ASCVD Pathology

Question 1

what is Arteriosclerosis

Answer 1

Vascular disease manifested by thickening and inelasticity of arteries

Question 2

what are the 3 patterns of arteriosclerosis

Answer 2

atherosclerosis (AS)
Monckeberg’s medial calcific sclerosis
arteriolosclerosis

Question 3

what is Medial Calcific Sclerosis

Answer 3

Calcification of muscle wall (media) of arteries
May ossify
No narrowing of vessel lumen
Patients older than 50 years.

Question 4

what are the two types of Arteriolosclerosis� and are associated with

Answer 4

Thickening and narrowing of vascular walls of small arteries and arterioles,Associated with hypertension and diabetes

Question 5

what are the two types of Arteriolosclerosis

Answer 5

hyaline and hyperplastic

Question 6

what is Atherosclerosis

Answer 6

Intimal fibrofatty plaques
narrow vascular lumen
weaken arterial wall (media)

Question 7

what are the major targets of Atherosclerosis

Answer 7

aorta, coronary arteries, cerebral arteries

Question 8

what is the epidemiology and risk factors of Atherosclerosis.

Answer 8

Responsible for half of all deaths in the western world
Ubiquitous in developed nations
Less common in Central and South America, Africa, Asia, Japan
Begins in early childhood

Question 9

What has caused a reduction in Atherosclerosis

Answer 9

Life-style changes (diet, smoking, control of HTN)
Improved therapy for IHD
Prevention of recurrences

Question 10

what are the constitutional RF for Atherosclerosis

Answer 10

Age 40 to 60 year olds have 5X incidence of MI
Sex (males have 5X death rate from IHD until menopause
same MI frequency by 7th to 8th decade)
Genetics (familial clustering of other risk factors
genetic defects (eg familial hypercholesterolemia)

Question 11

what are the acquired risk factors for Atherosclerosis

Answer 11

Hyperlipidemia
Hypertension 160/95 has 5X risk IHD than < 140/90
Smoking 1ppd X years has 200% increase in death rate from IHD
Diabetes 2X incidence of MI, increased risk of stroke, 100X risk of gangrene
C-reactive protein
“Soft” risk factors`

Question 12

What does C-Reactive protein tell us

Answer 12

Systemic marker of inflammation synthesized by liver

Level correlates with risk of IHD/MI, stroke, PVD, SCD

Question 13

what reduces CRP

Answer 13

smoking cessation, weight loss, exercise, statins

Question 14

what is the role of HDL

Answer 14

Reverse transport of cholesterol from cells/plaque to liver for excretion in bile

Question 15

what elevated HDL

Answer 15

Exercise and ETOH

Question 16

what reduces HDL

Answer 16

Obesity and smoking reduce HDL

Question 17

True of False risk factors are not additive

Answer 17

TRUE

Question 18

what are other RF for AS

Answer 18

Inadequate physical activity
Type A personality
Obesity
Estrogen deficiency
High carbohydrate diet
Hardened (trans) unsaturated fat intake
Chlamydia pneumoniae

Question 19

what is Hyperhomocystinemia

Answer 19

Inborn error of metabolism resulting in high levels of circulating homocysteine
Can also be caused by low folate and vitamin B intake
Level correlates with CAD, PVD, stroke and venous thrombosis

Question 20

what is Lipoprotein Lp (a)

Answer 20

Altered form of LDL (apolipoprotein B-100 of LDL linked to apolipoprotein A)
Correlation between increased lipoprotein Lp(a) and coronary and cerebral vascular disease

Question 21

Response to Injury Hypothesis

Answer 21

Focal chronic endothelial “injury”
Endothelial dysfunction and monocyte adhesion/emigration
Smooth muscle cell emigration and macrophage activation
Macrophages and SMCs engulf lipid
Proliferation of SMCs, ECM deposition, extracellular lipid.

Question 22

Cellular Events in AS

Answer 22

Endothelial injury
Lipids
Macrophages
Smooth muscle cells
Infection

Question 23

Endothelial Injury

Answer 23

Endotoxin		
Hypoxia	
Smoking 
Viruses
Immune reactions
Homocysteine
 Hemodynamics
Hypercholesterolemia

Question 24

Hemodynamics

Answer 24

Shear stress and turbulent flow
plaques occur at branch points and posterior abdominal aorta
Lesion protected areas associated with induction of atheroprotective genes

Question 25

Severity of AS correlates with total

Answer 25

LDL cholesterol levels

Question 26

``` AHA classifications of lesions Type I - Type II - Type III - Type IV - Type V - Type VI - ```

Answer 26

``` Fatty dot Fatty streak Intermediate lesion Atheroma Fibroatheroma Complicated plaque ```

Question 27

what is an Aneurysms

Answer 27

Abnormal dilatation of arteries/veins due to weakening of vessel wall

Question 28

What is the most common cause of aortic aneurysms

Answer 28

Atherosclerotic Aneurysms

Question 29

Ischemic Heart Disease

Answer 29

Also called coronary heart (artery) disease (most common cause is atherosclerosis) Most common cause of death (1/3 of all deaths) in developed countries

Question 30

Ischemic Heart Disease 4 syndromes

Answer 30

angina pectoris sudden cardiac death myocardial infarction chronic IHD

Question 31

Coronary Artery Thrombosis

Answer 31

Plaque rupture exposes thrombogenic lipids and subendothelial collagen Complete occlusion results in AMI Incomplete occlusion results in U/A or sudden death or microinfarcts downstream

Question 32

other causes of IHD

Answer 32

``` Emboli from vegetations Vasculitis Systemic hypotension Systemic hypertension Valvulopathy ```

Question 33

Angina Pectoris

Answer 33

Intermittent chest pain due to reversible myocardial ischemia

Question 34

Three types of angina pectoris

Answer 34

stable angina Prinzmetal's or variant angia unstable angina

Question 35

Stable Angina

Answer 35

Episodic chest pain associated with exertion or stress Chest pain is crushing, squeezing, may radiate to left arm Fixed lesions > 75% vessel lumen Relieved by rest, NTG (reduces preload and augments coronary blood flow)

Question 36

Prinzmetal’s Angina

Answer 36

Also called variant angina Chest pain occurs at rest or while sleeping Vasospasm near plaque Responds to vasodilators

Question 37

Unstable Angina

Answer 37

Also called crescendo and preinfarction angina Increasing frequency of chest pain More intense and longer duration Due to acute plaque change

Question 38

Myocardial Infarction

Answer 38

Local ischemia leading to corresponding myocardial necrosis | Single most common cause of death in industrialized nations

Question 39

Pathogenesis of MI

Answer 39

``` Coronary artery thrombosis most common cause of MI preexisting plaque disrupted Vasospasm Platelet aggregation Hypoperfusion ```

Question 40

Infarct location

Answer 40

LAD (40 to 50%) - anterior/apical infarcts RCA (30 to 40%) - posterior/basal infarcts LCX (15 to 20%) - lateral

Question 41

Complications of MI

Answer 41

``` Papillary muscle dysfunction Rupture Mural thrombi Acute pericarditis Ventricular aneurysm ```

Question 42

Clinical Features of MI

Answer 42

Severe crushing substernal chest pain +/- radiate to neck, jaw, epigastrium, shoulder, left arm for hours to days unrelieved by NTG Rapid weak pulse, diaphoretic, dyspnea (pulmonary edema), shock (if >40% of LV infarcted)