THE VIEW that coronary heart disease, or arteriosclerosis, is a multifactorial disease has always disturbed me -not because it isn't important to uncover the conditions that aggravate this disease, but because as a basis for scientific inquiry I feel that it may be a very long time before we can formulate a model that will be both scientifically sound as well as aesthetically pleasing.In some way nearly every process around us is mul tifactorial. Even a simple discussion about the weight of a gas can be conducted in multifactorial terms. The weight depends, of course, on its volume, pressure, temperature, molecular weight and the gravitational force. Even in this simple analysis at least flve factors determine the outcome of the inquiry. If we analyzed the question in terms of molecular, atomic or subatomic physics the number of factors involved in answering the inquiry would probably be increased manifold.Therefore, we should not be discouraged by the multitude of possible etiological and risk factors that compete for priority status. It is highly unlikely that we shall have to control each and every one of them to prevent the clinical manifestations of arteriosclerosis.However, it is still not possible to present a unitary view of the atherogenic process. Consequently, this presentation deals only with selected early manifestations of arterial pathology, i.e., lipid accumulation, and leans more heavily on my own work than is warranted by its importance. I shall, however, synthesize our findings with those of others in support of the view that arterial lipid accumulates as the result not only of abnormally high concentrations of low- density lipoproteins (LDL) in the blood plasma, but also as a consequence of the normal process of lipid absorption and transport. This normal process may be innocuous in persons who ingest low-fat diets, but is probably pathogenic in those who consume a diet rich in fat and cholesterol.
Lipid and AtherosclerosisCholesterol and AtherosclerosisMost scientists working in the atherosclerosis area see cholesterol as a pivotal element in the etiology of cardiovascular disease. At least five areas of research contribute to this view. In 1910, Windaus' described the presence of cholesterol in the lesions of diseased arteries. Since then, many studies have confirmed that free and esterified cholesterol accumulate in the aorta, coronary arteries, cerebral vessels and other large arteries at different rates in different persons or in different population groups.2 In persons with premature, genetically determined hypercholesterolemia, arterial cholesterol accumulates more rapidly and clinical manifestations of cardiovascular disease appear earlier in life.3 Epidemiological studies have repeatedly shown high degrees of correlation between the intake of cholesterol and other lipids with the prevalence of coronary heart disease in various populations.2 Animal studies show, almost without exception, that experimentally induced hypercholesterolemia is followed by the accumulation of cholesterol in...