Blood Pressure and Atherosclerosis: Subclinical Arteriosclerosis as an Early Sign of Organ Damage

  • Raimund ErbelEmail author
  • Nils Lehmann
  • Andreas Stang
  • Sofia Churzidse
  • Susanne Moebus
  • Karl-Heinz Jöckel
Part of the Updates in Hypertension and Cardiovascular Protection book series (UHCP)


Atherosclerosis shows during life a continuous, sometimes rapid or slow, development starting with fatty streaks and intermediate lesions based on small areas of intimal thickening. According to recommendations of the American Heart association these stages are called Stary I, II, and III. Within the eccentric lesions more and more lipid droplets form a lipid core. These lesions are called atheroma (Stary IV), incorporating collagen they are called fibroatheroma (Stary V). Due to a remodeling process these lesions remain asymptomatic until the increase of vessel circumference reaches >60% and plaque size >40–50%. At this point the compensation process is exhausted, so that a further increase of plaque size would result in luminal narrowing. Coronary artery calcification is found first intracellularly, later extracellularly in Stary III lesions, and is thus not a late, but early sign of atherosclerosis already found in lesions Stary III. Computed tomography (CT) is able to visualize arterial calcification and can therefore be used for early detection, localization, and quantification of coronary atherosclerosis, which is a unique feature not available with other methods. In addition CT for CAC scanning is quick and standardized. Even X-ray exposure is not any more a limitation as the new CT generation allows a full cardiac CT scan with <1.0 mSv, even <0.1 mSv.

In healthy subjects no CAC is detected, but CAC reaches values of up to 1000 and more units—quantified with the Agatston score—in high-risk individuals. The amount of CAC is directly related to the risk for coronary and cardiovascular events and even all-cause mortality. Population-based studies have shown that the CAC shows an age- and sex-related exponential distribution. The data of the Heinz Nixdorf Recall (HNR) study were used in order to detect early signs of coronary atherosclerosis as a marker of organ damage going beyond previous studies using endothelial dysfunction, signs of left ventricular hypertrophy or function as well as other signs like renal failure due to risk factor exposure. One of the main causal risk factors is hypertension, however, for many years prehypertension was not accepted due to conflicting results based on treatment with different antihypertensive agents. Systolic blood pressure has been identified as the strongest predictor of CAC in children followed until the young adulthood. The amount of CAC increases depending on the blood pressure level. Between normotensives and stage 2 hypertensives a striking difference was found, which was more obvious in women than men. Even in prehypertensives a higher CAC distribution was found in both men and women. In men a biological bias in the elderly men was found. The degree of CAC was associated with higher coronary and cardiovascular events in each blood pressure category. Compared to the blood pressure categories the CAC values were much more predictive for event rates, even in prehypertensives. This coronary sign of subclinical atherosclerosis may be used in the future to preselect those who would benefit from pharmaceutic intervention and avoid treatment in others. Meanwhile, McEvoy et al. (Circulation 135(2):153–165, 2017) have proposed CAC as a guide for a personalized risk-based approach to initiation and intensification of antihypertensive therapy. Recently, the AHA 2017 lowered the thresholds for indicating hypertension, so that now the values between 130 and 140 mmHg for the systolic blood pressure, previously included in the definition of prehypertension, are part of the definition used for indicating hypertension as a major risk factor for coronary, cardiovascular, and all-cause mortality.


Prehypertension Hypertension Organ damage Coronary artery calcification Atherosclerosis 


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Raimund Erbel
    • 1
    Email author
  • Nils Lehmann
    • 1
  • Andreas Stang
    • 1
  • Sofia Churzidse
    • 2
  • Susanne Moebus
    • 1
  • Karl-Heinz Jöckel
    • 1
  1. 1.Institute for Medical Informatics, Biometry and EpidemiologyUniversity Hospital Essen, University Duisburg-EssenEssenGermany
  2. 2.Medizinische Klinik I, Herzzentrum NiederrheinHelios Hospital KrefeldEssenGermany

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