# Exercise as it relates to Disease/Effective treatment for atherosclerosis - Surgery vs Exercise
## Background
### Prevalence

Atherosclerosis is a type of cardiovascular disease and is the top 10 causes of death worldwide. An estimated 92% of Australian adults had at least one of the nine risk factors with atherosclerosis being the most common cause of heart disease.

### What is Atherosclerosis?

Atherosclerosis is a condition where the arteries become narrow and hardened due to an accumulation of lipids called plaque inside the artery wall. This process reduces or completely blocks blood flow around the body, posing serious cardiovascular implications.

### Causes of Atherosclerosis

* Slow, complex disease that may start in childhood and develops faster with age
* Initiated by a damage occurring in the inner wall of an artery called the endothelium, overtime substances travelling in the blood such as cholesterol, fats and cellular waste products accumulate inside the damaged area of the artery wall
* Can affect the entire artery tree, but mainly affects the larger high-pressure arteries
These comorbidities significantly increase the chances of atherosclerosis, and stem from risk factors such as
| Preventable Factors | Non-Preventable Factors |
| * High Blood Pressure * High Cholesterol (poor diet) * Smoking * Obesity * Diabetes * Physical Inactivity | * Family History * Ethnicity * Gender |

## Effects of Atherosclerosis

* Coronary Artery Disease (plaque rupture and clotting causing heart muscle to die)
* Cerebrovascular Disease (plaque rupture in the brain's arteries cause’s strokes, with the potential for permanent brain damage)
* Peripheral Artery Disease (narrowing in the arteries of the legs caused by plaque. This causes pain on walking and poor wound healing. Severe disease may lead to amputations)

## Current Rehabilitation Methods

* Appropriate pharmacological therapy
* Modification of lifestyle (e.g. smoking cessation, balanced diet, stress management)
* Appropriate exercise regime
* Surgery - There are 2 major surgeries to treat atherosclerosis
    1. Stent Placement and Angioplasty (PCIs) - Inserting a tiny wire mesh tube and inflating a tiny balloon where the artery is clogged to help widen the artery
    2. Coronary Artery Bypass Graft Surgery (CABG) - Rerouting a healthier vessel onto a coronary artery bypassing the clogged artery

## Advantages and Disadvantages Of An Ongoing Intervention: Surgery vs. Exercise
### Surgery

| Advantages | Disadvantages |
| * PCIs has a low complication rate and recovery time is often less than one day * Increased survival rate with multiple or severely blocked coronary arteries * Improves or completely relieves angina symptoms in most patients | * Treatment with drugs can't control chronic chest pain * Recovery time can take weeks, even months for CABG surgery patients * Doesn't prevent other atherosclerotic plaques from causing problems * Needs to take a daily regime of anti-atherosclerosis medication * Costly |

### Exercise

| Advantages | Disadvantages |
| * Reduces atherosclerosis risk factors, including LDL cholesterol, high blood pressure and diabetes * Increases HDL cholesterol levels * Improved blood circulation * Stimulates production of new cells for arterial lining of vessels * Reduces plaque formation and inflammation in arteries * Decreases risk of plaque rupture * Cost-effecient | * Musculoskeletal injury * Major or fatal cardiac event occurring in high risk atherosclerosis patients |
Patients with major contraindications should not engage in physical activity without medical review prior commencing physical activity

## Recommendations for Effective Exercise Rehabilitation

Recommended Activity from the National Heart Foundation of Australia
* 30-45 min, preferably all days of the week of moderate-intensity physical activity using large muscle groups, such as walking, riding, or swimming
* Volume of physical activity should be increased gradually over time

## Improved Compliance

* Involvement and support from friends and family
* Positive mindset and an interest in physical activity which will lead to increased motivation
* Physicians and patients must be equally committed to achieving set goals and should communicate instructions clearly and prescribe therapies that are effective, affordable, and have minimal or no adverse effects on patient quality of life

## Further reading

* Australian Physical Activity Recommendations
* Atherosclerosis

## References

* 1 2 3 Bernenson, G. S., Srinivasan, S. R., Bao, W., Newman, W. P., Tracy, R. E. & Wattigney, W. A. (1998). 'Association between Multiple Cardiovascular Risk Factors and Atherosclerosis in Children and Young Adults.' New England Journal of Medicine, 338, 1650-1656.
* ↑ A.D.A.M. Medical Encyclopedia. 2012. Hardening of the arteries [Online]. Available: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001224/ [Accessed 22 October 2012].
* ↑ A., Salahi, & E, Sezavar. (2012). 'The in vitro Effect of Oxidized LDL and PHA on Proliferation and Gene Expression of Regulatory T Cells in Patients with Atherosclerosis'. Iranian Journal of Allergy, Asthma & Immunology, 11, 217-223.
* ↑ T., Raposo, M., Kazachkova, &, M. L. & Lima, M. (2011). Cross-sectional study of risk factors for atherosclerosis in the Azorean population. Annals of Human Biology, 38, 354-359.
* ↑ Huang, C.-C., Liu, K., Pope, R. M., Du, P., M. L. & LLlyod-JonesS, D. M. (2011). 'Activated TLR signaling in atherosclerosis among women with lower Framingham risk score: the multi-ethnic study of atherosclerosis.' PLoS ONE, 6, e21067-e21067.
* 1 2 3 Briffa, T. et al. (2006) 'National Heart Foundation of Australia physical activity reccomendations for people with cardiovascular disease.' Sydney. National Heart Foundation of Australia
* ↑ Thompson, P. D., Buchner. & Wenger, N. K. (2003). ‘Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease’. Circulation, 107, 3109-3116.
* ↑ Robert W. Hobson, II (2008)‘Management of atherosclerotic carotid artery disease: Clinical practice guidelines of the Society for Vascular Surgery’. Journal of Vascular Surgery Volume 48, Number 2. 48:480-6
* 1 2 3 4 Kadoglou, N. P. E., Iliadis, F. & Liapis, C. D.(2008). 'Exercise and carotid atherosclerosis. European Journal of Vascular and Endovascular Surgery', 35, 264-272.
* 1 2 Roitman, J. L. & Lafontaine, T. (2006). 'Special populations. Exercise, atherosclerosis, and the endothelium: where the action is (part II)'. Strength & Conditioning Journal (Allen Press), 28, 75-77.
* 1 2 Gordon, N. et al. (2004) ‘Physical Activity and Exercise Recommendations for Stroke Survivors: An American Heart Association Scientific Statement’ Journal of the American Heart Association. Vol. 109. pp 2031 – 2040