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diabetes
heart disease
atherosclerosis
Monckeberg

Part I The Significance of Monckeberg Atherosclerosis

broken foot

Monckeberg atherosclerosis is different from typical atherosclerosis and most commonly is associated with adult onset diabetes mellitus. It affects the medial layer of the artery while typical atherosclerosis affects the intimal layer. Monckeberg is typically more systemic (if you have it anywhere you have it everywhere) while typical atherosclerosis tends to occur around areas of increased turbulence of blood flow, usually branch points.


old adage from medical school

50% of people dying with their first heart attack with no known previous history of heart disease will have diabetes.

Monckeberg Atherosclerosis (Medial Artery Calcification)
stiff pipes

Two views of my right foot from July 1995. The normal non-inverted view (upper view) shows the fracture of the proximal fifth metatarsal and if you look carefully between the first and second metatarsals you can see what looks like a small white donut with tracks leading away from it.

broken foot

The inverted and enlarged view below shows the same except now the white is black and is marked by the black x's. This is calcification of the medium and small arteries of my foot of the Monckeberg variety. This calcification does not block the artery but does result in a very stiff artery. These calcified stiff arteries have reduced compliance (the ability to dilate or constrict when they need to).



Typical (intimal) atherosclerosis vs
Monckeberg atherosclerosis (medial layer)

broken foot

The two views below are from a Finnish study referenced below. The image on the right shows very discrete and uniform calcification of the artery in the thigh (superficial femoral artery) while the image on the left shows the irregular clumpy calcification of typical atherosclerosis of the non-Monckeberg variety. As is clearly evident two different appearances, two different processes. The process on the left affects the intimal layer of the artery (typical atherosclerosis) while the one on the right affects the medial layer of the artery. Arteries have three layers, intima, media and adventia.(from the inside out )

>>>beginning of Finnish study published in 1996

Medial Artery Calcification

A Neglected Harbinger of Cardiovascular Complications in Non–Insulin-Dependent Diabetes Mellitus Seppo Lehto; Leo Niskanen; Matti Suhonen; Tapani Rönnemaa; Markku Laakso

the Departments of Medicine (S.L., L.N., M.L.) and Radiology (M.S.), Kuopio University Hospital, Kuopio; the Department of Medicine (T.R.), Turku University Hospital, Turku; and the Research and Development Centre (T.R.), Social Insurance Institution, Turku, Finland.

broken foot

Correspondence to Markku Laakso, MD, Professor, Department of Medicine, University of Kuopio, SF-70210 Kuopio, Finland. E-mail Markku.Laakso@uku.fi.

Abstract

Medial artery calcification (MAC) is a nonobstructive condition leading to reduced arterial compliance that is commonly considered as a nonsignificant finding. The aim of our study was to investigate the predictive value of MAC in relation to 7-year cardiovascular mortality, coronary heart disease (CHD) events, stroke, and lower extremity amputation in 1059 patients (581 men and 478 women) with non–insulin-dependent diabetes mellitus (NIDDM). At baseline radiologically detectable MAC in femoral arteries was found in 439 patients (41.5%) and intimal-type calcification in 310 diabetic patients (29.3%). The mean fasting plasma glucose at baseline was somewhat higher in women and the duration of diabetes somewhat longer in patients with MAC than in those without, but otherwise the presence of MAC was unrelated to conventional cardiovascular risk factors. During the follow-up 305 diabetic patients died: 208 from cardiovascular disease, 158 from CHD, and 34 from stroke. Furthermore, 58 NIDDM patients underwent their first lower extremity amputation. MAC was a strong independent predictor of total (risk factor–adjusted odds ratio and 95% confidence interval: 1.6; 1.2, 2.2), cardiovascular (1.6; 1.1, 2.2), and CHD (1.5; 1.0, 2.2) mortality, and it was also a significant predictor of future CHD events (fatal or nonfatal myocardial infarction), stroke, and amputation. This relationship was observed regardless of glycemic control and known duration of NIDDM. MAC is a strong marker of future cardiovascular events in NIDDM unrelated to cardiovascular risk factors, supporting the hypothesis that reduced arterial elasticity could lead to clinical manifestations of diabetic macroangiopathy.

>>>end of Finnish Study

two types of atherosclerosis
two types of angina

These two different types of atherosclerosis yield two different patterns of angina (chest pain related to myocardial ischemia). While both are fixed lesions the intimal type usually doesn't become known until it is reducing blood supply sixty percent or more. Once this happens there is no other way for the blood to get to the heart muscle except for collateral arteries which may or may not be present. Once symptoms begin, they usually do not go away. However as I have personally experienced with Monckeberg atherosclerosis, the symptoms can be extremely severe one day and completely gone the next.

severe angina on the run

I have had to stop a run only once in the first mile in over thirty years of running. This happened one day as I headed out the canal path in Broad Ripple circa June 1994. The angina started in my neck and chin then the left arm, next the right arm and then the whole upper-half of my body. After about a half-mile I had to walk. I would walk for a while and then be able to run for a while, then I would have to walk again. This went on for about the first three miles of a six mile run. The day before I had eaten a vegan but fat filled scone in Bloomington. The rest of that day after recovering from the severe angina, I avoided eating any fat especially trans-fat. The next day I ran normally with no chest pain. I have had to become very aware of trans-fats as now even the slightest amount of them will give me angina. This is because the trans-fat molecules are either just too big or too solid to pass through the Monckeberg stiffened arteries and arterioles. These molecules can block the artery just like any solid embolus. This a form of fat embolization / microembolization.

Conclusion

As is clearly evident from the Finnish study and my own personal experience, Monckeberg Medial Artery Sclerosis is NOT to be ignored and is clearly associated with ischemic heart disease including sudden death.

Thanks for your time and your attention.
Copyright © John Mericle M.D. D.A.B.R. 2000-2012 All Rights Reserved

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