots, and buildup of plaque • Monitoring symptoms of bacterial- and viral-causing illnesses • Preventing diseases associated with atherosclerosis • Widening or bypassing diseased arteries Treatments for atherosclerosis include herbal medicines and/ or pharmaceutical drugs, medical procedures, or surgery.
Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Coronary artery bypass grafting CABG is a surgical procedure for helping a patient improve chances of survival. It is a last resort effort used for end-stage diseased coronary arteries or arteries of the legs. The diseased arteries are not removed. Healthy arteries or veins are selected and harvested from other areas of the body and attached at safe distances around the diseased and narrowed arteries so that blood can bypass it and flow.
Traditional Chinese medicine
Traditional Chinese medicine formulas for arrhythmia Herbal medicine Yue jian cao you jiao wan Bao jian mei jian fei cha Pu ji xiao du yin wan Gan mao ling Xi huang wan Zhi gan cao decoction Shen fu decoction Gui pi decoction
Action Invigorates blood, dispels phlegm Invigorates blood, dispels phlegm Clears toxic bacterial and viral heat Clears toxic bacterial and viral heat Clears heat, invigorates blood, protects the heart Recovers from illness, regulates heart functioning Recovers after an illness, warms yang Nourishes blood
Nutritional supplements Alpha lipoic acid Nutritional constituents: Lipoic acid Benefits: Targets nerve cells, kidney, liver, lowers blood pressure, prevents cell damage to improve insulin use Caution: May lower blood sugar too much; avoid in pregnancy and nursing
Cod liver oil Nutritional constituents: Vitamins A, D, and omega-3 fatty acids (fish oils, flax seed, primrose, borage, and flaxseed oils) Benefits: Reduces cardiometabolic risk factors, protects sudden cardiac death after myocardial infarction, reduces raised
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Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
plasma triglycerides, reduces blood pressure, and ameliorates atherogenic effects Caution: High doses required for reduction of blood pressure may have side effects.
Coenzyme Q-10 Nutritional constituents: CoQ10 Benefits: Heart, muscle, liver, and lungs; improves glycemic index, myocardial energy Caution: Body stores reduced when glyburide is prescribed for diabetes
Chromium Nutritional constituents: Picolinate, chloride, and nicotinate Benefits: pancreatic functioning and blood sugar Caution: May lower blood sugar excessively, causing concerns with medication indications
Magnesium Nutritional constituents: Citrate, stearate, and sulfate forms Benefits: Heart, kidneys, and muscle; improves type 2 insulin utilization in elderly Caution: May induce excessive stool elimination and diarrhea in patients at risk of inflammatory bowel disorders
Niacin Nutritional constituents: Vitamin B3 Benefits: Reduction of overall cholesterol levels, lowers triglycerides, increases HDL Caution: May cause nausea, may increase blood sugar levels, and may cause a prickly, flushing sensation on the skin
Potassium Nutritional constituents: Citrate Benefits: Cell membranes, reduces blood pressure Caution: May cause sodium retention and increased blood pressure
Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Selenium Nutritional constituents: Chelate Benefits: Small intestine and kidneys; helps protect nerves and vessels from excessive sugar intake damage Caution: Low levels may predispose to cancer, diabetes, and coronary artery disease
Vitamin B6 and Folic acid Nutritional constituents: Pyridoxine and folate Benefits: Liver, jejunum, ileum, and kidney; combined with B12 helps prevent stroke and loss of limbs and vision due to diabetes Caution: Excessive use of B6 may cause disfiguring skin lesions or folic acid nerve damage.
Vanadium Nutritional constituents: Sulfates and chelates Benefits: Liver and muscle cells to utilize insulin Caution: Nausea and cramping leading to diarrhea
Zinc Nutritional constituents: Picolinate Benefits: Production, storage, and secretion of insulin; blood sugar diffuse into cells Caution: May cause headache, nausea, vomiting, and drowsiness
Pharmaceutical drugs Atherosclerosis Ezetimibe: This drug reduces absorption of cholesterol in the small intestines and reduces LDL levels.
