Physical Factors Important in the Development of Atherosclerosis in Diabetes

Circulation of the blood is a process controlled by physical laws. The same physical laws also determine the sites of atherosclerotic plaques. Our understanding of their role in atherogenesis is aided by a review of (1) the difference between a solid and fluid, (2) strain and shear or strain rate and shear rate as describers of motion, (3) the distinction between force as pressure and as shear stress, (4) the effects of viscosity and inertia on fluid motion, and (5) the nonlinear responses of blood and blood vessels. Moving blood affects the vessel wall principally through shear stress, the force due to its viscosity applied parallel to the surface of the vessel. Excessive shear stress occurs near the orifices of branches of the aorta, the arterial areas where atherosclerotic plaques develop. It is produced by a change in blood flow pattern at these sites. Arterial stiffening in diabetes reduces the ability of the branches of the aorta to dilate during systole, a motion that helps to control high wall shear stress. At wall shear stress levels under 400 dynes/cm², a value only modestly higher than that normally achieved near the orifices of the major arterial branches, the endothelial lining of the arterial wall becomes disrupted, allowing entry of plasma proteins and lipids. Blood viscosity elevation in diabetes, linked to enhanced erythrocyte aggregation and reduced erythrocyte deformability, adds to the shear stress at the vessel wall, favoring increased lipid entry. Exposed to a high lipid influx secondary to excessive wall shear stress, the arterial wall must rely on physical as well as chemical means to remove the lipids. Subendothelial motion generated by diastolic arterial contraction and systolic expansion appears to cause plasmalemmal vesicle formation and dissolution, an event probably important in the removal process. The combination of arterial stiffening and hemorheologic disturbance adds to the burden of increased plasma lipids to favor the development of atherosclerosis in diabetes.