Atheroma formation

Question 1

what are the types of risk factors for atherosclerosis?

Answer 1

unmodifiable

modifiable

Question 2

unmodifiable risk factors for atherosclerosis

Answer 2

ageing
genetics
ethnicity
gender

Question 3

effect of genetics on atherosclerosis risk

Answer 3

fibrinogen clotting factor disorders
lipid disorders
unlikely to be a single gene disorders although family history is strong predictor

Question 4

effect of ethnicity on atherosclerosis risk

Answer 4

asians are at greater risk of heart disease and african and caribbeans have a higher risk of hypertension

Question 5

effect of gender on atherosclerosis risk

Answer 5

men more at risk than women as oestrogen acts as protective factor until menopause then equal risk

Question 6

modifiable risk factors for atherosclerosis

Answer 6

smoking
alcohol
diabetes
hypertension
obesity
raised cholesterol
physical inactivity
metabolic syndrome - abdominal girth
hyperglycaemia

Question 7

pathogenesis of atherosclerosis

Answer 7

1. endothelial dysfunction
2. LDL accumulation and oxidation in walls of arteries which damages endothelium
3. macrophages - foam cells when they phagocytose LDL and T cells recruited
4. inflammation
5. cell death
6. cell recruitment
7. smooth muscle cell proliferation - repair and remodelling
8. collagen deposition
9. formation of fibrin plug
10. fibrin plug weakens so more likely to cause plaque rupture
11. plaque rupture causes subendothelium to be exposed
12. activates platelets and coagulation cascade causing thrombus formation
13. fibrin clot can cause occlusion of artery
14. calcification of arteries - more likely to rupture
15. narrowing of arteries

Question 8

what is the end result of atherosclerosis formation?

Answer 8

occlusion of arteries causing:
MI
Stroke
Critical leg ischaemia
Cardiovascular death

Question 9

what is the tunica intima?

Answer 9

innermost layer of artery,

where LDL is deposited in artery

Question 10

what are the different types of angina?

Answer 10

stable

unstable

Question 11

how to treat stable angina?

Answer 11

GTN spray
aspirin
beta blocker/ calcium channel blocker
long acting nitrates

Question 12

what does GTN spray do?

Answer 12

dilates arteries

Question 13

where is LDL deposited?

Answer 13

tunica intima

Question 14

what does aspirin do?

Answer 14

prevents platelet aggregation

Question 15

what happens in stable angina?

Answer 15

there is not complete occlusion of artery/ not rupture, just narrowing.

Question 16

how to treat coronary thrombosis/ STEMI?

Answer 16

aspirin - 300mg loading dose
P2Y12 inhibitor - 600mg clopidogrel
unfractionated heparin in cath lab
PCI

Question 17

what is PCI?

Answer 17

percutaneous coronary intervention

Question 18

what is a pack year?

Answer 18

1 pack year = 20 cigarettes a day for a year, 20 in a pack

Question 19

what is T wave inversion a sign of?

Answer 19

myocardial ischaemia - NSTEMI

Question 20

difference between treating NSTEMI and unstable angina?

Answer 20

there is no difference

Question 21

how to detect an MI?

Answer 21

troponin T and I most sensitive

Question 22

what does creatinine kinase MB show?

Answer 22

re-infarction

Question 23

symptoms and signs of unstable plaque but without complete occlusion

Answer 23

chest pain intermittently but at rest
reduced exercise tolerance
associated ECG changes - T wave inversion

Question 24

how to treat NSTEMI

Answer 24

aspirin - 300mg loading dose
P2Y12 inhibitor - clopidogrel 600mg
unfractionated heparin (IV) in cath lab
anticoagulant - low molecular weight heparin until PCI
PCI ASAP but not emergency

Question 25

what is the difference between NSTEMI, STEMI, coronary thrombosis and unstable angina?

Answer 25

NSTEMI and STEMI - presentation of ECG

coronary thrombosis and unstable angina = how much occlusion there is

Question 26

how to treat unstable angina?

Answer 26

aspirin - 300mg loading dose
P2Y12 inhibitor - clopidogrel 600mg
unfractionated heparin (IV) in cath lab
anticoagulant - low molecular weight heparin until PCI
PCI ASAP but not emergency

Question 27

antiplatelet agents

Answer 27

glycoprotein IIb/IIIa inhibitors
e.g. aciximab
tirofiban
eptifibatide

Question 28

what do glycoprotein IIb/IIIa inhibitors do?

Answer 28

block integrin receptor for fibrinogen and block final platelet aggregation pathway by inhibiting fibrinogen bridges

Question 29

when are glycoprotein IIb/IIIa inhibitors used?

Answer 29

used if patient is going for PCI - just beforehand

Question 30

how can we regress or stabilise coronary plaques?

Answer 30

reduce vulnerability of plaque

risk factor management

Question 31

risk factor management

Answer 31

lower cholesterol with statins
control BP
quit smoking
other lifestyle factors - exercise, alcohol
reduce vulnerability of blood to thrombosis

Question 32

how to reduce the vulnerability of blood to thrombosis?

Answer 32

antithrombotic drugs - aspirin for life
clopidogrel or similar for 1 year following the event
need to compare bleeding risks for other agents used

Question 33

Post NSTEMI/ STEMI treatment

Answer 33

statins  - atorvastatin
antiplatelet - clopidogrel
beta blocker - bisoprolol
ACE inhibitor - ramipril
remember GI protection as these drugs cause GI bleeding - lansoprazole

Question 34

what do statins do after STEMI/ NSTEMI?

Answer 34

stabilise plaque

Question 35

what do antiplatelets do after STEMI/ NSTEMI?

Answer 35

maintain stent patency

Question 36

coronary stent

Answer 36

drug eluting stents
prevent proliferation of epithelium and reduce risk of restenosis but increases risk of stent thrombosis which is why anti-platelets are needed

Question 37

stent thrombosis

Answer 37

iatrogenic acute coronary syndrome

all stented coronaries are vulnerable

Question 38

how to prevent stent thrombosis?

Answer 38

good technique
anti-platelet drugs
90 times more likely if anti-platelets stopped early