Bile acid sequestrants These drugs bind to bile acids in the small intestines to lower the acid, because it requires cholesterol to create it.
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Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Prescription plant sterols These drugs are called proprotein convertase substilisin kexin type 9 inhibitors and contain omega 3s. They are used by patients who need to lower triglyceride and cholesterol levels to reduce stroke and myocardial infarction risk but cannot take statin drugs.
Reduce blood clots Antiplatelets and aspirin are blood thinners, which prevent blood from forming atheromas and other clots. Clopidogrel is used to prevent clots from forming inside of artery stents. Ticagrelor and prasugrel are drugs used to prevent clots from forming inside of artery stents. They can be taken with aspirin.
Statins These drugs lower LDL and triglyceride levels and raise HDL levels. They decrease inflammation and help reduce the size of plaque. However, they may cause liver and kidney failure and muscle disorders.
Fibrates These drugs lower LDL and triglyceride levels and raise HDL levels.
Drugs to reduce high blood pressure Adrenergic agent This drug is for mild hypertension and is often used with other antihypertensive drugs for more severe hypertension.
Aldosterone antagonists These selective drugs compete with aldosterone receptor sites, reducing blood pressure and sodium reabsorption.
Alpha blockers These drugs selectively block postsynaptic alpha1 -adrenergic receptors and lower blood pressure by dilating arterioles and veins. Side effects include dizziness, headache, and drowsiness, in addition to orthostatic and first-dose hypotension.
Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Angiotensin converting enzyme Inhibitors These drugs are used in patients with hypertension, chronic kidney disease, and proteinuria. They suppress the reninangiotensin-aldosterone system by preventing the conversion of angiotensin I to angiotensin II and blocking the major pathway of the degradation of bradykinin by inhibiting angiotensinconverting enzymes (ACEs). They are often considered strong when used alone without a diuretic but can be combined with one.
Angiotensin Receptor blockers These drugs are primarily used when a patient is unable to tolerate ACE inhibitors. They block the binding of angiotensin II to angiotensin type I receptors, reduce effects of angiotensin IIeinduced vasoconstriction, reduce sodium retention, and reduce aldosterone release. Angiotensin receptor blockers are used alone or often combined with a diuretic.
Beta blockers See Chapter 11.
Calcium channel blockers These drugs are either dihydropyridines or nondihydropyridines. Some bind to L-type calcium channels, causing vasodilatation and a decrease in blood pressure. Others bind to L-type calcium channels in the sinoatrial and atrioventricular node. These drugs are often suggested for American patients of distant African ancestry and the elderly.
Acute and chronic stages Patients at risk for life-threatening symptoms associated with atherosclerosis should be treated only with western medicine methods and approaches. One main reason is for diagnostic and follow-up monitoring of sudden death. Another reason is because patients indicated for blood thinners have an increased risk of bleeding and must use caution in diet and lifestyle, and many herbal formulations will enhance the effects of the drug to dangerous levels. For many patients, medication and lifestyle changes can reduce the health risk and may help them become indicated for the benefits of nutritional supplements and herbal medicines in the future.
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Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Recovery and prevention stages Patients who are at a lower risk due to lipid imbalances and obesity, yet are not indicated for drug therapy, and those not indicated for statin therapy may benefit from natural medicine for prevention. Patients who become stabilized after treatment using western medicine methods and approaches may be indicated for natural medicine in the recovery stages. These patients may also notice immune benefits of natural remedies for bacterial and viral infections and herbal medicines that help build energy and well-being after illness. Laboratory studies would continue to monitor progress, especially for patients still at risk of adverse health chances due to heart or vessel injuries during the chronic stages.
