Cardiovascular

Question 1

Risk factors for Coronary artery disease

Answer 1

• Age
• Tobacco smoking
• High serum cholesterol – LDL
• Obesity
• Diabetes
• Hypertension
• Family history (1st degree relative, around 40% of susceptibility, important to ask in history)

Question 2

What type of obesity particularly increases risk of coronary artery disease?

Answer 2

Pericardial fat – lots of inflammatory cells and cytokines. Specific types of fat

Question 3

What are the genetics of family history associated with coronary artery disease?

Answer 3

Chr 9 – peak , polygenic disease, number of genes associated with it

Question 4

Where are atherosclerotic plaques distributed?

Answer 4

Where there is obstruction to flow, found focally distributed along artery length

• Peripheral and coronary arteries
• so focal bc of local haemodynamic factors

Question 5

What is the structure of an atherosclerotic plaque?

Answer 5

• Endothelial layer
• Lipid – white and calcified area
• Necrotic core
• Connective tissue
• Fibrous ‘cap’

Question 6

What is the function of the fibrous cap in an atherosclerotic plaque?

Answer 6

Protect plaque from flowing blood

Question 7

Describe the pathogensis and progression of an atherosclerotic plaque?

Answer 7

1.Fatty streaks (age 10)
2.Intermediate lesions (adhesion and aggregation of platelets to vessel wall)
3.Fibrous plaques/Advanced lesions
TRANSITION POINT
4. Plaque rupture/ plaque erosion

Question 8

What type of arteries are coronary arteries

Answer 8

End arteries - block one and the heart muscle dies

Question 9

What is angina?

Answer 9

Stable CAD, angina occurs when there is a mismatch of oxygen supply (blood supply) and metabolic demand.

• Results in regional wall motion abnormalities
• ST-T changes and cardiac ischaemic pain

Question 10

Why is there pain in angina?

Answer 10

Ischaemic metabolites inc adenosine stimulate nerve endings and produce pain

Question 11

Commonest cause of angina?

Answer 11

Ischaemic Heart disease. Lumen v small. Atherosclerosis commonest reason

Question 12

What are exacerbating factors of angina?

Answer 12

Supply: Anaemiam, hypoxia, polycythemia, hypothermia, hypovolaemia, hypervolaemia

Demand: hypertension, tachycarrhythmia, valvular heart disease, hyperthyroidism, hypertrophic cardiomyopathy

Question 13

What environmental factors can bring on angina?

Answer 13

Cold weather, heavy meals, stress

Question 14

What is the science behind the sudden onset chest pain in angina?

Answer 14

Pouiseuille’s Law

• As narrowing gets worse over time – about 70% width of artery –>blood flow starts to exponentially decrease
• Explains sudden onset chest pain

Question 15

What is the coronary flow reserve?

Answer 15

• Despite all these diff changes in BP (between 2 black dots) –> heart will regulate the amount of blood flow – coronary blood flow wont increase/decrease massively
• By distal resistance increasing/ decreasing

Question 16

Presentation of classical angina

Answer 16

• Chest pain: tightness/discomfort, heavy, may radiate to jaw and or arms
• Pain occurs on exertion
• Pain eases rapidly with rest or GTN
• Breathlessness

Question 17

Pneumonic for pain in angina

Answer 17

OPQRST:
O-onset
P-middle of chest
Q-variable, heavy or tight 
R, on exertion, when bendover
R-radiates to arm
R-relieveing/ aggravating factors: cold weather
S-severity
T- timing: exertion
T- treatment:may have GTN spray

Question 18

What are the factors pointing towards ischaemic cardiac pain?

Answer 18

• Exertion , middle of chest, heavy or tight, cold weather, may be GTN spray

Question 19

Chest pain - differential diagnosis?

Answer 19

• Chest infection/ pleurisy – common
• Angina
• Acute coronary syndromes
• Pericarditis/myocarditis
• Pulmonary embolisi
• Dissection of aorta – VERY RARE
• GERD – spasm/ulceration -Common
• MSK – common
• Psychological – common - anxiety (chest pain, breathlessness, palpitations)