W25 - CVD

Question 1

atherosclerosis - what is it?

Answer 1

an arteriosclerosis characterized by atheromatous deposits in and fibrosis of the inner layer of the arteries

Question 2

Name 7 major risk factors for development of ischaemic heart disease/atherosclerosis?

Answer 2

1. Old age
2. Gender (premenopausal women protected, postmenopausal risk increases)
3. Genetics
4. Hyperlipidaemia
5. Hypertension
6. Smoking
7. Diabetes Mellitus

NB: Risk factors have a MULTIPLICATIVE EFFECT

Question 3

Which of the following is NOT a major risk factor for ischaemic heart disease?

A) Age

B) Male gender

C) High alcohol consumption

D) Hypertension

E) Smoking

Answer 3

C) High alcohol consumption

Question 4

Describe the pathogenesis behind atherosclerotic changes in a blood vessel

Answer 4

1. Endothelial injury
2. LDL accumulation
3. monocyte adhesion to endothelium
4. Monocyte migration into intima => macrophage + foam cells
5. Platelet aggregation
6. SM cell recruitment
7. Lipid accumulation - extra & intracellular, macrophages, SM cells

Question 5

In atherosclerotic changes, one of the earliest lesions seen is a ____ _____

Answer 5

In atherosclerotic changes, one of the earliest lesions seen is a fatty streak

Question 6

Fatty streak:

• affect on blood flow?
• in which age category is it always seen?
• relationship to plaques?

Answer 6

Fatty streak:

• no flow disturbance
• in virtually all children >10yrs
• relationship to plaques uncertain

Question 7

What is the arrow showing in this blood vessel specimen?

Answer 7

Fatty streak

Question 9

At which sites does atherosclerosis usually occur?

Answer 9

Vulnerable sites of arteries = bifurcations and curvatures (where we likely have turbulent flow)

Question 10

Athermoatous plaque can ____ or _____

Answer 10

Athermoatous plaque can obstruct or rupture

Question 11

Consequences of atheroma - critical stenosis occurd as _____% occlusion

Answer 11

Consequences of atheroma - critical stenosis occurd as 70% occlusion

Question 12

Consequences of atheroma - name 3 acute plaque changes

Answer 12

3 acute plaque changes:

1. rupture
2. erosion
3. haemorrhage into plaque

Question 13

In terms of atheromatic plaques, what 4 features make the plaque vulnerable?

Answer 13

• Lots foam cells or extracellular lipid
• Thin fibrous cap
• Few smooth muscle cells
• Clusters inflammatory cells

Question 14

What do you see here?

Answer 14

complete occlusion of LAD (left anterior descending) *most commonly occluded coronary artery*

Question 15

Why is atheromatic vessel changes considered to be the silent killer?

Answer 15

B/c it progresses without any symptoms, and when symptoms develop it’s usually due to reduced blood flow causing myocardial ischaemia

Question 17

Ischaemic heart disease could present in different ways based on severity and disease advancement. Name 4 presentations

Answer 17

1. Angina pectoris
2. MI
3. Chronic IHD with HF
4. Sudden cardiac death

Question 18

IHD pathogenesis?

Answer 18

Predominant cause is insufficient coronary perfusion relative to myocardial demand due to chronic progressive atherosclerotic narrowing of coronary arteries and variable degrees of superimposed plaque change, thrombosis and vasospasm

Question 19

IHD:

• at what % of stenosis does a patient typically get stable angina (pain on exertion)?
• at what % of stenosis does a patient typically get unstable angina (pain at rest)?

Answer 19

IHD:

• at what % of stenosis does a patient typically get stable angina (pain on exertion) = 75%
• at what % of stenosis does a patient typically get unstable angina (pain at rest) = 90%

Question 20

IHD: where are the plaques usually found?

• LAD
• LCX
• RCA

Answer 20

IHD: where are the plaques usually found?

• LAD = 1st few cms (most common)
• LCX = 1st few cms
• RCA = entire length

Question 21

Name 3 more common and 8 less common MI complications

Answer 21

1. Contractile dysfunction
2. Arrhythmia
3. Myocardial rupture
4. Pericarditis (Dressler Syndrome)
5. RV infarction
6. Infarct extension
7. Infarct expnsion
8. Mural thrombus
9. Ventricular aneurysm
10. Papillary muscle rupture
11. Chronic IHD => HF

Question 22

MI

• total mortality in 1st year
• mortality per year after 1st

Answer 22

MI

• total mortality in 1st year = 30%
• mortality per year after 1st = 3-4%

Question 23

Sudden cardiac death:

• what is it?
• aetiology?

