Cardiology - Atherosclerotic disease (CAS, CAD)

Question 1

A term used to describe arterial wall thickening (hardening) and elasticity loss

Answer 1

arteriosclerosis

Question 2

Most common type of arteriolosclerosis

Answer 2

atherosclerosis

Question 3

A multifactorial inflammatory disease of the intima of elastic arteries and large/medium sized muscular arteries at points of hemodynamic shear stress, characterized by a build-up of cholesterol plaques in the tunica intima.

Answer 3

atherosclerosis

Question 4

Assessment for ASCVD risk

Answer 4

• age
• sex
• ethnicity
• smoking status
• diabetes mellitus screening A1C
• hypertension screening
• lipid screening

Question 5

ABCDS of ASCVD primary prevention

Answer 5

A - aspirin if indicated
B - blood pressure control
C - cholesterol management
D - diabetes management
S - smoking cessation

Question 6

Ischemic heart disease due to narrowing or blockage of the coronary arteries, most commonly due to atherosclerosis, resulting in a mismatch between myocardial oxygen supply and demand

Answer 6

Coronary artery disease

Question 7

Patients with CAD usually be symptomatic when the degree of coronary stenosis reaches

Answer 7

70% or more

Question 8

Best initial test for all patients with chest pain

Answer 8

EKG (resting)

Question 9

Best initial test for diagnosis of CAD

Answer 9

Stress test (only done based on pretest probability)

Question 10

This test involves recording EKG before, during and after exercise on a treadmill if patients are able to exercise.

Answer 10

Stress EKG

Question 11

Detection of ischemia on stress EKG is based on presence of

Answer 11

• ST segment depression
• heart failure
• ventricular arrhythmia
• hypotension

Question 12

This diagnostic study is used to test coronary perfusion and inducible myocardial ischemia through echocardiogram performed before and immediately after exercise.

Answer 12

Stress echocardiogram

Question 13

Alternative stress test method for patients who are unable to exercise

Answer 13

pharmacological stress test (dobutamine, adenosine, or dipyridamole)

Question 14

Evidence of stress-induced ischemia on echocardiogram

Answer 14

• new or worsening wall motion abnormalities (akinesis or dyskinesis)
• change in left ventricular function

Question 15

If a patient has a positive stress test, the next best test is

Answer 15

Cardiac catheterization with coronary angiography

Question 16

A non-invasive method used to assess the amount of plaque in the coronary arteries involving a CT scan with IV contrast in patients with contraindications to cardiac stress testing

Answer 16

Coronary CT angiography (CCTA)

Question 17

Gold standard for CAD diagnosis

Answer 17

Coronary angiography (cardiac catheterization)

Question 18

A procedure that uses contrast due and radiography to take images of the coronary arteries, performed via cardiac catheterization via an artery in the arm or groin and guiding it to the coronary arteries

Answer 18

Coronary angiography (cardiac catheterization)

Question 19

Pharmacological treatment for all patients with CAD

Answer 19

• aspirin
• statin
• anti-anginal (beta blocker is first line, nitrate, CCB or ranolazine are second line)

Question 20

Indications for re-vascularization with CABG or PCI for stable CAD

Answer 20

• complex CAD
• 3 vessel disease
• Left Main Coronary artery stenosis (supplies 2/3 of the heart)

Question 21

Indications for CABG

Answer 21

• 50% or more Left Main Coronary Artery stenosis without patent bypass grafts
• complex CAD or 3 vessel disease with low surgical risk
• multi vessel disease with either proximal LAD stenosis or T2DM
• LV dysfunction

Question 22

Occlusive atherosclerotic disease of the lower extremities

Answer 22

Peripheral vascular disease (PAD)

Question 23

Common sites of occlusion in PAD

Answer 23

• superficial femoral artery (Hunter’s canal) is the most common site
• popliteal artery
• aortoiliac disease (Leriche syndrome)

Question 24

Triad of bilateral buttock, hip or thigh claudication, erectile dysfunction and absent or diminished femoral pulses