Further reading Bi Y, Chen J, Hu F, Liu J, Li M, Zhao L. M2 macrophages as a potential target for antiatherosclerosis treatment. Neural Plast. 2019;2019:6724903. https:// doi.org/10.1155/2019/6724903. Published 2019 Feb 21. Ehrlich KC, Lacey M, Ehrlich M. Tissue-specific epigenetics of atherosclerosisrelated ANGPT and ANGPTL genes. Epigenomics. 2019;11(2):169e186. https://doi.org/10.2217/epi-2018-0150. Han J, Wang Y, Yuan Z, et al. Nonalcoholic fatty liver disease represents a greater metabolic burden in patients with atherosclerosis: A cross-sectional study. Medicine (Baltimore). 2019;98(11):e14896. https://doi.org/10.1097/ MD.0000000000014896. Huang Y, Hu H, Liu L, et al. Interleukin-12p35 deficiency reverses the Th1/Th2 Imbalance, aggravates the Th17/Treg imbalance, and ameliorates atherosclerosis in ApoE-/- mice. Mediators Inflamm. 2019;2019:3152040. https://doi.org/10.1155/2019/3152040. Published 2019 Apr 10. Kim SM, Huh JW, Kim EY, et al. Endothelial dysfunction induces atherosclerosis: increased aggrecan expression promotes apoptosis in vascular smooth muscle cells. BMB Rep. 2019;52(2):145e150. https://doi.org/10.5483/ BMBRep.2019.52.2.282. Lietava J, Beerova N, Klymenko SV, Panghyova E, Varga I, Pechanova O. Effects of cornelian cherry on atherosclerosis and its risk factors. Oxid Med Cell Longev. 2019;2019:2515270. https://doi.org/10.1155/2019/2515270. Published 2019 Feb 17. Marchio P, Guerra-Ojeda S, Vila JM, Aldasoro M, Victor VM, Mauricio MD. Targeting early atherosclerosis: a focus on oxidative stress and inflammation. Oxid Med Cell Longev. 2019;2019:8563845. https://doi.org/10.1155/2019/ 8563845. Published 2019 Jul 1. Onat UI, Yildirim AD, Tufanli Ö, et al. Intercepting the lipid-induced integrated stress response reduces atherosclerosis. J Am Coll Cardiol. 2019;73(10): 1149e1169. https://doi.org/10.1016/j.jacc.2018.12.055. Summerhill VI, Grechko AV, Yet SF, Sobenin IA, Orekhov AN. The atherogenic role of circulating modified lipids in atherosclerosis. Int J Mol Sci. 2019; 20(14):3561. https://doi.org/10.3390/ijms20143561. Published 2019 Jul 20.
Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
€ ller M, et al. G-protein coupled receptor van der Vorst EPC, Peters LJF, Mu targeting on myeloid cells in atherosclerosis. Front Pharmacol. 2019;10:531. https://doi.org/10.3389/fphar.2019.00531. Published 2019 May 22. Yang L, Gao C. MiR-590 inhibits endothelial cell apoptosis by inactivating the TLR4/NF-kB pathway in atherosclerosis. Yonsei Med J. 2019;60(3):298e307. https://doi.org/10.3349/ymj.2019.60.3.298. Yu H, Ma S, Sun L, Gao J, Zhao C. TGF-b1 upregulates the expression of lncRNAATB to promote atherosclerosis. Mol Med Rep. 2019;19(5):4222e4228. https://doi.org/10.3892/mmr.2019.10109. Zhou Z, Chen Y, Zhang D, et al. MicroRNA-30-3p suppresses inflammatory factor-induced endothelial cell injury by targeting TCF21. Mediators Inflamm. 2019;2019:1342190. https://doi.org/10.1155/2019/1342190. Published 2019 Jul 2. Zhu J, Nelson K, Toth J, Muscat JE. Nicotine dependence as an independent risk factor for atherosclerosis in the National Lung Screening Trial. BMC Public Health. 2019;19(1):103. https://doi.org/10.1186/s12889-019-6419-8. Published 2019 Jan 22.
