Atherosclerosis

Question 1

What does Athero mean?

Answer 1

Soft/porridge like

Question 2

what does sclerosis mean?

Answer 2

Hardening

Question 3

Define Atherosclerosis

Answer 3

Atherosclerosis is the combination of atheromas (fatty deposits in the artery wall) and sclerosis (hardening or stiffening of the blood vessel wall)

Question 4

what arteries does AS affect?

Answer 4

Medium and large

Question 5

What is AS caused by?

Answer 5

Chronic inflammation and activation of immune system by artery walls.

Question 6

This causes deposition of _____ and development of _______ _________ ______

Answer 6

Lipids
Fibrous atheromatous plaques

Question 7

What do the Plaques result in?

Answer 7

Stiffening, stenosis and plaque rupture

Question 8

Stiffening of the artery walls leads to?

Answer 8

hypertension and strain as the blood is working to pump blood against the increased resistance

Question 9

Stenosis?

Answer 9

Stenosis is narrowing of the artery walls and leads to reduced blood flow e.g Angina

Question 10

Plaque ruptures lead to?

Answer 10

Thrombus forming and can block a distal vessel causing ischaemia. e.g acute coronary syndrome where the coronary artery becomes blocked.

Question 11

What three things happen to an artery during AS?

Answer 11

Question 12

What are the non-modifiable risk factors?

Answer 12

Older ages
Male
Family history

Question 13

What are the 8 modifiable risk factors?

Answer 13

Raised cholesterol
Smoking
Alcohol consumption
Stress
Obesity
Poor diet
Poor sleep
Lack of sleep

Question 14

What are the 5 medical Co-morbidities?

Answer 14

Diabetes
Inflammatory conditions e.g rheumatoid arthritis
Hypertension
Chronic Kidney Disease (CKD)
Atypical Antipsychotic Medication

Question 15

What are the 6 End results of AS?

Answer 15

Stroke
Transient Ischaemic Attack
Myocardial Infarction
Angina
Chronic Mesenteric Ischaemia
Peripheral Artery Disease

Question 16

Primary prevention…

Answer 16

Only possible when there’s no other cardiovascular condition diagnosed

Question 17

Secondary prevention…

Answer 17

After a diagnosis of MI, Angina, Stroke etc…

Question 18

How to optimise modifiable risk factors?

Answer 18

Fix patient diet, incorporate more exercise, stress management, stop smoking, reduce alcohol consumption, manage medical treatment for co-morbidites

Question 19

7 NICE guidelines for diet?

Answer 19

Total fat consumed <30% of total calories (primarily monounsaturated and polyunsaturated fats)
Saturated fat <7% of total calories consumed
Reduced sugar intake
Wholegrains
5 fruits and veg daily
2 fish a week (one oily)
4 times a week legumes seeds and nuts

Question 20

NICE guidelines for activity?

Answer 20

Anaerobic exercise 150 minutes per week if moderate intensity and 75 minutes for vigorous
Strength training activities 2 times a week

Question 21

Primary prevention of AS?

Answer 21

QRISK3 score >10% = initially offered atorvastatin 20mg at night

Question 22

what is the QRISK score?

Answer 22

The QRISK score is the percentage risk of a patient having a stroke of MI in the next 10 years.

Question 23

When else is 20mg Atorvastatin offered?

Answer 23

Chronic Kidney Disease (eGFR less than 60ml/min/1.73m2)
Type 1 Diabetes for more than 10 years or if patient over 40

Question 24

How do Statins work?

Answer 24

Statins Reduce cholesterol production in the liver by inhibiting HMG CoA reductase

Question 25

NICE recommendations for Statins regarding Lipids?

Answer 25

NICE recommend checking lipids 3 months after starting statins and increasing the dose to aim for a greater than 40% reduction in non-HDL cholesterol. Check adherence (are they taking the medications?) before increasing the dose.

Question 26

NICE recommendations for Statins regarding LFTS?

Answer 26

NICE also recommend checking LFTs within 3 months of starting a statin and again at 12 months. Statins can cause a transient and mild rise in ALT and AST in the first few weeks of use. They usually do not need to be stopped if the rise is less than 3 times the upper limit of normal.

Question 27

Side effects of Statins?

Answer 27

Myopathy (muscle weakness and pain) Rhabdomylosis ( muscle damage and check creatine kinase if patients report muscle weakness) Hemorrhagic Stroke (rarely) Type 2 Diabetes

Question 28

Other Cholesterol lowering Drugs?

Answer 28

Ezetimibe and PCSkG Inhibitors

Question 29

How does Ezetimibe work?

Answer 29

It lowers the absorption of cholesterol in the intestine, it can be used when statins are not tolerated or alongside statins when they are inadequate

Question 30

How do PCSkG Inhibitors work?

Answer 30

They are monoclonal antibodies that lower cholesterol. They are highly specialised and are given as subcutaneous injections every 2-4 weeks.

Question 31

Secondary Prevention of AS?

Answer 31

A- Atorvastatin 80mg A- Ace inhibitors ( commonly ramipril) titrated to its maximum tolerated dose A- Atenolol (or other beta blockers e.g bisoprolol) titrated to its maximum tolerated dose A- Antiplatelet medication ( Aspirin, clopidogrel, ticagroler)

Question 32

What dual antiplatelet treatment is offered to MI patients?

Answer 32

Aspirin 75mg (continued indefinitely) Clopidogrel or ticagroler ( max. 12months usually)

Question 33

What can be used for patients with Peripheral artery disease or after an ischaemic attack?

Answer 33

Clopidogrel

Question 34

What is family Hypercholestreolaemia?

Answer 34

It is an autosomal dominated condition that causes high levels of cholesterol. Several genes can cause the condition.

Question 35

Heterozygous =

Answer 35

Only one copy of the gene is abnormal. 1 in 250 people

Question 36

Homozygous =

Answer 36

both copies of abnormal gene, this is rare. Extremely high levels of cholesterol (> 13 mmol/L). Early CV disease almost guaranteed.

Question 37

Two criteria's for clinical diagnosis of Familial Hypercholestreolaemia?

Answer 37

Simone Broome Criteria Dutch Lipid Network Criteria

Question 38

Features of the two Criteria's?

Answer 38

Family history ( anyone under 60 that has CV disease) High levels of Cholesterol (>7.5 mmol/L) Tendon Xanthomata (Hard nodules in the tendons that contain cholesterol, usually found in the hands or Achilles)

Question 39

Clinical management of Familial Hypercholestreolaemia?

Answer 39

Specialist referral for gene testing and family testing Statins

Question 40

Clinical management of Familial Hypercholestreolaemia?