Archive for the ‘atherosclerosis’ Category

Is sudden, unaccustomed, physical exertion a trigger for plaque rupture and an ACS ?

Yes, it is, but don’t get apprehensive. The underlying risk factors, plaque burden, and its morphology matter much to result in a coronary event.

What is the mechanism?

Plaque morphology,  the lipid core, the shoulder region’s eccentricity, the crystallization of cholesterol lay the foundation. The Isometric component of stress surges Intra-coronary pressures and facilitate vascular injury.  Endothelial dysfunction leading to erosion and subsequent acute total thrombotic occlusion is a well-known response to stress. Currently, spontaneous coronary dissection secondary to unaccustomed stress is increasingly recognized to be a culprit.


plaque fissure and exertion physical and mental exertion and plaque

Which is more dangerous? Mental or physical stress* ?

No one can answer this query with certainty. The combination of both can prove deadly in vulnerable patients. The final common pathway for both physical and mental stress seems to be the same. Adrenergic toxicity at the cellular level.

* Mental stress-induced primary electrical events (CPVT/ Inherited channelopathy ) are unrelated to plaque destabilization that is often confused with ACS in many SCDs.

What are the natural protective factors to stress?

Coronary autoregulation,stress-busting hormones like endorphins , natural anti-fibrinolytic systems do play a role. Human beings experience infinite episodes of mental stress in their lifetime. Only a fraction (of a fraction ) result in ACS. It is obvious , there must be some major invisible protective factors. One may call this as metaphysical force ( scientific equivalent to fate ?) operating on a particular plaque to destabilize it.


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Every time , patients ask me  what diet he or she  should follow , Iam sort of  amused , as my understanding of diet and cardio vascular disease is at best primitive.I used  go with a standard single phrase  advice “Anything in moderate should be okay  “
What about going for a saturday night party doctor? One of  my shrewd looking  patient who was recently double stented with DES , asked.
Human body is a biological marvel.While medical professional divide it  into various systems  for our convenience. God doesn’t  think that way .He has no systems in mind when the body was designed . There is no wonder , the alimentary system and hematological system has to interact on a daily basis  with the help of circulatory system  to keep the  body alive. Platelets are unique blood cells that exist primarily to plug physiological bleeding if any  or for self-healing at sites of tissue injury.
 platelet lipid ldl tgl triglyceride ineraction 002
With human vascular system increasingly invaded by various metals and wires , platelet are a confused lot since their original biological functions are altered. They simply don’t know whether  fight these foreign body , aggregate over it , flush or simply pass over these .Adding to this  the powerful anti-platelet drugs targeting critical functional pathways .No wonder every other cardiovascular  patient  consumes at least one anti-platelet drug.
It seems diet  can have direct influence of platelet function
With human beings desire to add style to food consumption and eating habits  competing with  top slot of purpose of living , we often forget it is same prevent us from living a good life.
There has been numerous anecdotal and study population and experience  acute coronary events are more common after a heavy meal especially a fatty one .The immediate suspect has been high triglyceride and chilomicrons in blood stream shunted  intestines .
It is logical to expect , these high TGLs some how act a s trigger for pro-coagulant trigger .With the core thrombus  rich platelets it is assumed platelet stickiness is augmented and  maintained  by transient raise in triglyceride formation(Reference 1,4,5)
Glycerol component of  TGL is know for  its sickness and  making the companions wet.
The million dolor question is , at what level of TGL and which forms of TGL make the platelet cry and attract each other ?
Diet, anti platelet drug efficacy  ?
 Now , patients with coronary stents has to live at the mercy of these anti-platelet drugs. The drug resistance(Clopidgrel) is  threatening to be major issue.Like warfarin do we have real issue of dietary binge and acute neutralisation  of anti-platelet drug efficacy that can trigger acute stent thrombosis . This is potentially  important  area of study .
Final message
So does a fatty meal  a new trigger for ACS ? It may sound an alarmist statement .but as of now , its difficult to ignore this.So my advice for that  the that smart young man with soluble stent  was to avoid binge dinners that carries a definite risk of interfering with  stent maintenance .

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