Atherosclerosis—Know Your Risk—Is it Time for a Paradigm Shift?

US Endocrinology, 2014;10(2):105–10 DOI:


Atherosclerosis is a form of arteriosclerosis characterized by the deposition of atheromatous plaques containing cholesterol and lipids on the innermost layer of the walls of large and medium-sized arteries. People with atherosclerosis have a higher risk for cardiovascular disease (CVD) and stroke. Modification of traditional risk factors, such as smoking cessation, decreasing blood pressure, and lowering of cholesterol in high-risk individuals, has resulted in reducing CVD and stroke remarkably. However, the current standard of care using traditional modifiable risk factors alone is frequently inadequate to identify some individuals with atherosclerosis. Therefore, it is important to not rely solely on risk factor modification when assessing for CVD, but also to incorporate a disease platform. A new paradigm focusing on the disease itself (atherosclerosis) is necessary. This article will review the tools necessary to identify disease and will examine why it is critical to know the cause of the disease and to develop a treatment plan to eradicate it.
Keywords: Atherosclerosis, lumenology, arteriology, genetic testing, inflammatory biomarkers, insulin resistance, heart failure, periodontal disease, plant sterols
Disclosure: Claude K Lardinois, MD, FACP, MACN, FACE, has no conflicts of interest to declare. No funding was received for the publication of this article
Received: July 02, 2014 Accepted September 19, 2014
Correspondence: Claude K Lardinois, MD, FACP, MACN, FACE, 1700 Aquila Avenue, Reno, Nevada, US. E:

Atherosclerosis continues to be the number one cause of death in the US. Annually, 1,000,000 people will suffer a myocardial infarction (MI): one-third of those will occur in people who have already suffered an event.1 Despite treatment of major modifiable risk factors proved to reduce CVD,2,3 the high recurrence rate raises serious questions that the current standard of care using modifiable risk factors to reduce MI is inadequate and that it is critical to start looking beyond the status quo. Framingham and Reynolds Risk Scores fail to identify the majority of people who will have an event.4 Most MIs are caused by nonobstructing plaques of less than 50 % of the arterial lumen.5,6 Traditional cardiology focuses on stress testing and angiography to assess MI risk (‘lumenology’—is the lumen open?) The pitfall is that many people will still have atherosclerosis and be at high risk for a MI despite having a normal stress test or angiogram. A new paradigm (‘arteriology’—is disease present?) using noninvasive tools such as carotid intima media thickness (cIMT), carotid and aortic ultrasound, and coronary calcium score (CCS) is necessary. If disease (atherosclerosis) is discovered, a comprehensive evaluation and treatment plan must be implemented to reduce the high recurrence rate of MI.

Arteriology—Is Disease Present?

Direct examination of the endothelium is important to determine if disease (atherosclerosis) is present or not. Patient identification is categorized as primary, secondary, or tertiary (see Figure 1). Primary means no disease is present; secondary means that disease is present but the patient has not had an MI or stroke; tertiary means the patient has suffered an MI or stroke. cIMT is an excellent tool to detect and monitor plaque.1 cIMT thickness and presence or absence of plaque improves prediction of CVD risk.7,8 cIMT is noninvasive, inexpensive, repeatable without adverse effects, adds prognostic power to conventional risk stratification tools, and can be used to monitor the disease (atherosclerotic) process. CCS is another excellent tool to document the presence of atherosclerosis and identify patients at increased risk for CVD and stroke.9–11 The calcium scale is a linear scale with 4 calcium score categories that correlate directly with risk for events and likelihood of obstructive CVD: <11 none; 11–99 mild; 100– 400 moderate; >400 severe. CCS adds prognostic power to conventional risk stratification tools, alters therapeutic goals and improves compliance.

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Keywords: Atherosclerosis, lumenology, arteriology, genetic testing, inflammatory biomarkers, insulin resistance, heart failure, periodontal disease, plant sterols