Cardiovascular disease

Question 1

Atherosclerosis?

Answer 1

Atherosclerosis = atheromas (fatty deposits in the artery walls) + sclerosis (hardening or stiffening of vessel walls)

Question 2

What is atherosclerosis caused by?

Answer 2

Caused by chronic inflammation and activation of the immune system in the artery wall

This causes deposition of lipids in the artery wall then –> atheromatous plaques

Question 3

Consequences of atherosclerotic plaques? (3)

Answer 3

Stiffening of artery walls –> leads to hypertension and strain on the heart trying to pump blood against resistance

Stenosis –> leads to reduced blood flow (e.g. in angina)

Plaque rupture –> gives off thrombus that blocks a distal vessel leading to ischaemia, e.g. acute coronary syndrome

Question 4

Risk factors atherosclerosis?

Answer 4

Non-Modifiable Risk Factors

• Older age
• Family history
• Male

Modifiable Risk Factors

• Smoking
• Alcohol consumption
• Poor diet (high sugar and trans-fat and reduced fruit and vegetables and omega 3 consumption)
• Low exercise
• Obesity
• Poor sleep
• Stress

TOM TIP: Think about risk factors when taking a history from someone with suspected atherosclerotic disease (such as someone presenting with chest pain) and ask about their exercise, diet, past medical history, family history, occupation, smoking, alcohol intake and medications. This will help you score highly in exams and when presenting to seniors.

Question 5

Co-morbidities that increase the risk of atherosclerosis?

Answer 5

Diabetes
Hypertension
Chronic kidney disease
Inflammatory conditions, such as rheumatoid arthritis
Atypical antipsychotic medications

Question 6

End results of atherosclerosis?

Answer 6

Angina
Myocardial Infarction
Transient Ischaemic Attacks
Stroke
Peripheral Vascular Disease
Mesenteric Ischaemia

Question 7

Prevention of cardiovascular disease divided into?

Answer 7

Primary Prevention – for patients that have never had cardiovascular disease in the past

Secondary Prevention – for patients that have had angina, myocardial infarction, TIA, stroke or peripheral vascular disease

Question 8

Primary prevention of cardiovascular disease?

Answer 8

Optimise modifiable risk factors
- Advice on diet, exercise and weight loss, stop smoking, stop drinking alcohol, tightly treat co-morbidities (e.g. diabetes)

QRISK 3 score - risk of patient having stroke or MI in next 10 years
- if QRISK 3 score >10% then give statin - 20mg atorvastatin at night

All patients with CKD or T1DM for >10 years should be offered atorvastatin 20mg

Check lipids 3 months after statin, increase dose for >40% reduction in non-HDL cholesterol (always check adherence before increasing dose)

Check LFTs within 3 months of starting statin and at 12 months, don’t need to be checked after that if they are normal. NOTE - statins can cause transient mild increase in ALT and AST in first few weeks and don’t need to be stopped if rise is less than 3 times upper limit of normal

Question 9

Secondary prevention of cardiovascular disease?

Answer 9

Optimise modifiable risk factors
- Advice on diet, exercise and weight loss, stop smoking, stop drinking alcohol, tightly treat co-morbidities (e.g. diabetes)

5 A’s

A - aspirin
A - atorvastatin 80mg
A - atenolol (or bisoprolol) titrated to maximum tolerated dose
A - ACE inhibitor (ramipril) titrated to maximum tolerated dose
A - another antiplatelet i.e. clopidogrel for 12 months

Question 10

Side effects of statins?

Answer 10

Myopathy (check creatine kinase in patients with muscle pain or weakness)

Type 2 diabetes

Haemorrhagic strokes (very rarely)