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Background Atherosclerosis is the diseased condition of the arteries around the heart and in the peripheral body. Atheroma is a soft substance made up of cholesterol and other substances found in the blood. It builds on the artery walls over decades, eventually reducing or blocking the flow of oxygenated blood. Hardened atheromas are often called plaque. Due to blood flow turbulence and other factors, the plaque can break. Breakage of the plaque can spill the soft sticky center content into the artery, causing cell fragments and platelets to stick to the content and form clots. Rapid buildup blocks blood flow, causing occlusion of the artery. Herbal, Bio-nutrient and Drug Titration According to Disease Stages in Integrative Cardiovascular Chinese Medicine. https://doi.org/10.1016/B978-0-12-817580-4.00008-1 Copyright © 2020 Elsevier Inc. All rights reserved.
105
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Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
• • • • • • •
•
• •
Composition of plaque: Cholesterol Atheromas Triglycerides Calcium Elastin White blood cells Main areas of blockage within the body: Coronary arteries: • Supply blood to the heart • Complete blockage causes myocardial infarction/heart attack • Aorta • Left coronary artery - Left descending artery - Circumflex artery • Right coronary artery - Right posterior descending artery - Descending artery - Acute marginal artery Carotid artery: • Supply blood to the head • Complete blockage causes ischemic or hemorrhagic stroke • Internal carotid artery - Scalp - Face - Neck • External carotid artery - Brain Renal artery: • Hypertension, increased urine protein, decreased kidney function, and foot and ankle edema Peripheral arteries: • Blockage causes numbness and pain • Arms - Brachial artery - Radial artery - Ulnar artery - Palmar arch • Legs - Iliac arteries - Femoral arteries - Popliteal arteries - Tibial arteries - Dorsalis pedis arteries
Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Patients who are not recommended or are not indicated for statin drugs will visit the traditional Chinese medicine (TCM) physician for cholesterol-lowering remedies. Obvious treatment principles are to balance yin and yang, clear heat, transform turbidity, expel toxins, dispel phlegm, and invigorate blood.
History and physical examination Patients will most likely have a history of:
Lipid levels • High LDL cholesterol and low HDL cholesterol • High triglycerides • Bacteroides: Gram-negative rod bacteria found in the gastrointestinal biome, soil, and seawater
Blood pressure • Sustained 140/90 mmHg and climbing higher • 130/80 mmHg or higher with diabetes
Inflammation • • • •
High C-reactive protein result Injury to arteries walls High blood sugar levels: diabetes and insulin resistance Insulin resistance
Genetics • Familial hypercholesterolemia types I, II, III, and IV History of stroke or myocardial infarction or presymptoms warning of future event: • Tight chest, neck, jaw, left arm, or shoulder blade area of the back • Severe fatigue • Severe headache • Clammy skin or cold sweat • Nausea or vomiting • Inability to breathe • Numbness or inability to move the face, arm, or leg on one side of the body • Trouble speaking • Trouble seeing • Dizziness and loss of balance leading to falling • Loss of consciousness
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Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Physical examination with confirming evidence: • Patient reports brain fog and forgetfulness when answering questions • Potential for hyperthyroid on palpation • Possible xanthomas around the eyes • Rapid weight gain and palpation of fatty areas around the waist and hips • Numbness and tingling of the arms, hands, legs, and feet • Blood pressure sustaining at 140/90 or above consistently over several office visits • Positive stress test and nuclear stress test results
Differential diagnosis Lab test
Detection
C-reactive protein Triglycerides Cardiac stress testing
Detects inflammation, a strong predictor of cardiovascular disease High levels suggest probability of atheromas forming in the arteries Performing exercise while connected to EKG to detect QRSPR changes that indicate reduction in oxygenation to the heart Sending a tube catheter through the femoral artery or radial artery to the main arteries of the heart to help detect blockages on X-ray
Angiogram/percutaneous intervention
Treatment approaches In both TCM and western medicine, the treatment goals for atherosclerosis include: • Relieving symptoms associated with clogged arteries • Assisting patients with lifestyle changes to reduce or eliminate risk factors and improve life quality • Reducing the risk and creation of atheromas, blood clots, and buildup of plaque • Monitoring symptoms of bacterial- and viral-causing illnesses • Preventing diseases associated with atherosclerosis • Widening or bypassing diseased arteries Treatments for atherosclerosis include herbal medicines and/ or pharmaceutical drugs, medical procedures, or surgery.
Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Coronary artery bypass grafting CABG is a surgical procedure for helping a patient improve chances of survival. It is a last resort effort used for end-stage diseased coronary arteries or arteries of the legs. The diseased arteries are not removed. Healthy arteries or veins are selected and harvested from other areas of the body and attached at safe distances around the diseased and narrowed arteries so that blood can bypass it and flow.
Traditional Chinese medicine
Traditional Chinese medicine formulas for arrhythmia Herbal medicine Yue jian cao you jiao wan Bao jian mei jian fei cha Pu ji xiao du yin wan Gan mao ling Xi huang wan Zhi gan cao decoction Shen fu decoction Gui pi decoction
Action Invigorates blood, dispels phlegm Invigorates blood, dispels phlegm Clears toxic bacterial and viral heat Clears toxic bacterial and viral heat Clears heat, invigorates blood, protects the heart Recovers from illness, regulates heart functioning Recovers after an illness, warms yang Nourishes blood
Nutritional supplements Alpha lipoic acid Nutritional constituents: Lipoic acid Benefits: Targets nerve cells, kidney, liver, lowers blood pressure, prevents cell damage to improve insulin use Caution: May lower blood sugar too much; avoid in pregnancy and nursing
Cod liver oil Nutritional constituents: Vitamins A, D, and omega-3 fatty acids (fish oils, flax seed, primrose, borage, and flaxseed oils) Benefits: Reduces cardiometabolic risk factors, protects sudden cardiac death after myocardial infarction, reduces raised
109
110
Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
plasma triglycerides, reduces blood pressure, and ameliorates atherogenic effects Caution: High doses required for reduction of blood pressure may have side effects.
Coenzyme Q-10 Nutritional constituents: CoQ10 Benefits: Heart, muscle, liver, and lungs; improves glycemic index, myocardial energy Caution: Body stores reduced when glyburide is prescribed for diabetes
Chromium Nutritional constituents: Picolinate, chloride, and nicotinate Benefits: pancreatic functioning and blood sugar Caution: May lower blood sugar excessively, causing concerns with medication indications
Magnesium Nutritional constituents: Citrate, stearate, and sulfate forms Benefits: Heart, kidneys, and muscle; improves type 2 insulin utilization in elderly Caution: May induce excessive stool elimination and diarrhea in patients at risk of inflammatory bowel disorders
Niacin Nutritional constituents: Vitamin B3 Benefits: Reduction of overall cholesterol levels, lowers triglycerides, increases HDL Caution: May cause nausea, may increase blood sugar levels, and may cause a prickly, flushing sensation on the skin
Potassium Nutritional constituents: Citrate Benefits: Cell membranes, reduces blood pressure Caution: May cause sodium retention and increased blood pressure
Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Selenium Nutritional constituents: Chelate Benefits: Small intestine and kidneys; helps protect nerves and vessels from excessive sugar intake damage Caution: Low levels may predispose to cancer, diabetes, and coronary artery disease
Vitamin B6 and Folic acid Nutritional constituents: Pyridoxine and folate Benefits: Liver, jejunum, ileum, and kidney; combined with B12 helps prevent stroke and loss of limbs and vision due to diabetes Caution: Excessive use of B6 may cause disfiguring skin lesions or folic acid nerve damage.
Vanadium Nutritional constituents: Sulfates and chelates Benefits: Liver and muscle cells to utilize insulin Caution: Nausea and cramping leading to diarrhea
Zinc Nutritional constituents: Picolinate Benefits: Production, storage, and secretion of insulin; blood sugar diffuse into cells Caution: May cause headache, nausea, vomiting, and drowsiness
Pharmaceutical drugs Atherosclerosis Ezetimibe: This drug reduces absorption of cholesterol in the small intestines and reduces LDL levels.