Answer 23

Sudden cardiac death:

• what is it = Unexpected death from cardiac causes in individuals without symptomatic heart disease or early (1hr) after onset of symptoms
• aetiology = most commonly due to ischaemia-induced electrical instability (arrythmias)*

* other conditions also associated: aortic atenosis, mitral valve prolpase, pulmonary hypertension

Question 24

The major cause of ischaemic heart disease is…

A) Reduced blood flow due to atherosclerosis

B) Increased cardiac demand for oxygen

C) Increased compliment fixation

D) Pump failure leading to hypoperfusion

E) Uncoupling of Na/K channels

Answer 24

A) Reduced blood flow due to atherosclerosis

Question 25

Cardiac failure - 3 types

Answer 25

• Congestive Heart Failure (L&R)
• Left sided (-> SOB, pulmonary oedema)
• Right sided (-> peripheral oedema)

Question 26

Cardiac failure - causes (6)

Answer 26

–Ischaemic heart disease (IHD)

–Valve disease

–Hypertension

–Myocarditis

–Cardiomyopathy

– Left sided heart failure (Right)

Question 27

Complications of cardiac failure (4)

Answer 27

Sudden Death Arrhythmias Systemic emboli Pulmonary oedema (with superimposed infection)

Question 28

Cardiac failure pathology?

Answer 28

Dilated heart, Scarring & thinning of the walls •Microscopy: fibrosis and replacement of ventricular myocardium

Question 29

Cardiomyopathy - 3 types

Answer 29

Too thin, too thick, too stiff 1. dilated cardiomyopathy, 2. hypertrophic cardiomyopathy, 3. restrictive cardiomyopathy

Question 30

Dilated cardiomyopathy - definition + causes (6)

Answer 30

Dilated cardiomyopathy due to progressive loss of myocytes •Causes: 1. Idiopathic 2. Infective – viral myocarditis 3. Toxic: alcohol, chemotherapy 4. Hormonal – hyper-, hypo- thyroid, diabetes, peri-partum 5. Genetic – haemochromatosis, Fabry’s, McArdle’s 6. Immunological – myocarditis incl. viral

Question 31

Hypertrophic cardiomyopathy (HCM) - definition + causes (1)

Answer 31

Hypertrophic cardiomyopathy (HCM) - left ventricular hypertrophy of myocytes causes: 50% of cases are **familial (autosomal dominant, variable penetrance)**

Question 32

pathophysiology of HCM

Answer 32

mutations in gene encoding beta myosin heavy chain, leading to **thickening of septum and narrowing left ventricular outflow tract**

Question 33

Restrictive cardiomyopathy - definition and causes (3)

Answer 33

Restrictive cardiomyopathy = impaired ventricular compliance Causes: - idiopathic - 2ndary to other diseases (amyloid, sarcoidosis)

Question 34

In chronic rheumatic valvular disease, list the cardiac valves in order of most to leave affected

Answer 34

Mitral \> Aortic \> Tricuspid \> Pulmonic Left sided valves predominantly affected mitral alone 48%, mitral + aortic 42%

Question 35

1. Which valve is this? 2. Which is normal? Which is abnormal?

Answer 35

1. Which valve is this = **aortic valve** 2. Which is normal? Which is abnormal = **left is normal. Right is calcified (AS)**

Question 36

What is chronic rheumatic valvular disease?

Answer 36

Sequelae of earlier rheumtic fever, causing: 1) thickening of valve leaflet 2) fusion of commissures 3) thickening, shortening and suion of chordae tendinae

Question 37

Aortic stenosis - commonest cause? - pathophsyiology?

Answer 37

Aortic stenosis - commonest cause = **calcification** - pathophsyiology = **In elderly, c****alcium deposits outflow side cusp, impairing opening of valve, and causing outflow tract obstruction**

Question 39

Aortic regurgitation - causes (3)

Answer 39

Aortic regurgitation - causes: 1. **Rigidity** - rheumatic, degenerative 2. **Destruction** - microbial endocarditis 3. **Disease of aortic valve ring** =\> dilatation =\> valve insufficient to cover increased area (i.e. in Marfan's syndrome, dissecting aneurysm, syphilic aortitis, etc)

Question 40

Endocarditis - drug related usually results in vegetations on which side?

Answer 40

R sided valves

Question 41

True vs false aneurysms

Answer 41

True - all layers of wall False – extravascular haematoma

Question 42

A common cause of aneurysm is... A) Ulcerative colitis B) Liver failure C) Charcot disease D) Hypertension E) Fat embolus

Answer 42

D) Hypertension (damages the wall)

Question 43

Causes (3) of aneurysm and the pathophysiology

Answer 43

1. Congenital conditions i.e. Marfan's 2. Atherosclerosis 3. Hypertension ... all led to weakening of wall