Atherosclerosis: what it is, symptoms, causes and treatment

Atherosclerosis happens when fatty deposits build up in the arteries, which causes them to narrow. The British Heart Foundation (BHF) explains that a build-up of fatty material called atheroma (or plaque) in the artery walls makes them harden and narrow until blood cannot pass properly.

The BHF says it is a common condition that can affect anyone, particularly people over 65 or with a family history of heart or circulatory disease. Because atheroma takes time to build up, many people do not know they have it.

It is not the same as arteriosclerosis. The BHF describes arteriosclerosis as a general term for the hardening of arteries, and atherosclerosis as one form of it.

You may not have any symptoms. The BHF says most people with atherosclerosis do not know they have it, because symptoms usually do not show up until an artery is severely narrowed or blocked, and which symptoms you get depends on the arteries affected.

The NHS and the BHF list these possible symptoms:

• Chest pain (angina).

• Pain in the arms and legs, especially when exercising or walking.

• Feeling short of breath or having difficulty breathing.

• Feeling tired all the time or very tired.

• Feeling weak, or weak muscles.

• Feeling confused, which the BHF links to limited blood flow to the brain.

The NHS says to ask for an urgent GP appointment or get help from NHS 111 if you have chest pain that comes and goes, feel short of breath, have pain in your arms and legs when walking or exercising, or have any other symptoms you are worried about.

The NHS says to call 999 if you have any of the following, and not to drive yourself to A&E:

• Signs of a heart attack, such as pain like a tight band or heavy weight in your chest.

• Signs of a stroke: face dropping on one side, not being able to hold both arms up, or difficulty speaking.

• Difficulty breathing, such as gasping for breath, choking or not being able to get any words out.

• Sudden confusion, being unable to think or speak clearly, or suddenly not knowing where you are.

The NHS says there are currently no treatments to reverse atherosclerosis, but you may be offered medicines to lower your risk of having a heart attack or a stroke. The BHF adds that although there is no cure, medicines and treatments can slow its progress, reduce symptoms and let you live your normal life.

The NHS lists the medicines you may need, and says you may also need surgery to help improve blood flow through the affected arteries. The BHF names coronary bypass surgery or coronary angioplasty for seriously narrowed heart arteries.

• Medicines to lower your cholesterol, usually statins.

• Medicines to lower your blood pressure.

• Medicines to lower your risk of blood clots.

• Medicines to lower your blood sugar levels if you have diabetes.

• Surgery or a procedure to improve blood flow through affected arteries.

NICE guidance on cardiovascular disease risk assessment and lipid modification (NG238) sets out when statins are offered. For people without cardiovascular disease, it says to offer atorvastatin 20 mg for primary prevention to people who have a 10-year QRISK3 score of 10% or more. It also says treatment should not be ruled out for people with a lower score if they have an informed preference for taking a statin or there is concern that risk may be underestimated.

For people who already have cardiovascular disease, NICE says to offer atorvastatin 80 mg whatever their cholesterol level, unless specific criteria in the guideline apply, and says not to delay statin treatment while lifestyle changes are discussed. For secondary prevention it sets an aim of LDL cholesterol of 2.0 mmol per litre or less, or non-HDL cholesterol of 2.6 mmol per litre or less.

NICE also notes that ezetimibe, given with a statin, is recommended as an option in its technology appraisal guidance in some adults when cholesterol is not appropriately controlled on a statin. Your own doctor decides which treatment suits you, and you should not stop or change a medicine without advice.

The BHF says your doctor will ask questions about your lifestyle and family history and may send you for tests. If you can, find out whether you have a family history of atherosclerosis or heart disease so your doctor gets a full picture.

The BHF lists these tests, most of which are painless:

• Blood tests.

• A CT scan, including coronary calcium scoring, which shows how much plaque has built up in the arteries of your heart.

• An angiogram.

• An ECG, or an exercise ECG.

• A carotid ultrasound, which makes pictures of the two largest arteries in your neck.

The BHF says there is no specific reason why arteries become narrowed or blocked by atheroma, so anyone is at risk, but some things increase the chance. The NHS lists the following:

• Being over 50 years of age (the BHF says getting older, especially over 65).

• Smoking.

• Having high cholesterol, high blood pressure, diabetes or kidney disease.

• Living with overweight or obesity.

• Having close relatives who have cardiovascular disease.

• Being of Black African, African Caribbean or South Asian origin.

• Not exercising enough, an unhealthy diet and drinking more than 14 units of alcohol a week (BHF).

The NHS says that without lifestyle changes and medical treatment atherosclerosis may get worse over time and can cause heart attacks, stroke, peripheral arterial disease and other types of cardiovascular disease. The BHF describes how these arise.

The NHS says lifestyle changes can help stop atherosclerosis getting worse. It recommends the following, and says to take any medicines you have been prescribed for other health conditions and to attend your NHS Health Check when invited if you are aged 40 to 74.

• Eat healthily and eat less saturated fat and sugar.

• Exercise regularly and keep to a healthy weight.

• Do not smoke.

• Do not drink more than 14 units of alcohol per week.

• Keep your blood sugar levels under control if you have diabetes.

On the NHS, atherosclerosis is usually managed by your GP, with a referral to a cardiology or vascular service if you have symptoms, tests that need a specialist, or a procedure such as angioplasty or bypass. Emergency chest pain and stroke are treated through 999 and A&E.

Private cardiology and vascular clinics can offer scans, specialist opinions and procedures. Whichever route you use, ask which arteries are affected, which medicines you need to take long term and how your cholesterol and blood pressure will be reviewed.