Bile acid sequestrants These drugs bind to bile acids in the small intestines to lower the acid, because it requires cholesterol to create it.
111
112
Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Prescription plant sterols These drugs are called proprotein convertase substilisin kexin type 9 inhibitors and contain omega 3s. They are used by patients who need to lower triglyceride and cholesterol levels to reduce stroke and myocardial infarction risk but cannot take statin drugs.
Reduce blood clots Antiplatelets and aspirin are blood thinners, which prevent blood from forming atheromas and other clots. Clopidogrel is used to prevent clots from forming inside of artery stents. Ticagrelor and prasugrel are drugs used to prevent clots from forming inside of artery stents. They can be taken with aspirin.
Statins These drugs lower LDL and triglyceride levels and raise HDL levels. They decrease inflammation and help reduce the size of plaque. However, they may cause liver and kidney failure and muscle disorders.
Fibrates These drugs lower LDL and triglyceride levels and raise HDL levels.
Drugs to reduce high blood pressure Adrenergic agent This drug is for mild hypertension and is often used with other antihypertensive drugs for more severe hypertension.
Aldosterone antagonists These selective drugs compete with aldosterone receptor sites, reducing blood pressure and sodium reabsorption.
Alpha blockers These drugs selectively block postsynaptic alpha1 -adrenergic receptors and lower blood pressure by dilating arterioles and veins. Side effects include dizziness, headache, and drowsiness, in addition to orthostatic and first-dose hypotension.
Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Angiotensin converting enzyme Inhibitors These drugs are used in patients with hypertension, chronic kidney disease, and proteinuria. They suppress the reninangiotensin-aldosterone system by preventing the conversion of angiotensin I to angiotensin II and blocking the major pathway of the degradation of bradykinin by inhibiting angiotensinconverting enzymes (ACEs). They are often considered strong when used alone without a diuretic but can be combined with one.
Angiotensin Receptor blockers These drugs are primarily used when a patient is unable to tolerate ACE inhibitors. They block the binding of angiotensin II to angiotensin type I receptors, reduce effects of angiotensin IIeinduced vasoconstriction, reduce sodium retention, and reduce aldosterone release. Angiotensin receptor blockers are used alone or often combined with a diuretic.
Beta blockers See Chapter 11.
Calcium channel blockers These drugs are either dihydropyridines or nondihydropyridines. Some bind to L-type calcium channels, causing vasodilatation and a decrease in blood pressure. Others bind to L-type calcium channels in the sinoatrial and atrioventricular node. These drugs are often suggested for American patients of distant African ancestry and the elderly.
Acute and chronic stages Patients at risk for life-threatening symptoms associated with atherosclerosis should be treated only with western medicine methods and approaches. One main reason is for diagnostic and follow-up monitoring of sudden death. Another reason is because patients indicated for blood thinners have an increased risk of bleeding and must use caution in diet and lifestyle, and many herbal formulations will enhance the effects of the drug to dangerous levels. For many patients, medication and lifestyle changes can reduce the health risk and may help them become indicated for the benefits of nutritional supplements and herbal medicines in the future.
113
114
Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
Recovery and prevention stages Patients who are at a lower risk due to lipid imbalances and obesity, yet are not indicated for drug therapy, and those not indicated for statin therapy may benefit from natural medicine for prevention. Patients who become stabilized after treatment using western medicine methods and approaches may be indicated for natural medicine in the recovery stages. These patients may also notice immune benefits of natural remedies for bacterial and viral infections and herbal medicines that help build energy and well-being after illness. Laboratory studies would continue to monitor progress, especially for patients still at risk of adverse health chances due to heart or vessel injuries during the chronic stages.
