Cardiovascular disease

Question 1

What is atherosclerosis

Answer 1

Combination of atheromas(fatty deposits in the artery walls) and sclerosis(process of hardening or stiffening of the blood vessel walls)

Question 2

What does atherosclerosis lead to

Answer 2

Affects medium and large arteries

Causes deposition of lipids in the artery wall, followed by development of fibrous atheromatous plaques

Question 3

What do atheromatous plaques cause

Answer 3

Stiffening of the artery walls leading to hypertension

Stenosis leading to reduced blood flow(angina)

Plaque rupture giving off a thrombus that blocks a distal vessel leading to ischaemia(ACS)

Question 4

Non-modifiable risk factors for atherosclerosis

Answer 4

Older age
Family history
Male

Question 5

Modifiable risk factors for atherosclerosis

Answer 5

Smoking 
Alcohol consumption 
Poor diet(high sugar and trans-fats) 
Low exercise 
Obesity 
Poor sleep 
Stress

Question 6

Medical co-morbidities that increase the risk of atherosclerosis

Answer 6

Diabetes 
Hypertension 
CKD 
Inflammatory conditions(RA) 
Atypical antipsychotic meds

Question 7

End results of atherosclerosis

Answer 7

Angina 
MI 
TIA
Stroke 
Peripheral vascular disease 
Mesenteric ischaemia

Question 8

When should patients be offered a statin

Answer 8

QRISK score of 10% or more

All patients with CKD or T1DM for more than 10 yrs

Question 9

When does NICE recommend checking lipids after statins

Answer 9

At 3 months and increasing dose to aim for a greater than 40% reduction in non-HDL cholesterol

Question 10

What should be checked besides lipids in patients taking statins

Answer 10

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 first few weeks

Question 11

Secondary prevention of cardiovascular disease(4 A’s)

Answer 11

Aspirin(plus second antiplatelet such as clopidogrel for 12 months)

Atorvastatin 80mg

Atenolol(or bisoprolol) titrated to max tolerated dose

ACE inhibitor(ramipril)

Question 12

Notable side effects of statins

Answer 12

Myopathy(check CK in patients with muscle pain or weakness)

T2DM

Haemorrhagic strokes(rare)

Question 13

Signs of cardiogenic shock

Answer 13

Signs of inadequate blood flow include low urine production (<30 mL/hour), cool arms and legs, and altered level of consciousness.

People may also have a severely low blood pressure and heart rate.

Question 14

What is cardiogenic shock

Answer 14

Cardiogenic shock occurs when there is failure of the pump action of the heart, resulting in a decrease in cardiac output causing reduced end-organ perfusion

This leads to acute hypoperfusion and hypoxia of the tissues and organs, despite the presence of an adequate intravascular volume.

Question 15

Definition of cardiogenic shock

Answer 15

Sustained hypotension (systolic blood pressure (BP) <90 mm Hg for more than 30 minutes)

Tissue hypoperfusion (cold peripheries, or oliguria <30 ml/hour, or both).

Question 16

Causes of cardiogenic shock

Answer 16

MI.
Myocardial contusion (often from steering wheel impact).
Acute dysrhythmia compromising cardiac output.
Acute mitral regurgitation (usually as a complication of MI due to ruptured chordae tendinae).
Ventricular septal rupture (usually occurring as post-MI complication).
Cardiac rupture (rupture of the wall of the left ventricle can occur post-MI or due to cardiac trauma).
HOCM
Myocarditis.
Post-cardiac surgery

Question 17

Causes of cardiogenic shock not due to an intrinsic heart problem

Answer 17

Severe PE
Pericardial tamponade or severe constrictive pericarditis
Tension pneumothorax
Myocardial suppression due to bacteraemia or sepsis (although, strictly speaking, this may be defined as septic shock)
Suppression of myocardial contractility by drugs (eg, beta-blockers) or due to metabolic disturbance (eg, acidosis, hypokalaemia or hyperkalaemia, hypocalcaemia)
Thyrotoxic crisis

Question 18

Risk factors for cardiogenic shock

Answer 18

More likely to develop in the elderly and in those with diabetes

Anterior and right-ventricular MI are associated with an increased risk.

History of previous infarction, peripheral vascular disease, cerebrovascular disease and multi-vessel atheroma increases the likelihood of the development of cardiogenic shock.

Question 19

Correctable underlying causes of cardiogenic shock

Answer 19

Potentially correctable underlying causes such as tension pneumothorax, massive PE, occult haemorrhage or hypovolaemia, sepsis, pericardial tamponade, anaphylaxis or respiratory failure should be kept in mind while assessment is carried out

Question 20

Purpose of haemodynamic monitoring in cardiogenic shock mx

Answer 20

Haemodynamic monitoring using a Swan-Ganz catheter can help to differentiate cardiogenic shock from other causes of shock such as hypovolaemia. (Arterial line, simple central venous line for CVP monitoring and a PiCCO® line are alternatives to a Swan-Ganz catheter.)

Question 21

Pharmacological inotropic support usage in cardiogenic shock

Answer 21

Although inotropes increase cardiac output, they may also increase mortality due to increased tachycardia and myocardial oxygen consumption leading to arrhythmia and myocardial ischaemia

No data supporting any specific inotropic or vasodilation therapy

Question 22

What is intra-aortic balloon pump(IABP) counterpulsation

Answer 22

IABP counterpulsation increases cardiac output and improves coronary artery blood flow.

Although evidence suggests that IABP may have a beneficial effect on some haemodynamic parameters, there is no strong evidence of survival benefits to support the use of IABP in infarct-related cardiogenic shock

Question 23

Which type of carcinoid tumours result in pathological changes to the heart

Answer 23

Only carcinoid tumours that invade the liver

Question 24

What causes cardiac manifestations in carcinoid syndrome

Answer 24

The cardiac manifestations are caused by the paraneoplastic effects of vasoactive substances such as 5-hydroxytryptamine (5-HT or serotonin), histamine, tachykinins, and prostaglandins released by the malignant cells rather than any direct metastatic involvement of the heart

Question 25

Characteristic pathological findings of carcinoid heart disease

Answer 25

endocardial plaques of fibrous tissue

Results in distortion of valves causing either stenosis, regurgitation or both