Answer 24

Aortoiliac disease (Leriche syndrome)

Question 25

Most important risk factor for PAD

Answer 25

Smoking

Question 26

Indicators of prognosis of peripheral vascular disease

Answer 26

- intermittent claudication is a good prognosis - patients with rest pain or ischemic ulcers have the worst prognosis

Question 27

Cramping leg pain that is reliably reproduced by the same walking distance and completely relieved by rest

Answer 27

Intermittent claudication

Question 28

Pharmacological treatment for intermittent claudication

Answer 28

Cilostazol (PDE inhibitor)

Question 29

Clinical features of rest pain

Answer 29

- pain in the distal metatarsals where arteries are the smallest - prominent at night (wakes patient from sleep) - hanging the foot off the side of the bed or standing relieves the pain

Question 30

First line test for suspected non-acute PAD

Answer 30

Ankle-brachial index ( <0.9 is abnormal and > 1.4 is a non-compressible vessel wall)

Question 31

Treatment for PAD

Answer 31

- smoking cessation - graduated exercise program - risk factor reduction (HTN, T2DM, HLD) - aspirin and clopidogrel

Question 32

A vascular emergency with a critically reduced arterial blood supply of one or more extremities, caused by an arterial embolism, thrombosis or dissection.

Answer 32

Acute limb ischemia

Question 33

6 Ps of Acute Limb Ischemia

Answer 33

- pain - pallor - paresthesias - paralysis - pulselessness - poikilothermia (cold)

Question 34

Best initial test for detecting blood flow in acute limb ischemia

Answer 34

Doppler

Question 35

Next best step for threatened limb

Answer 35

Re-vascularization (do not delay treatment to obtain imaging is limb viability is threatened)

Question 36

Study used to identify site of occlusion in a viable, non-threatened limb

Answer 36

CT angiography (arteriogram)

Question 37

Next best step for non-viable limb

Answer 37

Amputation

Question 38

Options for re-vascularization

Answer 38

- bypass surgery - endarterectomy - embolectomy (Fogarty balloon)

Question 39

An atherosclerotic, degenerative disease of the common carotid and internal carotid arteries

Answer 39

Carotid artery stenosis

Question 40

Risk factors for carotid artery stenosis

Answer 40

- advanced age - tobacco use - hypertension - diabetes mellitus

Question 41

Clinical features of carotid artery stenosis

Answer 41

- transient ischemic attacks - amaurosis fugax - carotid bruit on auscultation - Hollenhorst plaque on fundoscopy

Question 42

A transient monocular or binocular loss of vision

Answer 42

Amaurosis fugax

Question 43

A retinal lesion caused by cholesterol crystal embolization, most commonly from the carotid artery, that appears as a bright yellow, refractive lesion.

Answer 43

Hollenhorst plaque

Question 44

First line imaging for suspected symptomatic carotid stenosis

Answer 44

Carotid duplex ultrasound

Question 45

Confirmatory test for carotid artery stenosis

Answer 45

MRA or CTA

Question 46

First line treatment for carotid stenosis

Answer 46

- asymptomatic - aspirin only - symptomatic - aspirin or clopidogrel (+/- carotid endarterectomy)

Question 47

Indications for Carotid endartectomy

Answer 47

- Asymptomatic patient with severe carotid stenosis ( > 70%) if benefit outweighs risk - Symptomatic patient with severe carotid stenosis (70-99%) - May consider if benefit outweighs risk for symptomatic patients with moderate stenosis (50-69%)

Question 48

Advantages to carotid artery stenting

Answer 48

An alternative to surgery and patient with poor surgical access or increased risk of preoperative complications

Question 49

Contraindications to carotid endarterectomy

Answer 49

- carotid stenosis < 50% - complete carotid occlusion (100%)

Question 50

Management of asymptomatic moderate carotid arteries stenosis (50-69%)

Answer 50

- reduction of atherosclerotic risk factors (HTN, T2DM, smoking, HLD, obesity) - aspirin - lifestyle changes - annual carotid duplex US