Further reading Bi Y, Chen J, Hu F, Liu J, Li M, Zhao L. M2 macrophages as a potential target for antiatherosclerosis treatment. Neural Plast. 2019;2019:6724903. https:// doi.org/10.1155/2019/6724903. Published 2019 Feb 21. Ehrlich KC, Lacey M, Ehrlich M. Tissue-specific epigenetics of atherosclerosisrelated ANGPT and ANGPTL genes. Epigenomics. 2019;11(2):169e186. https://doi.org/10.2217/epi-2018-0150. Han J, Wang Y, Yuan Z, et al. Nonalcoholic fatty liver disease represents a greater metabolic burden in patients with atherosclerosis: A cross-sectional study. Medicine (Baltimore). 2019;98(11):e14896. https://doi.org/10.1097/ MD.0000000000014896. Huang Y, Hu H, Liu L, et al. Interleukin-12p35 deficiency reverses the Th1/Th2 Imbalance, aggravates the Th17/Treg imbalance, and ameliorates atherosclerosis in ApoE-/- mice. Mediators Inflamm. 2019;2019:3152040. https://doi.org/10.1155/2019/3152040. Published 2019 Apr 10. Kim SM, Huh JW, Kim EY, et al. Endothelial dysfunction induces atherosclerosis: increased aggrecan expression promotes apoptosis in vascular smooth muscle cells. BMB Rep. 2019;52(2):145e150. https://doi.org/10.5483/ BMBRep.2019.52.2.282. Lietava J, Beerova N, Klymenko SV, Panghyova E, Varga I, Pechanova O. Effects of cornelian cherry on atherosclerosis and its risk factors. Oxid Med Cell Longev. 2019;2019:2515270. https://doi.org/10.1155/2019/2515270. Published 2019 Feb 17. Marchio P, Guerra-Ojeda S, Vila JM, Aldasoro M, Victor VM, Mauricio MD. Targeting early atherosclerosis: a focus on oxidative stress and inflammation. Oxid Med Cell Longev. 2019;2019:8563845. https://doi.org/10.1155/2019/ 8563845. Published 2019 Jul 1. Onat UI, Yildirim AD, Tufanli Ö, et al. Intercepting the lipid-induced integrated stress response reduces atherosclerosis. J Am Coll Cardiol. 2019;73(10): 1149e1169. https://doi.org/10.1016/j.jacc.2018.12.055. Summerhill VI, Grechko AV, Yet SF, Sobenin IA, Orekhov AN. The atherogenic role of circulating modified lipids in atherosclerosis. Int J Mol Sci. 2019; 20(14):3561. https://doi.org/10.3390/ijms20143561. Published 2019 Jul 20.
Chapter 8 Atherosclerosis: The acute, chronic, recovery and prevention stages
€ ller M, et al. G-protein coupled receptor van der Vorst EPC, Peters LJF, Mu targeting on myeloid cells in atherosclerosis. Front Pharmacol. 2019;10:531. https://doi.org/10.3389/fphar.2019.00531. Published 2019 May 22. Yang L, Gao C. MiR-590 inhibits endothelial cell apoptosis by inactivating the TLR4/NF-kB pathway in atherosclerosis. Yonsei Med J. 2019;60(3):298e307. https://doi.org/10.3349/ymj.2019.60.3.298. Yu H, Ma S, Sun L, Gao J, Zhao C. TGF-b1 upregulates the expression of lncRNAATB to promote atherosclerosis. Mol Med Rep. 2019;19(5):4222e4228. https://doi.org/10.3892/mmr.2019.10109. Zhou Z, Chen Y, Zhang D, et al. MicroRNA-30-3p suppresses inflammatory factor-induced endothelial cell injury by targeting TCF21. Mediators Inflamm. 2019;2019:1342190. https://doi.org/10.1155/2019/1342190. Published 2019 Jul 2. Zhu J, Nelson K, Toth J, Muscat JE. Nicotine dependence as an independent risk factor for atherosclerosis in the National Lung Screening Trial. BMC Public Health. 2019;19(1):103. https://doi.org/10.1186/s12889-019-6419-8. Published 2019 Jan 22.
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